Marjorie’s CASE Marjorie is a 60-year-old American

Marjorie’s CASE Marjorie is a 60-year-old American Indian woman who came to the extended care facility after a long and difficult hospital admission. She was a single woman who had enjoyed a rural farm life, including managing racehorses on a large property. Marjorie has a history of HTN, DM, PVD, and anxiety. She was a social drinker and smoked half a pack a day until 10 years ago. Marjorie has no children but a sister and a couple of nieces who she is close with. Initially, she was admitted to a surgical oncology unit with a Basal Cell Carcinoma diagnosis and surgery. Despite initial surgical intervention, the cancer had infiltrated her brain tissue. Following a second surgical intervention she had been in an ICU, where she was intubated and suffered seizures. After a successful extubation, and the use of anti-convulsant drugs, she was finally released from ICU. Unfortunately following the surgery, she also developed a deep intracranial infection that was not resolving. As her condition worsened, her sister requested a palliative care consultant. Marjorie had become unresponsive at the hospital, and it was agreed that she would be transferred to the extended care facility for hospice and end-of-life care. After a week at the extended care facility Marjorie did begin to wake and interact, although she is consistently confused. Her family chose to make her code status a Do Not Resuscitate (DNR) due to her poor prognosis and confusion. Marjorie does not consistently eat her meals and often requests snacks instead of being served meals. Her dentures fit poorly due to a weight loss she has experienced during these sequelae of events. Marjorie has a range of symptoms which are causing issues. These include ongoing seizure activity, headaches, and a hyperactive delirium. Her pain medication, seizure medications and medications associated a history of anxiety and depression were reviewed and revised numerous times. Marjorie is very frail, cannot get out of bed without help, and largely symptomatic, but she is stable. Marjorie has skin integrity issues. Two stage three pressure ulcers are present, one to her coccyx and one to her right, lateral, ankle due to her decreased mobility and incontinence of urine and stool. When changing her brief, there is a strong odor, and the urine appears a dark yellow. The previous nurse did send a urinalysis and a urine culture is pending. Her care needs/plan has been modified as her condition deteriorates. Management of her issues continues to be integral to Marjorie’s comfort and care. Her scalp wound has purulent drainage, and it is malodourous. Recent wound cultures have been sent the day before. Marjorie, being confused, is constantly attempting to remove dressing material. Nursing staff utilize a range of head wear to try and prevent or decrease Marjorie’s manipulation of the wound. ~ You are the nurse caring for Marjorie tonight at 7 PM and when you enter her room you find her on the floor with an obvious deformity to her left hip. She is in pain, confused, and you are unable to move her without assistance. You call for help and the assistive staff arrive. Marjorie is placed on her bed, although she screams the entire way. It is obvious she is in pain, so you see on her MAR she has extra strength Tylenol ordered PRN and you decide to administer it. Marjorie has already received all her regular medications today, along with her as needed anxiety medication. ~ Medications include: Metformin 500 mg BID, ASA 81 mg daily, Metoprolol 50 mg daily, HCTZ 25 mg BID, Ceftriaxone Sodium-Dextrose 3.75 GMs IV daily, Xanax 0.5mhg BID PRN, Percocet 10/325 TID PRN, Dilantin 100 mg TID, and Celexa 10 mg daily). ~You recognize Marjorie has an active DNR code status. ~After a physical assessment, her lungs are diminished and there are wheezes throughout. Her abdomen has regular bowel sounds and a rounded appearance. Marjorie’s peripheral pulses are strong and equal in her carotid and radial locations but weak and equal in her posterior tibial and dorsalis pedis. She does have a small wound to her left shin and left side of her chin from the fall. Her orientation level is x2 (self & situation), and she is crying intermittently in pain. Marjorie has a PICC line in her RUE for intermittent antibiotic treatments. There are no current IVF ordered. ~VS are 153/88, 120, 24, 99.5’F, and 94% on room air. Her blood glucose level is 276. Marjorie is 5’3″ and 160 pounds. She is allergic to shellfish and Levaquin. ~ Marjorie’s last set of blood work: Hemoglobin A1C 8, WBC 14, Hgb 13, NA 135, K 4, BUN 20, Cr 1, Urinalysis= pH 6, WBC 8, Bacteria 1+ ~ You must call the physician, Dr. Gupta, to notify them of her fall and proceed from there. SCIENCE HEALTH SCIENCE NURSING NR 452

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