Advice with a difficult pt!!!

nutella, MSN, RN · Dec 27, 2015

in the area where I work - unless the patient is DNR/DNI/DNH they will get send out from long term care to the hospital for a work up for mental state changes. Check with your facility MD and supervisor on that.

Granted I work in hospice - but I go to LTC facilities and recently saw a patient who also was in the high 80s for age and more confused, restless and so o. The facility did the usual work up with urine culture and blood work - all negative. In the end the did a chest x ray, which came back pneumonia. The patient got back to the usual self after the course of antibiotics was finished.

MPKH, BSN, RN · Dec 27, 2015

Can you get a prn restraint order for the patient?

I agree with nutella; I work acute care and receive confused, decreased LOC patients from LTC all the time. Most of the time, it is a infection of sorts. Sometimes it is more dire. Discuss with the doctor and see if you guys can't send the patient to the hospital to have them work him up? It could be anything from sepsis to tumour in the brain...and the sooner he is diagnosed and treated, the better.

walkingdeadhead · Dec 27, 2015

Did he start a new med or was a med discontinued? Does this happen all day or only at night? Is he new to the LTC (wasn't sure if he came a week and a half ago)? If so is withdrawal a possibility? Or the new environment?

How did you guys work him up? His neuro change makes it sound like he may need to be admitted for a full work up (cbc, cmp, bnp, enzymes, chest and head ct, cxr, ekg, abgs, etc.).

If there is nothing and this is just him, can you keep him at the nurses station or within sight in a chair that locks the patient in to prevent falls? I can't remember what those are called. I'm interested to see what others come up with. I have only worked in the hospital, where sitters and restraints are available but I know this isn't a real solution, especially in your setting.

tinytrexarms · Dec 27, 2015

He has had two full work ups. Sent him out twice, only to have the same results. He has been on my unit for 3-4 months. We have racked our brains trying to figure out how his deterioration was so quick with no apparent reason.

I had him in a recliner right outside my station, and he still managed to roll out of the chair. He is not sliding out, he is rolling himself sideways or reaching over the side.

I can't try a gerichair without an order.

He had no med changes, no contraindications with any of his meds, and blood levels were WNL.

They added Zyprexa which as of this hour, has him sleeping, but we will see what the day brings.

Honestly it's breaking my heart as this is a pt I've grown quite attached to, and I just really wanna minimize incidents until we get the dx figured out.

KatieMI, BSN, MSN, RN · Dec 27, 2015

Review all meds AND their combinations started within a week before it began. Were any of them changed from brand to generic? Why and when Ziprexa was added, it has a black box warning reg. increasing mortality among elderly? Can you get a PharmD for a cousult?

The patient needs to be admitted for full neurology and metabolic workup. Small lacunar strokes can manifest just like this, but from what you wrote I would not exclude polypharmacy as the first reason.

eris08, BSN, RN · Dec 27, 2015

Is the patient taking any psychiatric medications? Could it be Neuroleptic Malignant syndrome?

sailornurse · Dec 27, 2015

I am very impressed with the suggestions offered and have to agree he needs diagnostics of brain, etc. Good job to the PPs.

TheCommuter, BSN, RN · Dec 27, 2015

Can you get a prn restraint order for the patient?

Physical restraints are typically disallowed in the LTC setting due to it being one of the most regulated specialties in the U.S.

Kooky Korky, BSN, RN · Dec 28, 2015

He has had two full work ups. Sent him out twice, only to have the same results. He has been on my unit for 3-4 months. We have racked our brains trying to figure out how his deterioration was so quick with no apparent reason.
I had him in a recliner right outside my station, and he still managed to roll out of the chair. He is not sliding out, he is rolling himself sideways or reaching over the side.
I can't try a gerichair without an order.
He had no med changes, no contraindications with any of his meds, and blood levels were WNL.
They added Zyprexa which as of this hour, has him sleeping, but we will see what the day brings.
Honestly it's breaking my heart as this is a pt I've grown quite attached to, and I just really wanna minimize incidents until we get the dx figured out.

Get the order for gerichair.

Get order for sitter. Justified due to multiple falls and negative workups.

Get family to sit an hour at a time. Must have boss' permission for this or you will get fired!!!!!

Get Neuro consult.

Put him on a mattress on the floor. Again, get order.

Tell your manager what you've told us. The manager gives not a dam# about how hard it is to do your other work while also sitting on this patient. All of you need to go to the boss together. Take the pt with you so he doesn't fall in your absence, LOL.

Lev, MSN, RN, NP · Dec 28, 2015

Sounds drug induced. Is this patient on any psych meds?

Is the family poisoning him? Ok sort of joking about that one.

Have they checked his carotids?

Sounds like he needs a hospital trip.

CrunchRN, ADN, RN · Dec 30, 2015

Med review for sure.