MH Delerium Case Study Acute Delirium SKINNY Reasoning John Kelly, 77 years old [GRADED]

Acute Delirium SKINNY Reasoning John Kelly, 77 years old Primary Concept Cognition Interrelated Concepts (In order of emphasis) • Stress • Coping • Clinical Judgment • Patient Ed ucation 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%  Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!” Personal/Social History: John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife. He is a nonsmoker and has a glass of wine 2-3 times a week with dinner. 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: -77 y/o male -Right total hip arthroplasty post op day one -John is agitated, combative and resistive to staff -Pulled out foley, iv and removed his surgical bandage -Pt is oriented to self only -Pt insists he is in his home and yells “ You get the hell out of my home or I am going to call the police” The patient is an elderly gentleman who is post op day one from an arthroplasty which will put the patient at risk for falls and infection. The patients age puts him at a higher risk for delirium. The patient is aggravated, combative and resistive to staff which leads me to believe this is being caused by either medication he is taking maybe causing delirium. The patient has pulled out his foley cath and IV so that will need to be monitored for infection. The patient is oriented to self only which is significant to changes in his LOC due to possible UTI from infection or delirium from medication. RELEVANT Data from Social History: Clinical Significance: Pt lives at home independently with wife. Pt is a nonsmoker and has a glass of wine 2-3 times a week with dinner Pt is self-sufficient and not dependent on anyone Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details P: 102 (regular) Quality: Tenderness to palpation over incision site R: 18 (regular) Region/Radiation: Right hip BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but does not appear to be in acute discomfort based on assessment O2 sat: 95% room air Timing: Unable to verbalize 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: Temp 99.1 Patients temp is fairly elevated from the normal however we cannot rule it a fever Pulse 102 because we do not know his baseline or normal temperature. The patients O2 sat is low at O2 sat: 95% room air 95% room air which leads me to believe he may have some sort of circulation issues Pt is unable to verbalize pain due going on from possible medications and anxiety from the delirium. The patient is unable to confusion. to verbalize pain so as a nurse I need to look for any non-verbal communication the patient may be showing. Current Assessment: GENERAL APPEARANCE: Agitated, attempting to climb out of bed, pulled out Foley catheter and IV catheter, is not grimacing as if he is in pain but does grimace when incision site is palpated RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, slight edema present at incision site, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, no diaphoresis present NEURO: Alert & oriented to person only, very agitated, unable to maintain focus when asked questions, PERRL, emotionally labile, not easily re-directed, face is symmetrical, speech is clear GI: Abdomen flat, soft/nontender, bowel sounds hypoactive but audible per auscultation in all four quadrants GU: Foley cather pulled out, 400 mL clear, yellow urine in collection bag from the last eight hours SKIN: Incision to right hip intact, patient removed dressing and incision is approximated with sutures, some minor erythema at the site and minor bruising, no warmth, and scant blood tinged drainage noted on the dressing, no odor present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: General Appearance- Agitated, attempting to climb out of bed, pulled foley cath out, not grimacing as if he were in pain but does grimace when incision site is palpated. Resp- WNL Cardiac- WNL Neuro-Alert & oriented to person only, Very agitated. Unable to maintain focus when asked questions. Emotional labile, not easily re-directed GI-Hyperactive bowel sounds GU-Foley catheter pulled out, 400 mL clear, yellow urine in collection bag from the last eight hours Skin-Incision to right hip intact, approximated with sutures, minor erythema at the site, scant blood tinged drainage noted on dressing, no odor The patient has an altered LOC. Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Radiology: CT Results: Clinical Significance: No evidence of acute infarction, intracranial hemorrhage, or mass-effect seen. Results of CT are within WNL. The patient has no finding on the CT which would lead me to believe any major neurological issues were presence. The patient became very agitated quickly and that is a sign of delirium. Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Current: 10.8 10.1 225 74 Most Recent: 6.5 12.8 252 55 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: WBC 6.5 to 10.8 HGB 13.5-17.5 %Neuts 55 Elevated WBC could be indicative of infection. Decreased HGB can be indicative of anemia, which can lead to delirium and poor oxygenation of the blood which would be why his O2 sats are low. The neutrophils are low which also is indicidive of anemia. Improving Imporoving Improving Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 134 3.6 72 1.1 Most Recent: 136 3.7 114 0.8 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: Na- 134 WNL Stable K- 3.6 WNL Stable Gluc- 72 WNL Stable Creat.- 1.1 WNL Stable Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology in OWN Words: Delirium Patient went in for a routine surgery. One day post op patient started to experience delirium leading to agitation, and altered LOC. The patient’s current lab work shows anemia which can lead to a patient becoming delirium due to lack of oxygen in the blood. WBC and neutrophils are low as well which could possibly be aiding in the patient’s anemia. The patient is not getting enough oxygen to his brain therefor his LOC is altered, and he is not his normal self ultimately leading to delirium. Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: Discontinue Foley catheter I would discontinue due to the fact that the patient is having an episode of delirium and could possible cause more harm to himself. Patient will continue to void at least 30 ml/hr after foley is removed. Reinsert IV and saline lock Haloperidol 1-2 mg IV PRN every 4 hours The IV needs to be reinserted that way the patient can get the medications he need or fluids he needs in a quick timely manner. Haloperidol is given to help sedate the patient when he is having a delirium episode. Successful IV inserted in order to deliver medications and fluid. The patient will calm down during a delirious episode. Quetiapine 50 mg PO at bedtime This medication is given to help the patient get the much needed rest they need at bedtime. Patient will sleep well throughout the night. Acetaminophen 500 mg PO every 4 hours PRN pain This medication is given to help control the pain the patient is experiencing. The patient will express verbally or nonverbally the pain is decreasing. 12 lead EKG EKG can rule out any cardiac problem or potassium issues. Normal sinus rhythm on EKG One to one sitter A one to one sitter will give the patient the attention they need in order to keep him safe. The patient will do no harm to self or others. Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Impaired Gas Exchange r/t inability to transport oxygen AEB HGB 10.1 PRIORITY Nursing Interventions: Rationale: Expected Outcome: Monitor the patient’s behavior and mental status for the onset of restlessness, agitation, confusion and extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange. The patient will optimal gas exchange as evidence by usual mental status. 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 Evidence suggest that effective psychosocial care improves patients; health outcomes and quality of life. The patient’s overall health will improve. EMOTIONAL (How to develop a therapeutic relationship): Listen to the patient and build a good report Listening to the patient makes them feel as if they are being heard and they will trust you. The patient will trust your clinical decisions and trust that you have their best interest at heart. SPIRITUAL: Monitor patients support systems. Be aware of own belief systems and accept the client’s spiritual needs. To effectively help a client with spiritual needs, an understanding of one’s own spiritual dimension is essential. The patient will freely express his spiritual needs and beliefs to the nurse. 5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance) The patient should be educated about the medications they are currently taking and will be taking once they are released from the hospital. The patient should be educated on how to properly set up home to avoid falls or injury post op. Delirium and being Post off makes the patient at a higher risk for falls. The patient should inform the provider on any changes in LOC once discharged including confusion so that can be addressed before any permeant damage is done to the brain. The patient should be educated on what delirium is in regards to mental health and how to cope with any episodes he may have after being discharged. Show Less