Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Bradycardia, Confusional state, Hypotension, Syncope
Clinical narrative: Attestation signed by (M.D.) at 10/9/2023  6:15 PM   I was NOT present when pt was seen - history, exam and chart reviewed with GRN. We discussed the patient?s case, and I agree with note.   Per niece, patient mostly at baseline mental status.   May consider adding olanzapine 2.5mg q 12 prn severe agitation due to dementia or delirium.     Electronically signed by MD         Inpatient Multidisciplinary Delirium Consultation Hospital Day(s): 1   Initial Delirium Visit/Review:    Please note that this is not a formal consult but a recommendation and treatment plan for possible hospital delirium.    IDENTIFYING INFORMATION 87 Y female with PMH of atrial fibrillation on warfarin with goal INR 2-3, hypertension, hyperlipidemia, asthma, prediabetes, osteoporosis, GERD, dementia due to Alzheimer's, peripheral neuropathy, recent COVID-19 about 3 weeks ago, from memory care, who presents to ED on 10/8/2023  with episode of syncope at church today, found to be bradycardic and hypotensive.  Last mem clinic appointment on 10/29/21- reported. Previously worked as art teacher, moved julyj 2021.  Recent call to primary care physician in Sept indicates fam would like to move her due to cost.   Baseline cognitive function/behavior: Last Memory Clinic appt:10/29/21, lives in a memory care facility 9/2017 MOCA = 21/30 3/19/18 MOCA = 22/30 Sleep overnight:No sleep per doc flowsheet Tethers/lines: PIV  Potential Deliriogenic Medications:none Last BM:10/08/23 Last QTc:397 10/09/23   Interim Events: 10/9- Confused, attempted to get out of bed mult times, refused trazodone.  Posey vest restraint placed.  pulled IV out, bilat soft wrist restraints Did not get melatonin or trazodone as scheduled last night.   Rounding: Primary RN reports that the patient had been off vest and wrist restraints since 0800 and has been doing well off of them since.  During my visit she was calm and made good eye contact. When I asked her if a stone floats on water she said "well if it's soft it will float but if it's heavy it will sink so what do you think a stone will do on water?"  When I asked her the month or year she said "well don't you know?" and I couldn't get through much of the bCAM assessment because after every question asked, she would say "Why are you asking me? Is it for a study? For a book or a thesis? Are you checking if my brain is still working" she wouldn't answer questions appropriately.  Niece at bedside reports the patient's mental status is mostly at baseline. Plan for patient is to discharge today.      Recommendations: ? Medication recommendations as per Dr..  ? Continue to minimize deliriogenic medications if clinically appropriate   Nursing Recommendations: ? If the patient is becoming restless or agitated, address possible triggers such as pain, bowel and bladder related issues, overstimulation.  ? PRNS: If prn medications are used, please document behavior present and describe response to medication.  ? Monitor for side effects of antipsychotics if given (i.e. sedation, orthostatic hypotension).  ? If the patient is becoming agitated or resisting care, consider whether the care being provided is essential at that moment or can wait, consider trying again later if it will help patient calm down (i.e. taking routine vitals). ? Encourage family presence at bedside to provide reassurance, reorientation, and sense of familiarity ? Anticipate impulsivity and continue proactive rounding to meet toileting needs. Continue fall precautions. ? Minimize tethers as clinically appropriate.  ? Mobilize to maximal potential TID as safe and tolerated. OOB for meals as much as possible.  ? Promote sleep/ wake cycle with appropriate environment (open window shades in daytime, close in evening to help regulate sleep/wake cycle). Avoid excessive daytime sleeping. ? Continue to assess for and treat pain and consider nonverbal signs as appropriate (grimace, furrowed brow, moaning, restlessness) ? Continue to monitor oral intake, appetite, and continue aspiration precautions ? Continue to monitor bowel pattern ? Consider use of items in Activity Cart for sleep promotion and for daytime sensory and cognitive stimulation.   There are no FDA approved Rx to treat behavioral & psychiatric symptoms in dementia and delirium. Antipsychotics may provide sedation, reduce paranoia, and help regulate sleep-wake cycle, but are not approved for these indications & have potential risks & side effects. Atypical antipsychotics can exacerbate or induce the metabolic syndrome comprised of obesity, diabetes mellitus, dyslipemia, and are associated with increased risk of cerebrovascular accident and overall mortality in dementia patients. Typical antipsychotics can cause extrapyramidal side effects, hypotension, and occasionally anticholinergic toxicity with somatic symptoms & worsening confusion.        Cosigned by: (M.D.) at 10/9/2023  6:15 PM  Note Details  Author (R.N.) File Time 10/9/2023  6:15 PM Author Type REGISTERED NURSE Status Signed Last Editor (R.N.) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 10/8/2023  ED to Hosp-Admission (Discharged) on 10/8/2023  ED to Hosp-Admission (Discharged) on 10/8/2023   Revision History   Detailed Report  Note shared with patient Care Timeline  10/08   Admitted from ED (Observation) 2333 10/09   Discharged 1515