Physical Aggression/Dementia UNFOLDING Reasoning; Ron Jackson is an 87-year-old Caucasian male (Best suited for all Med/Surg students) Latest 2021
Question Dementia/Physical Aggression Ron Jackson, 87 years old Primary Concept COGNITION Interrelated Concepts (In order of emphasis) · Psychosis · Mood and Affect · Coping · Clinical Judgment Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Ron Jackson is an 87-year-old Caucasian male with a medical history of hypertension and Alzheimer's disease who was brought to the emergency department (ED) by paramedics for evaluation of hallucinations, increased agitation, and aggressive behavior toward Shirley, his elderly wife. His daughter was visiting and witnessed Ron becoming angry for no apparent reason, telling Shirley she had to leave the house. He then pushed her, causing her to fall to the ground. Ron has become progressively more agitated the past year and was started on quetiapine. Shirley confirms that Ron has been more verbally abusive the past week, believing that she divorced him and that she needs to get out of the house, but no physical aggression took place until today. Ron currently complains of a headache and insists that he got this because "the Koreans beat me up real good in the ambulance!" Personal/Social History: Ron lives at home with Shirley, his wife of 62 years and has three children. Ron is a Korean War veteran who saw active duty and is a retired salesman. Because his wife has been struggling to care for him, his family is in the process of making arrangements for him to reside at a local memory care unit. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: 1. Identify the relationship between the PMH and home medications. Which medication treats which condition? Draw a line to connect the PMH to the correct medication. Past Medical History (PMH): Home Meds: Hyperlipidemia Donepezil 10 mg PO at HS Hypertension Aspirin 325 mg PO daily Alzheimer's disease Memantine 10 mg PO BID Agitation/Delusions Simvastatin 20 mg PO HS Triamterene-HCTZ 75-50 mg PO daily Quetiapine 50 mg PO BID 2. Is there a relationship between any problem in his past medical history and the present problem? If so, describe. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.0 F/36.7 C (oral) Provoking/Palliative: "Those Koreans banged my head in the ambulance." P: 78 (regular) Quality: "That's a stupid question!" R: 18 (regular) Region/Radiation: "My head hurts all over!" BP: 148/90 Severity: "It just hurts!" O2 sat: 98% room air Timing: "All the time." 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: Current Assessment: GENERAL APPEARANCE: Thin elderly male, appears stated age, sitting upright on stretcher, appears tense RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk capillary refill NEURO: Oriented to person only, denies hallucinations GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination (MSE): APPEARANCE: Disheveled appearance; cooperative at times, other times irritable MOTOR BEHAVIOR: Variable; at times pacing and agitated; at other times sits quietly SPEECH: Able to understand what the patient is saying MOOD: Variable; quiet and calm with sudden episodes of anger, anxiety, and irritability AFFECT: Variable: looks calm, then may suddenly appear angry THOUGHT PROCESS: Able to understand what the patient is saying THOUGHT CONTENT: Paranoid and persecutory delusions/ideation; "Koreans" are harming him; delusions "believes wife divorced him" PERCEPTION: Denies hallucinations INSIGHT: Grossly impaired; attributes H/A to an attack by "Koreans"; not aware of illness or reason for ER visit JUDGMENT: Grossly impaired COGNITION: Oriented to person only. Significant short- and long-term memory deficits SUICIDAL/HOMICIDAL: High risk for physical aggression toward others; recently assaultive toward wife; unable to assess suicide ideation at this time What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: RELEVANT Mental Status Exam Data: Clinical Significance: Lab Results: Complete Blood Count (CBC) WBC Current: 5.8 Last adm: 6.5 HGB Current: 14.5 Last adm: 14.2 PLTs Current: 154 Last adm: 188 % Neuts Current: 69 Last adm: 75 Bands Current: 0 Last adm: 0 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: Basic Metabolic Panel (BMP) Na Current: 142 Last adm: 144 K Current: 3.3 Last adm: 3.5 Gluc. Current: 114 Last adm: 121 Creat. Current: 1.3 Last adm: 1.2 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: Urinalysis + UA Micro Color: Current: yellow Last adm: yellow Clarity: Current: clear Last adm: clear Sp. Gr. Current: 1.020 Last adm: 1.020 Protein Current: neg Last adm: neg Nitrite Current: neg Last adm: neg LET Current: neg Last adm: neg RBCs Current: neg Last adm: neg WBCs Current: neg Last adm: neg Bacteria Current: neg Last adm: neg Epithelial Current: none Last adm: 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/Stable: Part II: Put it All Together to THINK Like a Nurse! 1. Interpreting relevant clinical data, what is the primary problem? What primary health-related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Violence precautions Continue home medications Lorazepam 0.5 mg. po PRN every 4 hours x 24 hours Acetaminophen 2 tabs (325 mg) every 4 hours PRN pain. Not to exceed 4000 mg in 24 hours Consult: Mental Health/Behavioral Health professional Referral to social work for help with memory care facility placement after d/c from hospital Rationale: Expected Outcome: Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: 4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Physical comfort measures EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: · Rapport · Trust · Respect · Genuineness · Empathy Evaluation: Sixty Minutes Later... You go into the patient's room to re-evaluate his status. He states to you, "There are people who want to get me!" Ron becomes agitated and looks you in the eye and angrily states, "Who the hell are you and what are you doing in my house!" You tell him that he is at the hospital and in a safe place. He replies, "I am at home and what the hell are you doing here!" He suddenly takes his right arm and attempts to punch you and narrowly misses your face... 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: 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: 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: Use Reflection to Develop Clinical Judgment What did you do well in this case study? What knowledge deficits did you identify? What did you learn? How will you apply learning caring for future patients? This case study begins with the following scenario: Ron Jackson is an 87-year-old Caucasian male with a medical history of hypertension and Alzheimer’s disease who was brought to the emergency department (ED) by paramedics for evaluation of hallucinations, increased agitation, and aggressive behavior toward Shirley, his elderly wife. Ron has become progressively more agitated the past year and was started on quetiapine. Shirley confirms that Ron has been more verbally abusive the past week, believing that she divorced him and that she needs to get out of the house, but no physical aggression took place until today. Ron currently complains of a headache and insists that he got this because “the Koreans beat me up real good in the ambulance!” Key Components: 1. Develop “art” of Nursing By emphasizing importance of caring, compassion, and spiritual care. 2. Develop Ethical Decision Making By applying ethical decision making to real-life dilemmas of practice. 3. Develop Professional Behaviors By emphasizing how a nurse acts as a nursing professional.
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- Uploaded on
- March 8, 2021
- Number of pages
- 16
- Written in
- 2020/2021
- Type
- Case
- Professor(s)
- Prof;
- Grade
- A+
Subjects
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physical aggressiondementia unfolding reasoning
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best suited for all medsurg students cognitivesafety concept exemplar with a short
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versatile format that engages students with active learning to h
