You Do the Charting!
2013 is the year we quit talking and start doing. If you are bold enough. you could be the proud owner of a Haydel Consulting Services flash drive. Be the envy of your friends with this ultra sophisticated, data base storage device that has been proven secure and reliable and goes where you go. Better than a cloud drive, the HCS drive doesn’t rain, snow or block your sunshine. Mobile storage for mobile nurses! All you have to do is attempt the documentation challenge presented below and enter your response in the comments section.
Challenge: Consider the following information and write a brief but thorough narrative describing your care. Your vital signs and assessment are performed and documented.
You are on call on a Saturday evening when a physician calls you about a patient. You have never seen this patient but open up your computer and see that the patient is a 78 year old female with diabetes. Secondary diagnoses include congestive heart failure, kidney disease and Alzheimer’s Disease.
The physician is concerned because the patient’s daughter called and said her mother was ‘acting out really bad’. He wants a blood sugar and lab done to ensure her lytes are in range. He also wants to know if she may be hypoxic and asks you to weigh the patient and get a pulse ox reading.
Your assessment is unremarkable. Her fingerstick blood sugar after supper was 162. Her pulse ox is 99 and her weight is recorded at one pound less than the prior week. Vitals are good and the patient appears to be in her usual state of health other than the behavioral disturbances. You ask the daughter what prompted her to call the MD and she reported that her Mother did fine all day. She was confused but pleasant and content. Her mother listened to music and folded a laundry basket of dish towels while the daughter cooked for a family gathering later in the week.
At about 6:30, the patient began showing signs of agitation. Nothing seemed to work to quiet her anxiety. The daughter gave her some xanax as ordered and tried to reason with her mother. Twice the daughter had to go outside and bring her mother back indoors. The daughter is genuinely afraid she will have to put her mother in a home.
So, you’ve drawn the lab and performed the assessment. What else might help this patient and her daughter? How do you document it?
The winner will be announced a week from Friday. That means that if you have case conference or staff meeting between now and then, you can all practice ten days in a row. There is no limit to the number of entries but they all must be original. The grand prize will be chosen from all entries so it really doesn’t matter if you can’t chart a skill to save your life. You can still win and after next Friday, you will know how to document at least one skill.
Not sure if this is exactly what you wanted but here goes.
78 y/o white female /w history of DM, CHF, CKD, Alzheimer’s Disease. Alert, oriented to name and place, but according to daughter, began to wander earlier in the evening and appeared anxious. (I never use the word confused, was told it didn’t have any meaning in nursing school, and I stick to it. I describe orientation, behavior, hallucinations, etc, but never say that someone is confused.)
VSS (you didn’t give numbers) BS 162 after dinner, Pulse ox 99 on RA, weight (you didn’t give it, just that it was 1 lb less, so can’t chart weight) shows no gain. Lung sounds not documented so cannot comment.
Venipuncture performed, LAC, 1st attempt for BMP, will take to xxx lab (assuming you really have a lab you can take it to on a Saturday night, many of us don’t anymore.)
Assessed daughter’s knowledge of Alzheimer’s disease progression, educated on changes she’s witnessed and others that may come, including increased wandering, change in appetite, decrease in orientation and that she may forget family members. Daughter verbalized she is ‘afraid she will have to put her mother in a home’. Educated daughter in specialized placement for people with Alzheimer’s and Dementia. Asked if she needed help with resources and planning, she said yes.
Informed her I will call MD in AM and request order for MSW for long term planning, dementia placement options.
Daughter verbalized understanding and willingness to discuss needs with MSW.
Plan: Follow up with daughter tomorrow via phone to see how the rest of the night went.
How do you respond to OASIS M1710? “When confused (reported or observed within the past 14 days) NOC Outcomes Related to Acute Confusion: Moorhead, S., Johnson, M., & Maas,, M. (2004) are a response to “Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep-wake cycle.” So, yes, Elizabeth, there is a Santa Claus and a definition for confusion.
Check for UTI ……..
the patient is just sundowning , you dont need to do anything but reassure the daughter .. now i want one of those flash drives
Don’t forget your disclaimer in small print….”Haydel Consulting Services are not responsible for HIPPA violations resulting from use of this jump drive to store sensitive information on home health patients.” 🙂
Visit performed and assessment completed on patient who per the daughter is exhibiting behavioral disturbanes. Physical assessment unremarkable (not to repeat what was already written). After listening to the description of her mother’s behavior it appears that the patient is experiencing sundowning, a behavior that is typical to Alzheimer’s disease. Caregiver explained “I am afraid that I will have to put my mother in a home”. Support was provided to the patient’s daughter at this time. The suggestion of different types of activity/ likes or distraction for the evening hours was discussed. The daughter verbalized that her mother always liked to clean up after dinner and dry the dishes. “I will give her nonbreakable items to dry so that she feels as though she is helping me out after dinner”. According to the daughter the patient has not visited with her PCP since this behavior has increased. Xanax is what is ordered now, but maybe another medication would be beneficial. A medication reconciliation was performed since the patient has seen other healthcare providers in the last month. The daughter agreed to schedule and appointment with the PCP. The discussion also took place regarding a sitter for the patient in the evening/ night time hours so that the daughter can be productive and get some rest and not worry that her mom will wander out of the home. The suggestion of special locks for the doors was also made. The daughter agreed. Financially the private help (sitter) would be difficult according to the daughter. Call placed to the social worker on call who made an appointment to visit witht the patient and daughter early next week. Safety for the patient was discussed. As the daughter does realize that her mom is at a higher risk of getting lost, falling or hurting herself. A fall risk assessment was performed which did result in a higher risk level for falls then in the past. At this point in the visit the daughter did make the comment that ” As much as I am afraid to put my mom in a home it might just be the safest place for her. I can see that now”. Emotional support provided to the daughter. Call placed to the MD to increase the Xanax for the evening dose. Order was obtained and a dose administered to the patient. Patient was content with sitting in the TV room flipping through multiple magazines 20 min after the Xanax was administered. Visit scheduled tomorrow due to the medication increase and continued support for the daughter. Call placed to the social worker after home visit was made to discuss the plan of care.
Patient agitated on arrival pacing in home. Oriented to surrounding and reason for SNV. Head to Toe assessment completed. VP procedure explained to pt/cg.BMP and glucose drawn from left ac x 1 attempt, pressure held x 3 minutes with no bleeding or bruising at VP site. Pt toletated procedure well. RBS from VP sample 162. pt’s normal range 70-110 after pm meal.
CG states the agitation has gotten worse over the past few days. HR regular with no gallop, no edema, lungs clear. Voiding per diaper with not noted odor or discharge.
CG instructed to monitor urinary status for s/s of UTI ie temp >100.5,urinary odor or discharge.
CG instructed pt’s with demenita type diseases can have behavior changes in the evening called Sundowner’s syndrome. Keep pt on rountine, monitor diet for sugar and caffeine and keep room well lite in the pm.
SN to follow up after lab results received. SN to revisit in 2 days to assess behavior status.
All appropriate documentation, including assessment findings, vital signs, & lab draw have been recorded. Even though VS are good and all seems WNL, we still don’t have her lab results back. Until labs are available, (I included a U/A), my first task would be to perform a Safety Risk Assessment including Fall Risk. Obviously, wandering, would be #1on the list, and I would teach/instruct the caregiver on ways she can “Hazard-proof” the house, such as night-latches, removing small furniture or items patient might trip over and run to Wal-Mart and buy a room monitor to put by her bedside and next to patient’s bed. Any other safety issues identified would be addressed at that time. Secondly, I would perform a Needs Assessment. What does this patient and her caregiver need after safety has been addressed? She is probably “Sundowning.” Determine what the patient enjoys or enjoyed doing prior to her dementia. “Unfold” the dishtowels and redirect the patient. “These towels need to be folded. Can you help me with that?” The patient may fold towels until she falls asleep if necessary. After the needs assessment is complete, instruct the caregiver on activities that may be appropriate according to the findings. For example: if the patient took art classes several years ago; drag out the easle and paint. If she loved semi-classical music in the past; set the radio on an appropriate station. Next step is to perform a Knowledge-base assessment: Ask the caregiver, “What do you know about your mother’s Alzheimer’s?” Based on this assessment, education appropriate to the responses given would be initiated. Examples would be: Explanation of “Sundowning” and interventions to respond. Ask if the caregiver would like to speak to a Social Worker to go over all the options available for the situation. If so, set that up the following day. Ask if there are any other questions or concerns. Next step would be to inform the physician of all findings and interventions to inquire if he/she would like to see the patient in the office for evaluation and perhaps modify her medication regimen. Explain to the caregiver and the patient, that when the lab results are available to the physician, a determination will be made as to the next steps to take. As always, encourage the caregiver to call the nurse on call first if there are any concerns.
Well Juli, you going to reply?