Geriatric Case Study

1. Geriatric Case Study Patient Centered Care

2. Meet the patient H.A 76 y/o white female Allergies: NKDA, NKFA Admitted to MSU on 6/27/15 for LEFT HIP FRACTURE Hospital day: 3 Post-op day: 1 PMHx: HTN, BLE DVT, splenic vein thrombosis, glaucoma, urinary retention, UTIs, acute kidney injury in the past, Morbitz type I AV block, significant blood loss anemia ? r/t nonbleeding rectal mucosa ulceration in Nov 2014, PE in Nov 2014 , history of mechanical fall with acute compression of L1 Psych Hx: Bipolar affective disorder, dementia Social Hx: non smoker, no alcohol consumption, one son, separated but lives with husband (primary care give)

3. Shift report, June 30 • Hospital day: 3, Post-op day: 1 • Comes from Summit Elder Care 2days/week • Oriented to person only and confused at baseline • Returned from surgery @ 1700 (June 29), sleepy and lethargic but easily arousable. • @ 0030 agitated, pulled out IV line, POX senor from finger, attempted to “jump out” of bed several times, and tried to pull the catheter out. 0.5 mg Haldol x1 dose was given. • H/H: 6.5/19.4. MD notified. Order: 3 units of PRBC • Heparin drip D/C @0530. Now SCDs only. • LS diminished. O2sat 94% on RA • NSR • D5NS @ 80ml/hr

4. The Injury • Pt ambulating barefooted to the bathroom • Entangled with the floor rug and had a fall • Found on the floor by the husband • Brought to ED for complains of left hip pain • No report of loss of consciousness or head trauma

5. Assesment • Neuro: A+O x1, oriented to person only, confused. • CV: No c/o chest pain. Skin pale, warm & dry, cap refill < 3sec. HR 68 irregular. BP 111/68. No edema, +PP bilat. Tele: NSR. • Resp: RR 18, regular, non-labored, no SOB noted. O2sat 95% on RA. LS diminished but clear bilaterally throughout. • GI: Abd soft, non-tender, non-distended. +BS x4Q. 2 small BMs • GU: Foley catheter, clear, yellow urine. Output: 240 ml/shift • MSK: slight muscle atrophy noted, LLE weakness noted. • INTEG: Skin intact, warm and dry. Incision sites intact. Left hip middle dsg w/ serosanguineous drainage. Dsg changed. Dsgs clean, intact, and dry.

6. Home Medications • Tylenol 5mg PO q6h PRN • Calcium 600+ D3 1 tablet PO daily • Aspirin 81 mg PO daily • MiraLAx PO daily PRN • Potassium chloride ER 20 mg PO daily • Depakote ER 500 mg PO BID • Aricept 5 mg PO daily • Effexor XR 75 mg PO daily • Lovenox 100 mg injection 1.5 mg/kg subcutaneously daily (slightly higher dose) • Olanzapine 10 mg PO daily @ night • Chlorthalidone 25 mg PO daily • Lorazepam 0.5 mg three times/day • meTOPROLOL 12.5 mg PO BID

7. Medications: A contributing factor? • Valproates (Depakote) ER 500 mg PO BID (Mood Stabilizer) • Dizziness, sedation, confusion, visual disturbances, tremor, ataxia • Donepezil (Aricept) 5 mg PO daily (dementia/AD) • Dizziness, drowsiness, fatigue, syncope, frequent urination • Venlafaxine (Effexor) XR 75 mg PO daily (depression/anxiety) • Dizziness, weakness, urinary frequency, urinary retention • Olanzapine(Zyprexa)10 mg PO daily @ night (Mood stabilizer) • Dizziness, agitation, delirium, restlessness, sedation, speech imparment, tardive dyskinesia , urinary incontinence • Chlorthalidone 25 mg PO daily (HTN) • Dizziness, drowsiness, lethargy, weakness, hypotension, hypokalemia • Lorazepam (Ativan) 0.5 mg three times/day (Anxiety) • Dizziness, drowsiness, lethargy, weakness • meTOPROLOL 12.5 mg PO BID (HTN) • Dizziness, drowsiness, lethargy, weakness, hypotension, urinary frequency

8. Diagnostics Labs (on admission, 6/27): WBC: 8.5 RBC: 3.94 HGB: 12.7 HCT: 37.7 PLT: 157 Na: 140 K: 3.9 Cl: 106 Ca: 9.1 Mg: 1.8 BUN: 28 Creat: 0.99 Labs 6/30 (post-op day 1) WBC: 5.7 RBC: 2.03 HGB: 6.5 HCT: 19.4 PLT:136 Na: 142 K: 3.1 Cl: 109 Ca: 7.8 Mg: 1.6 BUN 16 Creat: 0.89

9. Orders • 3 units of PRBC • Potassium chloride 40mEq PO q4h x2 doses • Potassium chloride 40 mEq IV once (infuse 10 mEq over 1 hr) • Magnesium sulfate 1 g in D5W IV once • D5NS @ 80 ml/hr • Flurosemide (Lasix) 20 mg IV push one time after the second unit of PRBC.

10. Elder care considerations • Acute Delirium • Risk for Falls • Polypharmacy • Self care deficit • Care giver needs

11. Nursing Diagnosis • Fluid and Electrolyte imbalance r/t blood loss secondary to surgical procedure. • Risk for injury r/t delirium, confusion, wandering, and incontinence. • Self-care deficit (i.e. feeding, ADL performance) r/t cognitive and physical impairment. • Caregiver role strain r/t progression of chronic debilitating disease process

12. NCLEX QUESTIONS

13. 1. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply) • Stop the transfusion • Send the blood bag and IV tubing to the blood bank • Maintain an IV infusion with 0.9% sodium chloride • Elevate the client’s feet • Obtain blood culture

14. Answer 1 • The first action is to stop transfusion • The blood bag and IV tubing are send to the lab for analysis • 0.9% sodium chloride should be administered through new IV tubing

15. 2. A nurse is providing teaching to the partner of an older adult client who had dementia and has a new prescription for donepezil (Aricept). Which of the following statement by the partner indicates the teaching is effective? • “This medication should increase my wife’s appetite.” • “This medication should help my wife sleep better.” • “This medication should help my wife’s daily function.” • “This medication should increase my wife’s energy level.”

16. Answer 2 C. Donepezil helps slow the progression of dementia/AD and may help improve behavior and daily functions.

17. 3. A nurse is making a home visit to a client who has dementia. The client’s husband states that the client is often disoriented to time and place, is unsteady on her feet, and has a history of wandering. Which of the following safety measures should the nurse review with him? (Select all that apply) • Remove floor rugs. • Have door locks that are easily opened. • Provide increased lighting in stairwells. • Install handrails in the bathroom. • Place the mattress on the floor.

18. Answer 3 A, C, D, E