Chf/pneumonia and antipsychotics.

[TigerxLiLy]

What are your thoughts on this patient:

Admitted Med A to SNF with hospital Dx: pneumonia, uti. Hx of delusions on going with dementia(delusions were noted by psych Dr to not interfer with adls in hospital)

However,over the past 2 weeks- it was noted that resident was having a gradual increase in paranoia and agitation,in the beginning was easily redirected. Friday- I asker the nurses to watch her PO intake and to document on her sleep patterns (placed on documentation cue sheet for nurses to see as well as observing/assessing her respiratory status QD)..got back Monday..and of course only one person documented and it was generic crap. Yet some how over the weekend she got new haldol IM inj orders and risperdal orders due to refusing her meds (very short documentation about this in notes).

At 3pm today, I was informed by the therapy director that resident refused therapy x3 attempts. Went to go look at patient and try to get her to therapy myself. Entered room..and voila! Residents slumped in bed, resp 28, o2 sats 86, ronchi heard in bilateral lower lung bases,unproductive cough(yes. She woke up slightly to give a weak cough) lethargic and hard to hold head up, pulse 106, 150/82,98.4 temp.::Insert swear word::

Slapped O2 on her and got sats up to 93. No PRN neb txs so called MD with assessment.

Labs done today at 6am note BUN 15(N) and cr 0.7(N), Dx chf tho. Resident has not being eating except one meal a day and that at less then 25% per cnas,drinking supposedly adequately per cna reports...refusing medications which did include basic QOD. No increase in weight in 7 days. But physically looking at patient she looked dry when you pinched the skin at the chest and back of hand it tented.(but sometimes old people are like that...too). No edema noted except BLE 1+ which where present on admission and did not look worsened.

MD ordered news q4hrs x 7days,cxr,dcing haldol,holding risperdal x2 days,rocephin 1gm IMx1,and IV fluids NS@75cc/hr. I asked MD if 75 may be too fast with Dx CHF and current labs- said no.

Can someone explain the BUN/Cr and the MDs order for fluids ... Just to get a better understanding?I was thinking possibly resident was some how fluid overload despite I never heard crackles and she seemed dry.

[VANurse2010]

Based on the limited information here - sounds more like PNA that hasn't completely resolved. Maybe some oversedation from anti-psychotics thrown in - which, by the way, it is very inappropriate to give an older person all those anti-psychotics without a psychiatrist seeing the patient (I don't mean the acute care psychiatrist who wrote orders for the hospital).

[ixchel]

I think, if I'm understanding this correctly, with the BUN and creatinine being normal, and the evidence of dehydration (tenting) vs. overload (no additional edema or wet lungs), the fluids are necessary to ensure hydration.

[CapeCodMermaid, RN]

Based on the limited information here - sounds more like PNA that hasn't completely resolved. Maybe some oversedation from anti-psychotics thrown in - which, by the way, it is very inappropriate to give an older person all those anti-psychotics without a psychiatrist seeing the patient (I don't mean the acute care psychiatrist who wrote orders for the hospital).

Most facilities do NOT have psychiatrists who come in to assess the residents. We rely on the PCP and our psych services NP to recommend medications.

[VANurse2010]

Most facilities do NOT have psychiatrists who come in to assess the residents. We rely on the PCP and our psych services NP to recommend medications.

I believe you, but fortunately the LTC facilities I worked *did* have a geriatric psychiatrist who came and made rounds a few times per month. I would still question the appropriateness of a PCP prescribing hard core anti-psychotics for long term use.

[CapeCodMermaid, RN]

I am not a fan of most any kind of medication and think our residents take far too many. What 95 year old needs a statin and 5 vitamins? No one. BUT, I have residents with psychoses. They are in psychological pain....meds are the only things that work sometimes. Far better to give someone a smidge of risperdone than to watch them suffer needlessly.

[TigerxLiLy]

Her baseline status was thinking she was in the cia and was undercover and talking to her dead realities- wasn't combative at baseline... Didn't have any psych meds ordered.

When she started getting agitated,I kept telling staff to make sure it wasn't a medical issues causing this: pneumonia coming back? Uti?

They did a u/A and it was positive so pinned it on that.. But 2-3 days in nothing was changing.

I then asked the nurses to document on her PO intake and sleeping patterns (maybe she wasn't sleeping or was not eating and was hungry for agitiaton)

But I guess. When she kept refusing meds,instead of trying to do a physical assessment... They go for psych meds.