Posted: April 17th, 2015

Prompting questions

 

Prompting questions set 1

What actions should Mary Jo take immediately?

I believe Mary Jo should immediately remove the soft cuff restraints as he is somnolent due to the combination of lorazepam, haloperidol and oxazepam which had been given to him in the previous evening. He is obviously not at risk of climbing out of the bed when he is in this semi-conscious state.

I also believe Mary Jo should perform a pulse oximetry on Mr. Johns to assess his oxygen saturation levels. Mr. John’s respiratory rate is only 10 respirations per minute so he would almost certainly be compromised in this regard. It is important for Mary Jo to communicate her findings to the senior RN and contact the medical staff to arrange a MET review as soon as possible. The medical staff would almost certainly want to know Mr. John’s oxygen saturations when she makes the call to them.

It is obvious that Mr. Johns is dehydrated however Mary Jo must refrain from attempting to give him any fluids until he has been assessed by the MET staff. At this point, Mr. Johns is at risk of aspirating fluids due to a compromised swallowing reflex if she was to attempt to give him oral fluids until he was more awake.

It is extremely important for Mary Jo and the student to closely monitor Mr. Johns until the MET staff arrive to assess him.  There is an established view that patients whose conscious level has been compromised by medication should never be left unattended, even for a short time (Horsburgh 2004, p. 9). Mary Jo should document her findings in the notes as soon as safely possible to ensure that she meets her duty of care responsibilities and to ensure accuracy and timeliness in her documentation.

What are the best practice guidelines on restraint procedures? What risks must be considered?

Prior to using physical or chemical restraint on a patient it is considered best practice to consult the carer or legal representative of the person concerned (Peisah & Skladzien 2014, p 7). Emergency situations may arise whereby physical restraint needs to be applied immediately however contact with the carer should be made as soon as practically possible (Peisah & Skladzien 2014, p 7). Best practice and clinical guidelines recommend physical restraints should be used as a last resort (Burns et al., 2012 in Peisah & Skladzien 2014, p 12). Consideration should be given to the fact that the application of physical restraint hinders the person as little as possible and the least restrictive form of restraint is used (Peisah & Skladzien, 2014, p 12). The application of physical restraint should occur for the shortest time possible and there should be strict adherence to guidelines and procedures (Muir- Cochrane, Barkway & Nizette 2012, p 124).

There are risks or negative consequences in regards to the use of physical restraint which may include:

• Bruising or skin tears caused directly by the physical restraint
• Certain medical conditions may arise from being immobilized by the physical restraint such as respiratory complications, urinary incontinence, constipation and reduced cardiovascular output and endurance.
• The patient may also experience psychological distress by being restrained which could result in increasing their levels of agitation, fear, depression and anxiety.
• There is often a greater risk of injury if the restrained patient attempts to escape. (Peisah & Skladzien 2014, p 11-12).

What is the pharmacokinetics of haloperidol and of benzodiazepines? 

Haloperidol:

Haloperidol is a butyrophenone derivative with antipsychotic properties that has been considered particularly effective in the management of hyperactivity, agitation, and mania (RxMed, 2015).  Haloperidol is a typical or first generation antipsychotic and the mode of action is blockage of dopamine and 5-HT2A receptors within the central nervous system (Muir- Cochrane, Barkway & Nizette 2012, p 90).

Peak plasma levels of haloperidol occur within 2 to 6 hours of oral dosing and about 20 minutes after intramuscular administration (RxMed, 2015). The mean plasma (terminal elimination) half-life has been determined as 20.7 hours (RxMed, 2015).

Lower doses are recommended in elderly patients since they may be more sensitive to the drug (RxMed, 2015). Elderly or debilitated patients receiving the drug should be carefully observed for lethargy and a decreased sensation of thirst due to central inhibition which might lead to dehydration and reduced pulmonary ventilation and could result in complications, such as terminal bronchopneumonia (RxMed, 2015).

Since QT-prolongation has been observed during haloperidol treatment, it is advisable to be cautious in patients with QT-prolonging conditions (RxMed, 2015).  Mr. Johns was admitted to the ward for cardiac insufficiency for investigation so care needed to be taken when calculating a dosage of administration of haloperidol.

Recommended dosage for the elderly is 1-3 mg per day (MIMS 2009, p 115)

Benzodiazepines:

Benzodiazepines are effective in relieving the symptoms of anxiety and they also have sedative and effects (Usher, Foster & Bullock 2009, p 99). Benzodiazepines act on the GABA receptor complex within the central nervous system by binding to the receptor and enhancing the action of GABA when it interacts with receptor (Usher, Foster & Bullock 2009, p 101). Benzodiazepines  have very long elimination half-lives which can accumulate with chronic dosing and produce prolonged effects, especially in elderly or obese patients, those with liver disease, or with concurrent use of other drugs that compete for hepatic oxidation(RxMed, 2015).

Benzodiazepine use in the elderly can be problematic due to age-related changes in hepatic and renal function (Usher, Foster & Bullock 2009, p 106). Altered drug pharmacokinetics of the elderly can result in prolonged or increased drug effects (Usher, Foster & Bullock 2009, p 106). In general, dosages of benzodiazepines for elderly patients tend to be approximately one-third to one-half of the recommended dose for younger adults (RxMed, 2015).

What do you make of the night nurse’s decision not to call Mrs. Johns in?

I personally believe that this was a poor decision in respect to not asking Mrs. Johns to come into hospital. She is his primary carer and it would be highly likely that Mr. Johns would settle and be less anxious if she was able to sit with him.

What advice could be given to the student to avoid becoming injured?

I would advise the student to speak slowly and calmly to Mr. Johns. She should seek his permission before she attempts to perform any tasks. It would also be helpful to have Mrs. Johns at his bedside as her presence would almost certainly calm him. The student should be aware of any signs of aggression and ensure that she is out of his reach should he lash out at her. If Mr. Johns becomes aggressive, the student may find that he will settle down if she leaves the room for a short period of time.

What are the responsibilities of the nurse who was harmed and how will she be supported?

The nurse needs to document the incident in Mr. Johns’ clinical notes and also inform the Nurse Unit Manager (NUM) of the incident. She should also complete a Workcover form and be assessed by her local doctor or in the Emergency Department of the hospital. It would be appropriate for the NUM to offer the nurse some clinical supervision or access to the hospital-based counselling service.

What do you make of the assumptions the student is making?

She may be feeling anxious about caring for Mr. Johns as he had been aggressive to the night nurse. Rather than admitting to this, her claim that there were ‘more interesting cases’ would be a way to avoid being involved in the care of Mr. Johns. It is important for her to learn how to care for an individual with dementia as she is very likely to have to nurse an elderly person in the future.

Is it possible that Mr. Johns was just experiencing nightmares?

According to the Alzheimer’s Australia website, individuals with Alzheimer’s Dementia (AD) can experience sleeping problems due to a variety of different causes. One of those causes could be disturbing dreams but there are many other possible causes responsible for Mr. Johns being unsettled overnight.

References:

Alzheimer’s Australia: http://www.fightdementia.org.au Viewed 16 April 2015

Horsburgh, D 2004, ‘How, and when, can I restrain a patient?’ Postgraduate Medical Journal vol 80, pp.7–12. Retrieved on 15 April 2015

Mims Australia 2009, MIMS Issue No.2 2009, CMPMedica Australia, Sydney, NSW

Muir-Cochrane, E, Barkway, P & Nizette, D 2012, Mosby’s Pocketbook of Mental Health, Elsevier Australia, Sydney, NSW

Peisah, C & Skladzien E 2014, The Use of Restraints and Psychotropic Medications in People with Dementia: A report for Alzheimer’s Australia. Alzheimer’s Australia Inc. http://fightdementia.org.au. Retrieved on 15 April, 2015

RxMed (2015) viewed 16 April, 2015, http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20 (General%20Monographs-%20H)/HALDOL.html

Usher, K, Foster, K & Bullock, S 2009, Psychopharmacology for Health Professionals, Elsevier Australia, Sydney, NSW

 

Prompting questions set 2

What is your hypothesis as to what could account for Mr. Johns’ symptoms?

As Mary Jo had ruled out Mr. Johns having a fever or a urinary tract infection, it seems more likely to me that he was experiencing the effects of medication interactions. The combination of haloperidol, lorazepam and oxazepam may be responsible for causing some of the symptoms experienced by Mr. Johns. The common side effects of anxiolytics (benzodiazepines) are headache, nausea, hypotension and unsteadiness (Muir- Cochrane, Barkway & Nizette 2012, p 86).  Mr. Johns had oxazepam 15 mg on settling and then he was given Lorazepam 1 mg around 7 hours later. Haloperidol can also cause postural hypotension and a dry mouth (Muir- Cochrane, Barkway & Nizette 2012, p 95). Some antipsychotics have side-effects that include excessive sedation, dizziness, unsteadiness and symptoms that resemble those of Parkinson’s disease (Alzheimer’s Australia).

What criteria is Mary Jo using to make a differential diagnosis?

Mary Jo wonders if Mr. Johns has Lewy dementia rather than Alzheimer’s disease as this type of dementia has the particular characteristics of visual hallucinations and Parkinsonism type movements and gait (Alzheimer’s Australia). She also noted that the MET call documentation indicated that his neurological responses were ‘grossly intact’ which would possibly exclude a cerebrovascular accident (CVA) or any form of organic brain injury or infection.

What are the defining differences between Lewy body dementia and Alzheimer’s disease?

Lewy body dementia differs from Alzheimer’s disease in that there are three distinct symptoms, two of which need to be present in order to make a diagnosis of Lewy body dementia. These symptoms are:

• Visual hallucinations
• Parkinsonism (tremors and stiffness similar to that seen in Parkinson’s disease)
• Rapid fluctuation in mental state

(Alzheimer’s Australia, De Bellis et al 2009, p. 10)

The other symptoms of Lewy body dementia include the following:

• Difficulty with concentration and attention
• Extreme confusion
• Difficulties judging distances, often resulting in falls. (Alzheimer’s Australia)

Alternatively with Alzheimer’s disease the most common presenting symptom is memory loss with associated variable deficits in the areas of planning, reasoning, speech and orientation (De Bellis et al 2009, p. 10).

What does a score of 19/30 indicate on an MMSE? Why should it be repeated?

A score of less than 24 on a Mini Mental Status Examination (MMSE) indicates the presence of dementia, delirium or another condition that is affecting an individual’s mental state or cognition (Gerstein 2007). Ideally, in Mr. Johns’ situation a MMSE should be conducted on admission and at regular intervals until his discharge from hospital. In this way, his fluctuating mental state can be documented in respect his medication regime and his generalised progress.

Summarise the important information that you as a health professional would cover with a student.

I would discuss the following with the student:

• The effects and symptoms of polypharmacy in the management of the elderly patient. Older patients tend to have multiple co-morbidities and their absorption and excretion of various different medications may be compromised. This age-related situation puts them at a greater risk of drug interactions and side effects (Muir- Cochrane, Barkway & Nizette 2012, p 152). I would suggest the student be aware of the importance of medications being commenced at a low dose and then gradually increased with careful monitoring of improvement and side effects (Muir- Cochrane, Barkway & Nizette 2012, p 152).
• I would discuss the importance of including carers and families in the care of the elderly patient.
• I would discuss the difference in signs and symptoms between dementia and delirium.
• I would discuss the effects and possible outcomes that can arise from the use of physical restraints (soft cuffs) and chemical restraints (medications).
• I would also discuss the importance of regular assessment of the elderly patient during their hospital stay. For example, Mini Mental Status Examination (MMSE) needs to be performed at frequent intervals during the elderly person’s hospitalization.
• I would also discuss strategies that can be employed to reduce chances of being injured when caring for an agitated or aggressive patient.
• I would discuss the importance of documentation and completion of forms should she ever be injured by a patient. She should also be aware of the importance of reporting incidents to the Nurse Unit Manager or senior staff.
• I would also suggest to the student that it is extremely important to have experience in nursing elderly patients as Australia is an ageing population.

References:

Alzheimer’s Australia: http://www.fightdementia.org.au Viewed 16 April 2015

De Bellis A, Bradley SL, Wotherspoon A, Walter B, Guerin P, Cecchin M and Paterson, J (2009) Come Into My World – How to Interact with a Person who has Dementia: An educational resource for undergraduate healthcare students on person-centred care, Flinders University, Hyde Park Press, Adelaide.http://nursing.flinders.edu.au/comintomyworld

Gerstein, PS 2007, ‘Delirium, dementia, and amnesia’, eMedicine, http://www.emedicine.com/EMERG/topic345.htm.

Muir-Cochrane, E, Barkway, P & Nizette, D 2012, Mosby’s Pocketbook of Mental Health, Elsevier Australia, Sydney, NSW

 

Prompting question set 3

What care would you ensure for Mr. Johns?

There are quite a number of nursing actions that could be put in place for Mr. Johns which may reduce the degree of delirium he is experiencing and it would make his hospitalization less stressful for him and also Mrs. Johns.

I would ensure his hydration is maintained as this would reduce the incidence of dehydration and electrolyte imbalances which may account for his episode of delirium (Davis, 2008, p. 7). Mr. Johns should be encouraged to drink fluids and he may prefer to drink high calorie fluids rather than eating solid food. The dietician could be contacted to arrange this dietary supplement.

It would advantageous for the medical staff to review his medications as one of the possible reasons that  he developed delirium during his hospitalisation was due to polypharmacy and that the medication dosage was too high (Davis, 2008, p. 7, Muir- Cochrane, Barkway & Nizette 2012, p 152). As Mr. Johns’ respiratory function was compromised he may also benefit from supplemental oxygen therapy however he may not find the nasal prongs comfortable and therefore he would probably remove this therapy (Davis, 2008, p. 7). If possible the use of physical restraints should be avoided and that Mr. Johns is only medicated when required to ensure that he can get some sleep (Davis, 2008, p. 9).

If possible, it would probably be beneficial to have the same nurses allocated to care for Mr. Johns as this would be less confusing for him and the staff would be in the position to be able to closely monitor any changes in his behaviour (Davis, 2008, p. 8). This action would also be more reassuring for Mrs. Johns as she would know who was caring for her husband. I would also encourage Mrs. Johns to report to nursing staff in changes she noticed in Mr. Johns that were a deviation from his normal behaviour. It is essential that staff address him in a clear and calm manner and demonstrate a level of patience so that he does not become stressed or agitated (Davis, 2008, p. 9).

It is extremely important that Mr. Johns is cared for in a quiet, appropriately lit room that is free from extraneous objects that may result in a tripping hazard or some other form of injury (Davis, 2008, p. 8). He should be encouraged to mobilise if he able as this would assist him in returning to his previous levels of urinary and bowel function and continence (Davis, 2008, p. 8). Mobilisation and sitting out of bed for short periods would also prevent him from developing pressure areas and becoming stiff from remaining in bed for many hours. It is important that any visual or hearing aids he uses are clean and in good working order (Davis, 2008, p. 9). This would assist him to communicate and mobilise safely.

Prompting questions set 4

What legislation allows Mrs. Johns to decide her husband’s care?

The legislation that allows Mrs. Johns to make decisions in regards to her husband’s care and financial matters is called an Enduring Power of Attorney (EPOA). This legal document allows another individual to make financial and personal decisions for the person concerned if they are unable to make their own decisions due to failing medical or cognitive health. For financial decisions, the person concerned can nominate whether they would like the attorney to begin making financial decisions for them immediately or only once they have lost capacity (Queensland Government, 2015).

How would you respond to Mrs. Johns’ concerns and criticisms of the care?

I would respectfully listen to Mrs. Johns and I would arrange for her to discuss her concerns and criticisms with the senior RN or the Nurse Unit Manager if she so desired. I would also provide Mrs. Johns with the necessary paperwork to make a formal complaint to the hospital Liaison Officer about the care Mr. Johns received whilst he was in hospital. I would also provide her with information that can support the carers of persons with dementia in the community. I would encourage her to peruse the Alzheimer’s Australia website if she had access to the internet.

References:

Davis, S 2008, Delirium in older people, written for the 3Ds: Dementia, Delirium and Depression

Muir-Cochrane, E, Barkway, P & Nizette, D 2012, Mosby’s Pocketbook of Mental Health, Elsevier Australia, Sydney, NSW

Queensland Government 2015, ‘Power of attorney’, Queensland Government website, viewed 17 April 2015,

https://www.qld.gov.au/law/legal-mediation-and-justice-of-the-peace/power-of-attorney-and-making-decisions-for-others/power-of-attorney/