Assignment task:
CASE STUDY: Crisis Intervention and Safety Planning for the Adult/Geriatric Patient
Mr. Z, age 68, is a new resident of a long-term care facility in the Alzheimer Unit. He was recently taken by his family for evaluation in the Emergency Department after he was found to be confused, physically aggressive with family members, threatening to burn the house down, and paranoid that someone was trying to kill him. The medical work up in the ED was unremarkable. He was discharged from the ED and since arriving at the facility, he has been verbally aggressive with staff, depressed, throwing food, wanders around, and tries to leave. He does not answer most questions when asked by staff and appears agitated. Psychiatry is consulted for management of his behavioral and psychological symptoms.
Medical History: Diagnosed with Alzheimer's Disease 2 years ago (diagnosed based on symptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)
Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3 drinks on the weekends x 10 years. Married. Previously employed as accountant
Family History: No history of dementia or mental health disorders. Mother deceased from colon cancer. Father deceased from MI. Son is 31 and healthy.
Medications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS
Allergies: NKDA
Physical Exam Notes
Constitutional: Appears agitated. Not cooperative. Speech noted is rapid and confused. Inattentive and distracted. Appears slightly hyperactive. Pacing hallways at times.
Head: Normocephalic, atraumatic
Cardiac: RRR, no murmurs noted
Lungs: CTA A/P
Abdomen: BS x active x 4, soft/non-tender, LBM 2 days ago
Musculoskeletal: Moves all extremities, abnormal/unsteady gait
Neuro: Cranial nerves appear grossly intact but patient not cooperative enough for complete testing. DTRs 1+ symmetric. Disoriented to place and time. Is able to state his name. Unable to complete MMSE.
Vitals: T: 98.8, P 88, R 18, BP 132/78
INSTRUCTIONS:
Read the case study here.
Complete a SOAP Note on the patient. (In your SOAP note: Give an example of documentation for the PMHNP provider; (include prescription details as well as instructions for staff to give medication and monitor patient))
In your SOAP note, design a treatment plan that includes PRN medications in case the patient continues to be agitated.
Answer the questions listed below:
- What medications would you prescribe? Why?
- What doses?
- Would you have these listed as standing orders for the nursing home staff or would you want to be notified before given to verify and determine need?
- Would you want to visually see the patient before having the medications given?
- What monitoring would need to be provided after medication is given?
- What documentation would need to be provided and how often for the medication to be continued?
- Would the medication be considered chemical restraints? Why or Why not?