Patient experiencing hallucinations...no new orders!

[PortCity_RN]

I have been caring for an older adult female for the last two weeks in a SNF. She refuses to get out of bed due to lower back pain related to a spinal surgery with complications. She has always been A+Ox3, up until recently. She was trying to get out of bed in the middle of the night (by herself) calling help because she needed to "get out of here" she began seeing a litter of kittens in her room, and her husband (deceased) sleeping in a chair in her room. These are just a few of her hallucinations, she is also experiencing delusions thinking that the nursing staff is giving her "poison pills" to make her sleep...which is not the case.

I took a urine sample via straight cath after talking with the MD because we wanted to r/o a UTI...it came back negative. I let the doc know, and the doc doesn't want any new orders. She's been getting progressively worse, and still no new orders! The patient was recently taken off a few antidepressants, and started on Cymbalta which can cause hyponatremia (so I'm thinking lets just check her electrolytes) but they drug itself can also cause hallucinations in some patients! What do you all think I should do to try and get the doctor to look into it further? Do you have any other ideas of what may be the cause of her hallucinations. Her other medications include a BB for htn, vitamins, tylenol and ultram for pain. Thanks for your help! I'm a new nurse and it is bothering me that we still haven't determined the cause of mental status change

[Meriwhen, ASN, BSN, MSN, RN]

Tramadol (Ultram) can also cause hallucinations.

Is she hydrated?

[Anna Flaxis, BSN, RN]

Keep at it. This is a change in condition, and just because a UTI has been ruled out doesn't mean it's time to stop looking for the cause.

[PortCity_RN]

I didn't know tramadol could also cause hallucinations..very interesting, that could definitely be playing into this because it is scheduled as well as prn. She probably gets close to 300-400mg in a 24 hour period. I will have to do more research on that. And she hasn't been taking very many fluids, she will drink a little to take her medications. But has been refusing most of her meals including beverages...I will keep on trying! I hope she gets well soon. Thanks for your input!