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Dementia/Physical Aggression

Unfolding Reasoning

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History of Present Problem

Ron Jackson is an 87-year-old Caucasian male with a medical history of hypertension and Alzheimer’s disease who was brought to the emergency department (ED) by paramedics for evaluation of hallucinations, increased agitation, and aggressive behavior toward Shirley, his elderly wife.

His daughter was visiting and witnessed Ron becoming angry for no apparent reason, telling Shirley she had to leave the house. He then pushed her, causing her to fall to the ground.

Ron has become progressively more agitated the past year and was started on quetiapine. Shirley confirms that Ron has been more verbally abusive the past week, believing that she divorced him and that she needs to get out of the house, but no physical aggression took place until today.

Ron currently complains of a headache and insists that he got this because “the Koreans beat me up real good in the ambulance!”

What data is RELEVANT and Why is it clinically significant?

2

Personal/Social History

Ron lives at home with Shirley, his wife of 62 years and has three children.

Ron is a Korean War veteran who saw active duty and is a retired salesman.

Because his wife has been struggling to care for him, his family is in the process of making arrangements for him to reside at a local memory care unit.

What data is RELEVANT and Why is it clinically significant?

3

Relationship of PMH & Current Meds

Past Medical History (PMH):Home Meds:
Hyperlipidemia Hypertension Alzheimer’s disease Agitation/Delusions  Donepezil 10 mg PO at HS Aspirin 325 mg PO daily Memantine 10 mg PO BID Simvastatin 20 mg PO HS Triamterene-HCTZ 75-50 mg PO daily Quetiapine 50 mg PO BID

2. Is there a relationship between any problem in his past medical history and the present problem? If so, describe.

Is there a relationship between any problem in his past medical history and the present problem? If so, describe.

4

Vital Signs

Current VS:P-Q-R-S-T Pain Assessment:
T: 98.0 F/36.7 C (oral)Provoking/ Palliative:“Those Koreans banged my head in the ambulance.”
P: 78 (regular)Quality:“That’s a stupid question!”
R: 18 (regular)Region/ Radiation:“My head hurts all over!”
BP: 148/90Severity:“It just hurts!”
O2 sat: 98% room airTiming:“All the time.”

What data is RELEVANT and Why is it clinically significant?

5

Initial Assessment: Priority Body System/Assessments

Current Assessment:
GENERAL APPEARANCE:Thin elderly male, appears stated age, sitting upright on stretcher, appears tense
RESP:Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort
CARDIAC:Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk capillary refill
NEURO:Oriented to person only, denies hallucinations
GI:Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants
GU:Voiding without difficulty, urine clear/yellow
SKIN:Skin integrity intact, skin turgor elastic, no tenting present

6

Mental Status Examination

Mental Status Examination (MSE):
APPEARANCE:Disheveled appearance; cooperative at times, other times irritable
MOTOR BEHAVIOR:Variable; at times pacing and agitated; at other times sits quietly
SPEECH:Able to understand what the patient is saying
MOOD:Variable; quiet and calm with sudden episodes of anger, anxiety, and irritability
AFFECT:Variable: looks calm, then may suddenly appear angry
THOUGHT PROCESS:Able to understand what the patient is saying
THOUGHT CONTENT:Paranoid and persecutory delusions/ideation; “Koreans” are harming him; delusions “believes wife divorced him”
PERCEPTION:Denies hallucinations
INSIGHT:Grossly impaired; attributes H/A to an attack by “Koreans”; not aware of illness or reason for ER visit
JUDGMENT:Grossly impaired
COGNITION:Oriented to person only. Significant short- and long-term memory deficits
SUICIDAL/ HOMICIDAL:High risk for physical aggression toward others; recently assaultive toward wife; unable to assess suicide ideation at this time

What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

7

Diagnostic Data

Complete Blood Count (CBC)
 WBCHGBPLTs% NeutsBands
Current:5.814.5154690
Last Adm:6.514.2188750
Basic Metabolic Panel (BMP)
 NaKGluc.Creat. 
Current:1423.31141.3 
Last Adm:1443.51211.2 
Urinalysis + UA Micro
 Color:Clarity:Sp. Gr.ProteinNitriteLETRBCsWBCsBacteriaEpithelial
Current:YellowClear1.020NegNegNegNegNegNegNone
Last Adm:YellowClear1.020NegNegNegNegNegNegNone

What data is RELEVANT and Why is it clinically significant?

8

Put it All Together!

Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most thoroughly based on the primary/priority concern?

What’s the Problem?What’s Causing the Problem? (explain pathophysiology in OWN words)PRIORITY Body System to Assess:
     

Collaborative Care: Medical Management

Medical Management:Rationale:Expected Outcome:
Violence precautions   Continue home medications Lorazepam 0.5 mg. po PRN every 4 hours x 24 hours    Acetaminophen 2 tabs (325 mg) every 4 hours PRN pain. Not to exceed 4000 mg in 24 hours   Consult: Mental Health/Behavioral Health professional   Referral to social work for help with memory care facility placement after d/c from hospital  

Collaborative Care: Nursing

What nursing priority (ies) will guide your plan of care?

Nursing PRIORITY: 
PRIORITY Nursing Interventions:Rationale:Expected Outcome:
                 

Psychosocial Priorities

Psychosocial PRIORITIES:Addressing anxiety and stress as a new mother
PRIORITY Nursing Interventions:Rationale:Expected Outcome:
CARE/COMFORT: Caring/compassion as a nurse     Physical comfort measures    
EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: Rapport Trust Respect Genuineness Empathy                                  

Evaluation: Sixty Minutes Later…

You go into the patient’s room to re-evaluate his status.

He states to you, “There are people who want to get me!” Ron becomes agitated and looks you in the eye and angrily states, “Who the hell are you and what are you doing in my house!” You tell him that he is at the hospital and in a safe place. He replies, “I am at home and what the hell are you doing here!” He suddenly takes his right arm and attempts to punch you and narrowly misses your face…

What data is RELEVANT and must be interpreted as clinically significant by the nurse?

13

Status Improved? Modify?

Evaluation of Current Status:Modifications to Current Plan of Care:
    

Current Nursing Priorities

CURRENT Nursing PRIORITY:   
PRIORITY Nursing Interventions:Rationale:Expected Outcome:
                   

Use Reflection to Develop Clinical Judgment

What did you do well in this case study?What knowledge deficits did you identify?
        
What did you learn?How will you apply learning caring for future patients?
        

Use Reflection to Develop Clinical Judgment

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