Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Patient restraint, Refusal of treatment by patient, Renal replacement therapy, Somnolence, Unresponsive to stimuli
Clinical narrative: (R.N.)  REGISTERED NURSE Specialty:  GENERAL, OTHER Case Management    Signed  Signed    Case Management Note 81 Y male with COVID-19 DISEASE   Pertinent Medical Hx:    HTN (HYPERTENSION) HYPERLIPIDEMIA GOUT RIGHT OPEN ANGLE GLAUCOMA, MODERATE STAGE DM 2 W CKD STAGE 3A (GFR 45-59) MULTIFACTORIAL ENCEPHALOPATHY CAUSE OF INJURY, FALL MAJOR VASCULAR NEUROCOGNITIVE DISORDER, MODERATE, WO BEHAVIORAL DISTURBANCE FALL RISK COVID-19 DISEASE FEVER LEFT OPEN ANGLE GLAUCOMA, SEVERE STAGE DM 2 DM 2 W ERECTILE DYSFUNCTION DM 2 W PERIPHERAL NEUROPATHY MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION HYPERPARATHYROIDISM, UNSPECIFIED DM 2 W CATARACT DM 2 W GLAUCOMA OBESITY. ARTHROPATHY, FACET, W/BACK PAIN. ARTHRITIS, DEGENERATIVE, LOWER BACK. SPINAL STENOSIS BPH (BENIGN PROSTATIC HYPERPLASIA) HX OF ADENOMATOUS COLONIC POLYPS ARTHRITIS OF BILAT HANDS SKIN LESION HYPERCALCEMIA BUTTOCK PAIN   BASELINE SOCIAL/FUNCTIONAL ASSESSMENT:  Baseline Mental Status  Lives With Dwelling Type  MENTAL STATUS: Confused spouse      in single level home, no steps to entrance     Support at Home Caregiver, family and/or social support available to assist patient at discharge: Family Member: Wife MSW Consult needs identified: None at this time MSW consult order placed: No    Prior Level Of Function DME Owned Patient receiving OP services (HH, Hospice, Home infusion pharmacy, etc)      some assistance with ADLs (medication management, transporting , appointments , cooking ).Does not drive (Wife for transportation)  ambulatory and uses cane Cane and glucometer no   Agency name/contact info: NA    Dialysis     IP Readmission  <30 Days ? Best contact person  or DDM HD: no no   If yes, IP admission with same dx: No  Relationship: Wife    Non-facility patient?:  no Does patient fill meds at specific Pharmacy?: yes   INPATIENT/OBS CLINICAL REVIEW  8/4/2023 Alb 3.5. VSS, afebrile, confused on vest restraint. COVID precaution observed. Pt on  IV Remdesivir, IV LR, IV ofirmev. Spoke with wife on the phone. Wife denied any DC concern at this time. Wife in agreement with current treatment plan. RN  8/4/2023 11:44 AM 8/5/2023 VSS, Afebrile, Pt still on vest and B wrist restraints. COVID precaution observed. On IV Remdisiver, IV NS at 75ml/hr, IM Zyprexa given for delirium. Poor PO intake noted due to pt refusing meals and meds. Per HBS, not medically stable to DC today. Spoke with wife on the phone and wife in agreement with current treatment plan. RN  8/5/2023 4:57 PM 08/06/2023 OBS Enhanced respiratory and contact isolation observed.  on cont IVF d5ns at 75ml/hr,  remdesivir iv, per nursing pt continues to refused most medication, cares. zyprexa im given today. Afebrile, bp 148/83, 97-99% sats on RA. Pt ate 55% breakfast. UOP 1,440ml/24 hr. Per HBS, not medically stable for DC today. Spoke with wife via phone, updated with the POC, acknowledged understanding. RN  8/6/2023 2:19 PM 8/7/23:  Pt remains on covid iso.  IVF & IV remdesivir cont.  Per bedside RN, pt has been sleepy today since his RRT early this am.  Per bedside RN, pt was found unresponsive, CT head done, which was neg for anything acute.  Per HBS RRT note, possible medication side effect.  VSS & pt remains on RA.  RN  8/7/2023 11:56 AM 8/8/23 Continue COVID isolation. Pt remains confused and agitated, often refusing care.  Continue IVF, IV RDV , Zyprexa PRN, cultures and sensitives pending, monitor labs, monitor mental status/delirum rounds ongoing, MSW consult w/husband for cg support vs placement options. RN  8/8/2023 10:09 AM 8/9/23 Continue COVID iso. Pt continues to be confused and agitated/ restraints for safety. Continue IVF, last day of IV RDV IV x 5 days, Zyprexa and Seroquel PO OTC, psychiatry/deliurm rounds ongoing. Called wife who stated she is still very weak with COVID herself, states she is the sole cg of pt and that it has been harder to care for pt d/t to her own illness currently, however, she believes she can handle caring for pt once she regains her own strength back. Per wife, there are 4 local children but she cannot bother them because they work. Granddaughter has 4 young children of her own and wife states its too hard for her to help them too. Routed MSW consult for cg support vs possible memory care if wife interested as pt's dementia is progressing.. Dispo pending improved agitation and PO intake.  RN  8/9/2023 10:19 AM  ADDENDUM: Spoke to granddaughter at bedside. Per Granddaughter, pt has a lot of support at home and there will be no problem with care, however, they would still like cg resources for the future should they need some extra help. RN  8/9/2023 11:49 AM 08/10/2023 Covid isolation observed. Per nursing, pt remains confused, agitated. On bilateral mittens and vest restraint for safety.  New iv fluid ordered today D5 1/2 NS at 75ml/hr. zyprexa oral held today-sedated per nursing. Called pt wife number, granddaughter answered the call, per agreed to give information to pt granddaughter, RN CM updated both of them about the treatment plan, dispo pending agitation, po intake, restraint. Denies any other needs at this time. RN  8/10/2023 3:43 PM 08/11/2023 Covid isolation observed. Per nursing had episode of hallucinating at times, seeing spider in the ceiling. Remain on vest restraint. Pt tried to get out of bed. Spoke with pt wife via phone, updated with the treatment plan, barriers to discharge due to delirium. RN  8/11/2023 6:22 PM 8/12/23:  Pt remains confused and delirious.  WBC 3.6.  Continues on Covid isolation, posey vest, and IV potassium phosphate.  RN  8/12/2023 3:44 PM 8/13/23 Soft wrist restraints and vest, Zyprexa IM, per ID "This patient meets county public health and NCAL KP consensus guidelines for de-isolation."  RN  8/13/2023 1:29 PM 8/14/23:  RRT called for patient, was in chair when he became unresponsive after working with PT.  Pt transferred to chair.  And CT head ordered.  RN@1344. 8/15/23:  Pt is agitated today, Physical therapy on hold today due to elevated heart rate while lying down, and agitation.  Plan is to cont to titrate Zyprexa.  RN@1339.   08/16/2023: Per AM RN pt agitated overnight and early this AM, continues with vest restraint. Rapid response this afternoon for decreased responsiveness. Continues to require zyprexa medication adjustments per HBS, pt not medically stable for d/c today. CM met with pt at bedside during AM rounds briefly, pt calm. CM called pt's spouse to discuss POC, anticipated d/c plan, d/c transport, pt's spouse states has spoken with MSW regarding long term plan and wants to visit pt "soon", pt's spouse states no questions or concerns at this time, however declined to speak more with this CM regarding the POC and d/c plan. RN  8/16/2023 1:58 PM   08/17/2023: Per AM RN pt agitated overnight and early this AM, continues with vest restraint, PT attempted, on delirium rounding team. Per HBS pt not medically stable for d/c at this time. RN  8/17/2023 1:52 PM   ANTICIPATED DISCHARGE PLAN SNF vs HHPT w/cgs vs memory care?   Case Manager to follow up:   -off restraints x 24hrs, tolerates medication adjustments -improved mentation to baseline ( Per wife, hx of dementia, confused most of the time) -PO intake improved -Order FWW and deliver at bedside prior to DC. -HHPT vs SNF -MSW consult-wife cares for pt alone and interested in cg support, maybe placement? 4 Children local but work and no numbers to reach them/ Granddaugher has 4 children and too busy to help;per MSW "Family reports pt has the support of several family members - wife, two adult dtrs and two adult grandchildren lives with pt, and will be assisting with his care needs which they already have been doing. Granddtr who lives about 5 minutes away, and has also been helping/and will continue to assist with pt's care needs. They accepted the Community resource list "    DME  -Recommended DME Needs: FWW   -DME Copay: No Copay      DME item      Deliver To: (Home, Hospital Room, B&C, etc)     Order date   Delivery date FWW room                COC RNCM handout provided to patient: Yes, Date:8/4/2023 **Best Practice insurance Post Discharge Meal referral completed: Yes  Date: 8/12/2023** MOON letter: Yes, Date:8/4/2023 IM letter last given: 08/16/23 Transitional Risk Score: Low    Anticipated Transportation for DC: Wife vs BLS? MD  0.0 $ RN  8/17/2023 1:52 PM     Note Details  Author (R.N.) File Time 8/17/2023  1:53 PM Author Type REGISTERED NURSE Status Signed Last Editor (R.N.) Specialty GENERAL, OTHER  Admit Date 8/3/2023  ED to Hosp-Admission (Current) on 8/3/2023  ED to Hosp-Admission (Current) on 8/3/2023   Detailed Report  Note shared with patient Care Timeline  08/04   Admitted from ED (Observation) 0027 08/07   Rapid Response    Admitted 1223