Crisis Intervention and Safety Planning for the Adult\/Geriatric Patient
\nMr. Z, age 68, is a new resident of a long-term care facility in the Alzheimer Unit. He was
\nrecently taken by his family for evaluation in the Emergency Department after he was found to
\nbe confused, physically aggressive with family members, threatening to burn the house down,
\nand paranoid that someone was trying to kill him. The medical work up in the ED was
\nunremarkable. He was discharged from the ED and since arriving at the facility, he has been
\nverbally aggressive with staff, depressed, throwing food, wanders around, and tries to leave. He
\ndoes not answer most questions when asked by staff and appears agitated. Psychiatry is
\nconsulted for management of his behavioral and psychological symptoms.
\nMedical History: Diagnosed with Alzheimer\u2019s Disease 2 years ago (diagnosed based on
\nsymptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)
\nSocial History: Former smoker 1\/2 pack per day x 20 years, no substance abuse. ETOH 2-3
\ndrinks on the weekends x 10 years. Married. Previously employed as accountant
\nFamily History: No history of dementia or mental health disorders. Mother deceased from colon
\ncancer. Father deceased from MI. Son is 31 and healthy.
\nMedications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS
\nAllergies: NKDA
\nPhysical Exam Notes
\nConstitutional: Appears agitated. Not cooperative. Speech noted is rapid and confused.
\nInattentive and distracted. Appears slightly hyperactive. Pacing hallways at times.
\nHead: Normocephalic, atraumatic
\nCardiac: RRR, no murmurs noted
\nLungs: CTA A\/P
\nAbdomen: BS x active x 4, soft\/non-tender, LBM 2 days ago
\nMusculoskeletal: Moves all extremities, abnormal\/unsteady gait
\nNeuro: Cranial nerves appear grossly intact but patient not cooperative enough for complete
\ntesting. DTRs 1+ symmetric. Disoriented to place and time. Is able to state his name. Unable to
\ncomplete MMSE.
\nVitals: T: 98.8, P 88, R 18, BP 132\/78
\nPlease follow directions and answer the questions outlined in the Assignment prompt
\nRead the case study located in the reading document.
\nComplete a SOAP Note on the patient. (In your SOAP note: Give an example of documentation
\nfor the PMHNP provider; (include prescription details as well as instructions for staff to give
\nmedication and monitor patient))
\nIn your SOAP note, design a treatment plan that includes PRN medications in case the patient
\ncontinues to be agitated.
\nAnswer the questions listed below:
\n\u2022 What medications would you prescribe? Why?
\n\u2022 What doses?
\n\u2022 Would you have these listed as standing orders for the nursing home staff or would you
\nwant to be notified before given to verify and determine need?
\n\u2022 Would you want to visually see the patient before having the medications given?
\n\u2022 What monitoring would need to be provided after medication is given?
\n\u2022 What documentation would need to be provided and how often for the medication to be
\ncontinued?
\n\u2022 Would the medication be considered chemical restraints? Why or Why not?<\/p>\n
_____________________________-
\nSOAP Note:<\/p>\n
Subjective:
\nMr. Z, a 68-year-old male with a diagnosis of Alzheimer’s disease, was recently admitted to the long-term care facility due to escalating behavioral and psychological symptoms. His family reported episodes of confusion, physical aggression, threats, paranoia, and depressive symptoms. The patient has been verbally aggressive with staff, displayed agitated behavior, and exhibited signs of restlessness, such as wandering and attempts to leave. He appears to be experiencing significant distress.<\/p>\n
Objective:<\/p>\n
General Appearance: Mr. Z appears agitated, uncooperative, and exhibits rapid and confused speech. He is inattentive, distracted, and displays hyperactive behavior, including pacing in the hallways.
\nHead: Normocephalic and atraumatic.
\nCardiac: Regular rate and rhythm, with no murmurs noted.
\nLungs: Clear to auscultation bilaterally.
\nAbdomen: Bowel sounds are present and normal. The abdomen is soft and non-tender.
\nMusculoskeletal: Mr. Z moves all extremities, but his gait is abnormal and unsteady.
\nNeurological: Cranial nerves appear grossly intact, but the patient’s level of cooperation limits a comprehensive assessment. Deep tendon reflexes are 1+ and symmetric. He is disoriented to place and time and unable to complete the Mini-Mental State Examination (MMSE).
\nVitals: Temperature 98.8\u00b0F, pulse rate 88 bpm, respiratory rate 18 breaths per minute, blood pressure 132\/78 mmHg.
\nAssessment:
\nMr. Z is a geriatric patient with a diagnosis of Alzheimer’s disease, presenting with escalating behavioral and psychological symptoms, including agitation, aggression, restlessness, depression, and paranoia. These symptoms are likely related to his underlying neurodegenerative condition.<\/p>\n
Plan:<\/p>\n
Medications:<\/p>\n
Continue current medications:
\nDonepezil 5 mg PO HS: Continue to support cognitive function.
\nPrazosin 1 mg PO HS: Continue for management of nightmares and sleep disturbances.
\nCrestor 20 mg PO at HS: Continue for hyperlipidemia management.
\nInitiate PRN medications for agitation:
\nLorazepam 0.5 mg PO\/SL\/IM PRN agitation\/anxiety, not to exceed 2 mg in 24 hours: This benzodiazepine can provide short-term relief from acute agitation or anxiety.
\nHaloperidol 0.5 mg PO\/IM PRN severe agitation\/hostility, not to exceed 5 mg in 24 hours: This antipsychotic can help manage severe agitation or hostility.
\nMedication Instructions for Staff:<\/p>\n
Lorazepam: Administer 0.5 mg PO\/SL\/IM PRN for agitation\/anxiety, not exceeding a total of 2 mg within 24 hours. Monitor for sedation and respiratory depression.
\nHaloperidol: Administer 0.5 mg PO\/IM PRN for severe agitation\/hostility, not exceeding a total of 5 mg within 24 hours. Monitor for extrapyramidal symptoms and sedation.
\nTreatment Plan:<\/p>\n
Non-pharmacological interventions: Implement environmental modifications, including visual cues, familiar objects, and a structured routine. Offer sensory stimulation and engage in calming activities. Provide regular reassurance and support.
\nBehavioral interventions: Use redirection techniques, provide validation and empathy, and ensure a calm and supportive care environment. Maintain a consistent caregiver approach and communicate effectively.
\nRegular psychiatric follow-up: Assess response to treatment, monitor for adverse effects, and adjust the treatment plan as needed.
\nAnswering the additional questions:<\/p>\n
Medications prescribed:
\nMedications prescribed:<\/p>\n
Donepezil 5 mg PO HS: This medication is a cholinesterase inhibitor used for the treatment of Alzheimer’s disease. It helps to improve cognitive function and delay the progression of symptoms associated with the disease.<\/p>\n
Prazosin 1 mg PO HS: Prazosin is an alpha-1 adrenergic antagonist primarily used for the treatment of hypertension. In this case, it is prescribed to manage nightmares and sleep disturbances, which are common in patients with Alzheimer’s disease.<\/p>\n
Crestor 20 mg PO at HS: Crestor is a statin medication used for the management of hyperlipidemia. It helps to lower cholesterol levels and reduce the risk of cardiovascular events.<\/p>\n
PRN Medications for Agitation:<\/p>\n
Lorazepam 0.5 mg PO\/SL\/IM PRN agitation\/anxiety, not to exceed 2 mg in 24 hours: Lorazepam is a benzodiazepine that can provide short-term relief from acute agitation or anxiety. It has sedative and anxiolytic properties.<\/p>\n
Haloperidol 0.5 mg PO\/IM PRN severe agitation\/hostility, not to exceed 5 mg in 24 hours: Haloperidol is an antipsychotic medication used for the management of severe agitation or hostility. It helps to regulate behavior and reduce symptoms of aggression.<\/p>\n
Dosing instructions:
\nThe doses mentioned above are based on standard starting doses for the respective medications. However, individual patient factors such as renal or hepatic function, response to treatment, and tolerability should be considered. The prescribed doses may need to be adjusted based on clinical judgment and ongoing assessment of the patient’s condition.<\/p>\n
Regarding the remaining questions:<\/p>\n
Standing orders or notification:
\nThe PRN medications (lorazepam and haloperidol) should be listed as standing orders for the nursing home staff. Staff should follow the prescribed dosage and administration instructions when the need arises. However, it is important to document the administration and notify the PMHNP provider to verify and determine the ongoing need for these medications.<\/p>\n
Visual assessment:
\nIdeally, it is recommended to visually assess the patient before administering the PRN medications to ensure the appropriateness of their use. Visual assessment allows for an evaluation of the patient’s current state and level of agitation, which can inform the decision to administer medication.<\/p>\n
Monitoring after medication administration:
\nAfter the administration of PRN medications, staff should closely monitor the patient for any adverse effects, changes in behavior, sedation, or respiratory depression. Vital signs, including blood pressure, heart rate, and respiratory rate, should be monitored periodically. Staff should document any observations or changes in the patient’s condition.<\/p>\n
Documentation frequency for medication continuation:
\nDocumentation should be provided after each administration of the PRN medications, including the time of administration, dosage given, route of administration, and the patient’s response. The frequency of documentation should align with the facility’s protocols, but it is recommended to document at least once during each shift or as needed based on the patient’s condition.<\/p>\n
Consideration of medication as chemical restraints:
\nThe PRN medications (lorazepam and haloperidol) should not be considered as chemical restraints in this case. Chemical restraints refer to the inappropriate or excessive use of medication to control or restrict a patient’s behavior without proper clinical justification. In this case, the medications are prescribed to manage severe agitation, hostility, and anxiety, which can significantly impact the patient’s safety and well-being. The use of these medications is based on a clinical assessment and the need for symptom management in a controlled and therapeutic manner.<\/p>\n","protected":false},"excerpt":{"rendered":"
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