Case Study: Managing Sepsis and Dementia in an Elderly Patient, Exams of Nursing

Download Case Study: Managing Sepsis and Dementia in an Elderly Patient and more Exams Nursing in PDF only on Docsity! Case Study Sepsis Dementia Unfolding Dementia UNFOLDING Case Study Morgan Adams, 72 years old Primary Concept Cognition Interrelated Concepts (In order of emphasis) • Pain • Mood and Affect • Psychosis • Clinical Judgment • Patient Education • Communication • Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% ✓ • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity • Basic Care and Comfort 6-12% ✓ • Pharmacological and Parenteral Therapies 12-18% ✓ • Reduction of Risk Potential 9-15% ✓ • Physiological Adaptation 11-17% ✓ reabsorption of water. This both reduces blood pressure and water retention which can cause edema. 7. Serum glucose is reduced by metformin’s action of decreasing hepatic glucose production (gluconeogenesis), decreasing the intestinal absorption of glucose, and increasing insulin sensitivity by increasing peripheral glucose uptake and utilization. 8. Glyburide acts by closing ATP-sensitive potassium channels on pancreatic beta cells stimulating release of insulin thereby reducing blood glucose. 9. Memantine is an uncompetitive (open- channel) NMDA receptor antagonist, preventing glutamate action on this receptor. This action helps to decrease glutamate One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in Morgan’s life? COPD likely occurred first… COPD, when it becomes severe, can affect the heart by causing a development in right-sided heart failure. This happens because chronic lower oxygen levels create increased blood pressure in the lung’s arteries. This is known as pulmonary hypertension where the lung’s blood vessels narrow or become blocked or even destroyed. All of this leads to the heart becoming weaker and blood is harder to distribute throughout the body. Body tissues and organs do not perfuse as efficiently, thus decreasing oxygenation. Oxygen deficits to the brain’s tissues doubly increase the chances of developing dementia. Therefore, Morgan’s diseases are a cascade of one disease setting off the next, and so on. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.8 F/37.7 C (oral) Provoking/Palliative: “Standing and moving.” P: 60 (regular) Quality: “Dull” R: 16 (regular) Region/Radiation: “Lower back” BP: 115/72 Severity: “4/10” O2 sat: 96% room air Timing: “It is always there.” What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Slight elevation in temperature, and persistent dull, low- grade lower back pain, standing/moving provokes Currently suspecting an infection due to the lower back pain and slightly elevated temperature- possible UTI. I would want to clarify where exactly in the lower back the pain is located and perhaps do a UA. Are kidneys damaged? Mental Status Examination (MSE): APPEARANCE: Dressed in t-shirt and pants. His pants are urine soaked. Wearing a sweater even though it is summer. MOTOR BEHAVIOR: Ambulates with a walker, shuffling gait SPEECH: Clear MOOD/AFFECT: Pleasant, except when talking about being at Pineville Healthcare Center, becomes agitated Anxiety increases, and angry affect displayed; emotionally labile – can become easily angered THOUGHT PROCESS: Generally coherent conversation; can make himself understood THOUGHT CONTENT: Preoccupied with not wanting to be at Pine Healthcare Center. Talks about how they are not helping him. Wants to go home and get his hunting license so he can go hunting. PERCEPTION: Reports having seen a friend, Roger, from the Navy climbing down the side of the building yesterday. No other current evidence of hallucinations INSIGHT/JUDGMENT: Insight – poor- not understanding why he needs to be at a facility and not at home. (thinks he is here for rehab) Unable to recognize own deficits in functioning Judgment Poor-often asks his wife to bring him take-out food (which she does), then he eats an additional dinner in the cafeteria. Na K Gluc. Creat . Current: 140 3.4 225 1.2 Most Recent: 140 3.5 182 1.1 What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Sta ble: The trends in glucose and creatinine are getting higher and potassium is going lower. Hypokalemia can impact many things. Muscles can become weak and cramp which can be a fall and respiratory hazard. This is distressing because the pt already has COPD. Heart function may be altered by production of abnormal rhythms, which is especially dangerous because of his HF. Serum glucose is trending upward and is too high. Possible High glucose from kidney fxn decrease, dehydration, or medication SE? Hyperglycemia can cause damage to the kidneys and blood vessels and can also lead to delirium. Increased creatinine levels can indicate a change in the function of the kidneys. This can point to anything from blockages in the kidneys to dehydration, but most significantly, decreased blood flow to the kidneys as a result of uncontrolled hyperglycemia. Na- stable K- worsening Glucose- worsening Creatinine- Worsening Complete Blood Count (CBC) WBC HGB PLTs % Neuts Band s Current: 6.0 15.2 202 55 0% Most Recent: 5.8 14.5 198 52 0% What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Sta ble: I do not see any relevant labs except for the fact that these labs might rule out infection. All labs in the CBC are within normal limits. I think that perhaps this points to another reason for the confusion and bladder or kidney issues other than infection. All CBC values are relatively stable. However, I would like to monitor the WBC should the trend continue to go up. Misc. HGB A1C Current: 7.8 Most Recent: 5.5 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: HGB A1C has dramatically jumped from 5.5 to 7.8 This is definitely a huge jump in glucose. This reading continues to point to the kidneys as a possible problem for many, if not all, of the medical issues he is currently dealing with. Worsening. Urinalysis + UA Micro Color: Clarity : Sp. Gr. Protei n Nitrit e LET RBCs WBCs Bacteria Epithelia l Current: Yellow Clear 1.015 Neg Neg Neg 0 4 Trace Few Most Recent: Yellow Clear 1.018 Neg Neg Neg 0 0 None None What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/St able: -The specific gravity of the urine also falls within the normal range, however it was on the high normal side on the most recent test. The - WBC count is still normal, but encroaching the high side of normal. -A few epithelial cells is somewhat normal. -Now that specific gravity is 1.015 it may indicate that some slight dehydration may be resolving itself. -The WBC is encroaching the high side of normal, however, the leukocyte esterase (LET) is negative. The combination of a + LET and high WBC would indicate a possible infection. At this time, I will watch the WBC for further upward trending. -While having a few epithelial cells in the UA is normal, the trend is going up, and along with the WBCs and trace bacteria, can indicate inflammatory conditions that point to where one might suspect infection Color and clarity- stable Specific gravity- improving Protein, nitrite, LET- stable RBC- stable WBC- Worsening Bacteria- Worsening Epithelial- Worsening 1) Neuropsychiatric eval 2) Urinalysis (UA) 3)Haloperidol 2.5 mg PO bid 4)Acetaminophen 325mg two tablets PO every 6 hours PRN 5) Insulin glargine 10 units sub q HS 6) Increase memantine to 10 mg PO daily 7) Donepezil 5 mg PO daily 8) Trazodone 50 mg PO at HS PRN 1) measures the degree of progression of the dementia, assesses for delirium and cause of hallucinations, assesses for suicide potential, assess for Alzheimer’s related psychoses progression 2) another UA will continue to trend whether or not it is apparent that the patient has a Urinary tract infection or inflammation of the GU. 3) Haloperidol is an antipsychotic which relieves positive Sx of a psychotic episode like hallucinations. 4)Acetaminophen is a mild analgesic and antipyretic. 5) Insulin is an exogenous hormone replacement for the management of diabetes. 6-7) memantine increase and donepezil addition to treat dementia. 8) atypical antidepressant to deal with feelings of hopelessness while living in LTCF. 1)To decrease the rapid progression of dementia, to treat the factors that are contributing to confusion and/or delirium, to decrease potential for suicide by explaining the true reason he is at LTC facility and helping him cope with the truth, treat possible signs of psychoses brought on by the dementia. 2) If the patient has inflammation or infection of the GU, antibacterial treatments can be started to help relieve the patient of the infection. 3)Absence of hallucinations 4) Since the patient’s temp is slightly elevated, it can reduce any possible fever, and because he has persistent back pain, the acetaminophen will help to control the pain. 5) Management of hyperglycemia not controlled via oral antidiabetics. 6-7) increasing memantine helps to treat dementia by blocking the glutamate receptors on NMDA and donepezil inhibits ACh- esterase. By attacking both, the hope is to decrease the symptoms of dementia from two different angles so that the patient can continue to function as independently as possible. 8) My patient has low insight as to why he is residing in the LTCF and has feelings of hopelessness surrounding it. Adding an antidepressant will help improve his mood and decrease or subside suicidal ideations. Trazadone is also used off-label as a sleep aid, which will help the patient’s insomnia. PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: • Neuropsychiatr ic evaluation • Urinalysis (UA) • Haloperidol 2.5 mg PO BID • Acetaminophen 325mg two tablets PO every 6 hours PRN • Insulin glargine 10 units sub q HS • Increase memantine to 10 mg PO daily • Donepezil 5 mg PO daily 1)Neuropsychiatric Eval 2) UA 3) Acetaminophen 4) Insulin 5) Add donepezil 1)The root of all of his current medical exacerbations is his mental status, so the sooner he can be evaluated the better. 2) UA is a physical need in case he is in current need of treatment for an infection, this can be determined ASAP 3) Pain and possible temperature needs to be addressed to promote that patient’s comfort 4) The patient’s blood sugars must be managed to prevent HHNS or more confusion or kidney injury. 5) Treating dementia via a different neurotransmitter will help the patient maintain independent function through his dementia for as long as he can. 6) Increasing memantine will also help the patient maintain independent function through his dementia for as long as he can. Collaborative Care: Nursing 1. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Safety, Infection, Hyperglycemia PRIORITY Nursing Interventions: Rationale: Expected Outcome: 1) Safety- patient needs to walk with his walker or assistance and non-slip shoes 2) Infection- Have HCP prescribe antibiotics, ensure proper hydration, check VS. 3) Hyperglycemia- give insulin, check serum glucose pre-prandial 1) The patient’s condition proves to be leaving him unstable of gait. 2) The patient seems to possibly be brewing up a slight infection. 3) The patient is in need of better glycemic control 1) No falls 2) Antibiotics will take care of the infection and alleviate his discomforts caused by the infection. 3) Exogenous insulin will better control excess blood glucose than the oral antidiabetics. 2. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) APPEARANCE : RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Continues to be incontinent but is agreeable to be changed. The results of the urinalysis returned and were negative. SKIN: Skin folds in the peri area are red and irritated. Mental Status Examination (MSE): APPEARANCE: Dressed in a clean t-shirt and pants. Patient has a new adult diaper in place MOTOR BEHAVIOR: Ambulates with walker, shuffling gait SPEECH: Clear MOOD/AFFECT: Pleasant, except when talking about Pineville Center, then becomes agitated. Anxiety increases, and angry affect displayed; easily becomes angry. THOUGHT PROCESS: Generally coherent conversation; can make himself understood. THOUGHT CONTENT: Continues to display some agitation about Pineville Center. States, “I can take care of myself. There is nothing they do for me that I can’t do for myself. It is against the law for them to keep me here.” PERCEPTION: No other current evidence of hallucinations INSIGHT/JUDGMENT: Insight – poor as evidenced by not understanding why he needs to be at a facility and not at home. (Thinks he is here for rehab) Unable to recognize own deficits in functioning. Judgment Poor Continues to ask his wife to bring him in takeout food. Stated, “I don’t eat dinner in the cafeteria.” COGNITION: The client’s neuropsychiatric evaluation was completed, and it was determined that the cause of the patient’s dementia is Alzheimer’s disease. Oriented to person and place. Not oriented to time or purpose. Believes it is 2017. Able to recognize it is spring. Short-term memory impaired: Doesn’t always remember that he has eaten a meal, forgets that wife visits; forgets to use a walker. Long-term memory seems to be intact. Remembers personal history. INTERACTIONS: Pleasant when spoken to. Hesitant to initiate conversation. SUICIDAL/HOMICIDAL : Stated, “I would rather die than live in a nursing home.” Also expressed that he would never do anything to hurt himself because of his Catholic faith. 1. What clinical data are RELEVANT that must be recognized as clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: BP is low and has dropped quite a bit Current blood glucose is starting to climb again. Lower back pain has become stronger at 6/10 pain. Blood pressure and hyperglycemia can be inversely related. When blood glucose levels are high, blood volume and blood pressure can become low. It is also suspected that both may be having an impact on the kidneys. Back pain increase can be related to kidney issues, as well. RELEVANT Assessment Data: Clinical Significance: Pt. continues to be incontinent and has some integumentary irritation and redness in the peri area r/t starting to wear an adult brief. Incontinence continues despite the fact that he no longer is suspected of having a UTI. Needing to wear an adult brief/diaper seems to now be causing some skin breakdown which can lead to a skin infection. RELEVANT MSE Assessment Data: Clinical Significance: Pt. continues to become angered about living in the LTCF and continues to lack insight as to his need to be there. Still depressed but states is not a suicidal risk d/t his faith Dementia identified as Alzheimer’s 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: The patient’s situation has both improved in some systems and worsened in some systems. Something that may be interconnected is the relationship between the low blood pressure, the low back pain Blood pressure medications adjusted to prevent hypotension Insulin glargine dosage adjustment or adding a short action insulin as an additional medication to cover meals pre-prandially. Kidneys need to be assessed still. BUN, creatinine, GFR, renal US and the blood glucose once again elevating. 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: Kidneys PRIORITY Nursing Interventions: Rationale: Expected Outcome: Kidneys need to be assessed still. BUN, creatinine, GFR, renal US The pain generated in the back can be from a blockage of the kidney, perhaps kidney stones, or it can be from kidney disease. Either way, the kidney function needs to be looked at. May need a stronger pain medication Manage disease progression in kidney, whether it is kidney stones or kidney disease, medications can manage symptoms, further deterioration of the kidneys, and resolve pain Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) Education PRIORITY: Patient needs to be educated about his blood glucose and the impact of eating too many meals. PRIORITY Topics to Teach: Rationale: Needs to have a method of managing whether or not he had eaten his dinner already, like a diary or dining punch card so that he can remember that he had eaten. Teach wife to look at food diary before brining another meal to the patient and log that meal on the food diary so that staff can be aware of his meal status. Eating too many meals is increasing the patient’s blood glucose and this can be negatively affecting his kidney function and deteriorating his brain function. Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) What Patient is Experiencing: How to Engage: The patient seems to frustrated and helpless. He is feeling like his dignity is being stripped and is confused as to why he needs the long- term care. Help promote the patient’s dignity by helping to do bladder training to possibly get him out of adult diapers and back to self- toileting. Offer self to talk to patient when he is feeling frustrated or sad. Offer the patient activities he may enjoy, like playing cards or art, so that he might feel useful. Help patient come to terms with his deficits. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention at the moment as the events are unfolding to make a correct clinical judgment. What did I learn from this scenario? How can I use what has been learned from this scenario to improve patient care in the future? What Did You Learn? How to Use to Improve Future Patient Care: I learned that situations are not always what they seem. I truly thought my client had a UTI because of the hallucinations, slightly elevated temp and minor markers on the UA+. Now, I see his hallucinations may have been exacerbations of his AD and the back pain may be something else or just plain old back pain. Look at the BIG picture. Take all information into account and reroute suspicions once the information is present that I’m on the wrong track. Find other ways to come to the right conclusion. Case Study Sepsis Dementia Unfoldi ng