Running head: ALTERED MENTAL STATUS 1
Patient Profile for Patient in Room 125-2 with Altered Mental Status
Joshua Fleming
Liberty University Department of Nursing
09/20/13
ALTERED MENTAL STATUS 2
Student Name: Joshua Fleming
1. Patient Profile Worksheet (1 point)
ALTERED MENTAL STATUS 3
A. Personal Information
Room #125-2 Gender: M Ethnicity: African-American Age if < 90: 85
Place of Residence: Lynchburg MD: Olmsted, John
Emergency Contact: Spouse Marital Status: Married
Admitting Diagnosis: Altered Mental Status
Current Diagnosis (es): Altered Mental Status
Date of Current Surgery: None Allergies: NKA
Code Status: DNR Mental Status: Unable to Assess (Nurse’s Note)
B. Activity and Nutrition
Diet order: ADA (Level 3 Dysphagia) Route/Rate: Feed Last Wt: 43.091 Kg
Level of Activity (bedrest, up ad lib, BRP, turning): Bed rest, turning
Level of self-care: Assist x2
ALTERED MENTAL STATUS 4
C. Nursing Care
Drainage devices (foley, NGT, JPs, T-tube, etc.): None
Wound care/Dressing (be specific): #1: Lt knee stage 2 PU that is 2 cm long, 3.5 cm wide, 0.2
cm deep, unaproximated, non-granulating, red, dried edges, healing not anticipated, scant serous
drainage, cleaned with soap and tap water, foam/ mepilex xeroform dressing
#2: Lt hip unstageable PU that is 2 cm long, 3 cm wide, 0 cm deep, unaproximated, non-
granulating, pink, yellow slough, open edges, small serosanguinous drainage, cleaned with soap and
tap water, foam/ mepilex xeroform dressing
#3: Rt hip stage 2 PU that is 0.5 cm long, 0.5 cm wide, 0 cm deep, granulated, pink, open edge,
scant serous drainage, cleaned with soap and tap water, foam/ mepilex xeroform dressing
#4: Mid-line sacral stage 2 PU that is 1 cm long, 0.5 cm wide, 0 cm deep, unaproximated, non-
granulating, pink, open edges, small serosanguinous drainage, cleaned with soap and tap water,
foam/ mepilex, xeroform dressing
#5: Rt sacral stage 2 PU that is 0.5 cm long, 0.5 cm wide, 0 cm deep, unapproximated, red, pink,
open edges, no drainage, foam/ mepilex xeroform dressing
#6: Lt dorsal ankle stage 4 PU that is 7 cm long, 2 cm wide, and 0.3 cm deep, black eschar is
present, granulating, “mummified”, open edge, peri-wound erythema, no drainage, tendon visible,
ABD pad and gauze with silk tape securement, Carosyn gel on tendon
#7: Lt heel stage 3 PU that is 1 cm long, 3.5 cm wide, 0.3 cm deep, non-granulating, pink, rolled
edges, wound base is minimally moist, small serosanguinous drainage, ABD pad and gauze with
silk tape securement, alginate
IV access (peripheral, central, location, care): All IVs DC’d
Frequency of vital signs (including pulse oximetry): Q-shift
Frequency of Glucometer: None Supplemental oxygen: None OSA: High risk
Falls Risk: 30- Low Risk (25-50) Bed Surface: Accumax
D. Skill Lab Assistant Initial or Reference
Health Assessment Perry, A., & Potter, P. (2010). Clinical nursing
skills and techniques. (7 ed., pp. 106-172). St.
Louis, MO: Mosby Elsevier.
Vital Signs Perry, A., & Potter, P. (2010). Clinical nursing
skills and techniques. (7 ed., pp. 64-106). St.
Louis, MO: Mosby Elsevier.
Bed Making Perry, A., & Potter, P. (2010). Clinical nursing
skills and techniques. (7 ed., pp. 459-462). St.
Louis, MO: Mosby Elsevier.
Transfers Perry, A., & Potter, P. (2010). Clinical nursing
ALTERED MENTAL STATUS 5
skills and techniques. (7 ed., pp. 203-226). St.
Louis, MO: Mosby Elsevier.
Patient History Worksheet (1 Point)
Chief Complaint: Altered Mental Status
History of Present Illness: An 85 year-old African male who has severe PVD with
no interventions that are available. He presented to the hospital with sepsis, and
was also found to have a UTI and a wound on his heel. He has not eaten much food
for a week, and also has significant cachexia and underlying dementia. He was
seen in consultation by the palliative care team, and his family has requested him
to be moved to the Skilled Care unit for inpatient hospice care for end-of-life
circumstances. His family has also elected for comfort measures to be taken.
Past Medical History:
Pressure Ulcer on left heel with exposed tendon and stage three ulcer of the left
calcaneus
A-fib
Coagulopathy on Xarelto
Cerebrovascular disease
Dementia that is multi-infarct vs. Alzheimer’s in nature
HTN,
Glaucoma
Hyperlipidemia
Hyperparathyroidism
DM type 2
Diverticulosis
Hx of prostate cancer with prostectomy
PVD with left leg ischemia
Severe protein calorie malnutrition
Hypoglycemia
Hypernatremia
Lactic acidosis
Past Surgical History: Prostectomy
Family History: Significant for HTN
ALTERED MENTAL STATUS 6
Tobacco: None Alcohol: None Illegal Drugs: None
Occupational Status: Retired
Religious Preference: None noted
Cultural Support Needs: None noted
He is married with a wife that is also in poor health
ALTERED MENTAL STATUS 7
II. Medications (1 point)
Student should also have medication cards or book available on clinical.
Include PRNs that have been administered with the last 24 hours.
Medication Route Dosage &
Frequency
Category/Mechanism
of Action
Contraindications
/ Cautions
Side Effects Use for this
patient
Latanoprost Eye-
left
1 Drop/ Rtn
Bedtime
prostaglandin F2α
analogue/
Latanoprost is a
prostanoid selective
FP receptor agonist
that is believed to
reduce the intraocular
pressure (IOP) by
increasing the outflow
of aqueous humor.
Studies in animals
and man suggest that
the main mechanism
of action is increased
uveoscleral outflow.
Elevated IOP
represents a
major risk factor for
glaucomatous field
loss. The higher the
level of IOP, the
greater the likelihood
of optic nerve damage
and visual field loss.
Known
hypersensitivity to
latanoprost,
benzalkonium
chloride, or any
other ingredients
in this product.
Redness,
swelling,
itching, pain
in and around
the eyes,
oozing or
discharge
from the eye,
increased
sensitivity to
light, vision
changes,
chest pain,
cold-like
symptoms
Treatment of
high pressure
in the eye r/t
glaucoma
Roxanol Oral 10 Mg= 0.5 mL Narcotic: Opiate Hypersensitivity, Sedation, Relief of
ALTERED MENTAL STATUS 8
(Morphine
Conc Oral
Syrg)
Soln/ Prn Q2Hp analgesic/ binds with
opioid receptors
within CNS, alters
processes affecting
pain perception,
emotional response to
pain, produces
generalized CNS
depression
severe respiratory
depression,
acute/severe
asthma, severe
hepatic/renal
impairment, GI
obstruction
decreased
B/P,
diaphoresis,
constipation,
N&V,
disorientation
, flushed face
severe/acute
pain PRN,
comfort level,
High risk :
maximum
single dose-
15 mg
References:
Skidmore-Roth, L. (2011). Mosb'ys nursing drug reference. (24th ed.). St. Louis, MO: Elsevier Mosby
ALTERED MENTAL STATUS 9
V. Top three priority Medical with Nursing Diagnosis (1 point)
1. Altered Mental Status: Adult failure to thrive r/t the inability to take care of oneself AEB presence of multiple pressure ulcers, presence
of UTI on arrival to hospital, multi-infarct dementia, and not eating much food for the past week.
2. Altered Mental Status: Chronic confusion r/t Alzheimer’s disease AEB hx of multi-infarct, presence of multiple pressure ulcers,
presence of UTI, and A&O status not being able to be determined
3. Altered Mental Status: Impaired memory r/t neurological disturbances AEB Alzheimer’s disease, dementia, altered mental status, and
presence of UTI upon arrival to the hospital
Care Plan (1 point)
Medical & Nursing Dx Nursing Outcomes (NOC) Nursing Interventions (NIC) Evaluation
Altered Mental Status: Adult
failure to thrive r/t the inability to
take care of oneself AEB
presence of multiple pressure
ulcers, presence of UTI on arrival
to hospital, multi-infarct
dementia, and not eating much
food for the past week.
1. Within one shift the patient
will have an increased
participation in social interactions
2. Within one shift the patient
will meet the desired comfort
goals that are desirable for end-
of-life circumstances
3. Within one shift the patient
will express an understanding of
the spiritual resources that are
available to him
1a. Encourage the patient to
remember the family that is
present with him in order to have
meaningful conversation with
them and staff
1b. Give the patient multiple
forms of communication if he is
unable to speak write clearly
1c. Comfort patient with
meaningful conversation even if
he is not able to participate, and
look directly at him so he
understands
2a. Monitor patient for any
apparent signs of pain or distress
2b. Hydrate patient through IV
therapy if appropriate
(Include Goal Statement)
ALTERED MENTAL STATUS 10
2c. Encourage family members to
visit, and stay as much as they
can to provide comfort for the
patient
3a. Ask the patient if he would
like to be prayed for
3b. Ask the patient and family
what their preference is regarding
ministers and denominations
3c. Ask the patient if he would
like someone to read the Bible to
him
References
Ackley, B., & Ladwig, G. (2009). Nursing diagnosis handbook. (9th ed., pp. 430-431). St. Louis, MO: Mosby Elsevier.
