Patient Introduction
Millie Larsen is an 84-year-old female who was admitted yesterday evening with confusion and urinary tract infection. Upon admission, the Confusion Assessment Method (CAM) algorithm showed evidence
...
Patient Introduction
Millie Larsen is an 84-year-old female who was admitted yesterday evening with confusion and urinary tract infection. Upon admission, the Confusion Assessment Method (CAM) algorithm showed evidence of delirium. Her blood pressure was very elevated yesterday, but we were able to restart her medication, and her blood pressure this morning is down to 160/92 mmHg. She has had 450 mL of amber urine output, and she had no pain during the night. She had a near fall around 6 AM when she was trying to get to the bathroom. She has no visible injuries, and her primary care provider and her daughter have been notified.
It seems like the confusion has begun to clear, but please do an assessment. She also needs an overall assessment, and her independence in activities of daily living should be assessed, but
I didn’t have the time to complete these assessments. Would you please get that done this morning and then notify Dr. Lund? I just completed her fall risk assessment, and it indicates a high risk for falls. I have not yet reported the result of the fall risk assessment, so please also report that. Depending on the assessment results, she may be discharged later today. However, she lives alone and her daughter Dina, who is with her in the room, is concerned about Millie going home alone, so discharge plans need to be discussed.
Report:
Medical Dx: uncontrolled HTN controlled with meds 160/92, UTI, confusion (beginning to clear)
Previous shift states that they have done a fall assessment but did not document, therefore, another assessment must be done.
• Perform a head-to-toe physical assessment
• Assess the patient's individual aging pattern and functional status, using standardized assessment tools, to include:
o SPICES: An overall Assessment Tool of Older Adults
o Katz Inde of Independence in Activities of Daily Living (ADL)
o confusion Assessment Method (CAM)
o Hendrich II Fall Risk Model (Copy of this is in your text)
• Identify changes in mental status
• Recognize conflict between daughter and patient regarding discharge plan
• Communicate therapeutically with the patient and daughter
• Discuss the risks and benefits of discharge to home in light of Millie's wishes to go home
• Identify and discuss geriatric syndromes evident in the simulation, to include:
o Fall Risk
o Confusion
o Incontinence
ML
84yr-old
Admission: confusion
Hx: HTN, osteoporosis, Cholesterol, stress Incontinence, arthritis, glaucoma
Captopril HTN
Metoprolol HTN
Pilocarpine HTN
Furosemide Diuretic
Cipro Antibiotic
Celecoxib NSAIDs- osteoarthritis
atorvastatin cholesterol
Vitals:
*Pain assessment- describe and quality of pain. Activity cause pain? Head-to-toe:
Head-
**wear gloves if you have any suspicions on **
*ask about why the glasses were for*
*carotid*
Abdominal- lay them flat
*Skin turgor*
Incontinent with either or both.
IV site
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