Posted: September 4th, 2023

Mr. Z, a 68-year-old male with a diagnosis of Alzheimer’s disease

Crisis Intervention and Safety Planning for the Adult/Geriatric Patient
Mr. Z, age 68, is a new resident of a long-term care facility in the Alzheimer Unit. He was
recently taken by his family for evaluation in the Emergency Department after he was found to
be confused, physically aggressive with family members, threatening to burn the house down,
and paranoid that someone was trying to kill him. The medical work up in the ED was
unremarkable. He was discharged from the ED and since arriving at the facility, he has been
verbally aggressive with staff, depressed, throwing food, wanders around, and tries to leave. He
does not answer most questions when asked by staff and appears agitated. Psychiatry is
consulted for management of his behavioral and psychological symptoms.
Medical History: Diagnosed with Alzheimer’s Disease 2 years ago (diagnosed based on
symptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)
Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3
drinks on the weekends x 10 years. Married. Previously employed as accountant
Family History: No history of dementia or mental health disorders. Mother deceased from colon
cancer. Father deceased from MI. Son is 31 and healthy.
Medications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS
Allergies: NKDA
Physical Exam Notes
Constitutional: Appears agitated. Not cooperative. Speech noted is rapid and confused.
Inattentive and distracted. Appears slightly hyperactive. Pacing hallways at times.
Head: Normocephalic, atraumatic
Cardiac: RRR, no murmurs noted
Lungs: CTA A/P
Abdomen: BS x active x 4, soft/non-tender, LBM 2 days ago
Musculoskeletal: Moves all extremities, abnormal/unsteady gait
Neuro: Cranial nerves appear grossly intact but patient not cooperative enough for complete
testing. DTRs 1+ symmetric. Disoriented to place and time. Is able to state his name. Unable to
complete MMSE.
Vitals: T: 98.8, P 88, R 18, BP 132/78
Please follow directions and answer the questions outlined in the Assignment prompt
Read the case study located in the reading document.
Complete a SOAP Note on the patient. (In your SOAP note: Give an example of documentation
for the PMHNP provider; (include prescription details as well as instructions for staff to give
medication and monitor patient))
In your SOAP note, design a treatment plan that includes PRN medications in case the patient
continues to be agitated.
Answer the questions listed below:
• What medications would you prescribe? Why?
• What doses?
• Would you have these listed as standing orders for the nursing home staff or would you
want to be notified before given to verify and determine need?
• Would you want to visually see the patient before having the medications given?
• What monitoring would need to be provided after medication is given?
• What documentation would need to be provided and how often for the medication to be
continued?
• Would the medication be considered chemical restraints? Why or Why not?

_____________________________-
SOAP Note:

Subjective:
Mr. 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.

Objective:

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.
Head: Normocephalic and atraumatic.
Cardiac: Regular rate and rhythm, with no murmurs noted.
Lungs: Clear to auscultation bilaterally.
Abdomen: Bowel sounds are present and normal. The abdomen is soft and non-tender.
Musculoskeletal: Mr. Z moves all extremities, but his gait is abnormal and unsteady.
Neurological: 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).
Vitals: Temperature 98.8°F, pulse rate 88 bpm, respiratory rate 18 breaths per minute, blood pressure 132/78 mmHg.
Assessment:
Mr. 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.

Plan:

Medications:

Continue current medications:
Donepezil 5 mg PO HS: Continue to support cognitive function.
Prazosin 1 mg PO HS: Continue for management of nightmares and sleep disturbances.
Crestor 20 mg PO at HS: Continue for hyperlipidemia management.
Initiate PRN medications for agitation:
Lorazepam 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.
Haloperidol 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.
Medication Instructions for Staff:

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.
Haloperidol: 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.
Treatment Plan:

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.
Behavioral interventions: Use redirection techniques, provide validation and empathy, and ensure a calm and supportive care environment. Maintain a consistent caregiver approach and communicate effectively.
Regular psychiatric follow-up: Assess response to treatment, monitor for adverse effects, and adjust the treatment plan as needed.
Answering the additional questions:

Medications prescribed:
Medications prescribed:

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.

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.

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.

PRN Medications for Agitation:

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.

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.

Dosing instructions:
The 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.

Regarding the remaining questions:

Standing orders or notification:
The 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.

Visual assessment:
Ideally, 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.

Monitoring after medication administration:
After 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.

Documentation frequency for medication continuation:
Documentation 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.

Consideration of medication as chemical restraints:
The 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.

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