Case Study: Crisis Intervention And Safety Planning 199541
Case Study Crisis Intervention And Safety Planning For The Adultgeri
Case Study 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, presbycusis, osteoarthritis. Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3 drinks on weekends x 10 years. Married. 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 20 mg PO at HS. Allergies: NKDA.
Physical Exam Notes: Constitutional: Appears agitated. Not cooperative. Speech is rapid and confused. Inattentive and distracted. Slight hyperactivity. Pacing hallways. Head: Normocephalic, atraumatic. Cardiac: RRR, no murmurs. Lungs: CTA A/P. Abdomen: BS x4, soft, non-tender, LBM 2 days ago. Musculoskeletal: Moves all extremities, unsteady gait. Neuro: Cranial nerves grossly intact but patient not cooperative for full testing. DTRs 1+ symmetric. Disoriented to place and time. Able to state name. Unable to complete MMSE. Vitals: T 98.8, P 88, R 18, BP 132/78.
Assessment:
Subjective Data:
- Confusion, agitation, aggression, paranoia, wandering, refusal to answer questions.
- Family reports recent behavioral deterioration.
- No current suicidal ideation but significant risk related to aggression and wandering.
- Medication adherence appears adequate.
Objective Data:
- Physical examination shows agitation, confusion, rapid speech, hyperactivity.
- Neuro exam limited due to patient cooperation.
- Vital signs stable.
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Sample Paper For Above instruction
Introduction
Geriatric patients with Alzheimer’s Disease frequently exhibit behavioral and psychological symptoms that pose significant challenges for caregivers and healthcare providers. Acute agitation, aggression, and wandering are common and can escalate to safety concerns requiring prompt intervention. The case of Mr. Z exemplifies the critical need for an effective crisis intervention and safety plan, including appropriate pharmacologic management, staff protocols, and ongoing monitoring tailored to his complex needs. This paper presents a comprehensive SOAP note for Mr. Z, developing a treatment plan that incorporates PRN medications, delineates prescribing strategies, and discusses ethical considerations, including the use of chemical restraints.
SOAP Note for Mr. Z
Subjective
Mr. Z, an 68-year-old male with a history of Alzheimer’s disease, recent onset of agitation, paranoia, and aggression, presents with worsening behavioral disturbances since admission to the long-term care facility. Family reports episodes of threatening behavior, wandering, and food throwing. No suicidal ideation reported. No recent changes in medication adherence. No known allergies.
Objective
Physical exam highlights agitation, confusion, rapid speech, hyperactivity, and limited cooperation due to agitation. Vital signs are within normal limits. Neuro exam limited, disoriented to place/time, but able to verbally state his name. No signs of acute medical illness.
Assessment
Primary issues include exacerbation of behavioral and psychological symptoms of dementia (BPSD), specifically agitation and paranoia. Risks involve injury to self or others, wandering leading to elopement, and interference with care. Potential contributing factors include disease progression and environmental stressors.
Plan
Pharmacologic Interventions
Given Mr. Z’s ongoing agitation, a PRN medication strategy should be implemented for episodes of severe agitation. Considering his medical history and current state, the following medications are recommended:
- Lorazepam 0.5 mg PO as needed: Chosen for its rapid onset and efficacy in acute agitation. Doses should be limited to prevent over-sedation and ensure safety. The medication should be available as standing orders, with staff instructed to notify the provider before administration unless in an emergency.
- Haloperidol 0.5 mg PO as needed: For refractory agitation unresponsive to benzodiazepines, particularly with paranoid features. Use cautiously due to risk of extrapyramidal symptoms and QT prolongation; medication should be administered only after notification and verification of no contraindications.
Doses and Administration Strategies
- Both medications would be listed as standing orders, but staff must notify the provider prior to giving unless in an immediate safety situation.
- Visually assessing the patient before medication administration is essential to ascertain current condition and need.
- Continuous observation should follow administration, monitoring for excessive sedation, respiratory depression, or new neurological signs.
- Documentation must include medication name, dose, time, reason for administration, observed effects, and any adverse reactions. Monitoring should be documented every 30 minutes for the first two hours post-administration and then per facility protocol.
Monitoring Post-Medication Administration
- Vital signs and mental status evaluations.
- Observation for sedation levels, airway protection, and signs of adverse effects.
- Behavioral response to medication, noting any reduction in agitation or adverse reactions.
- Frequent re-assessment for ongoing safety.
Long-term Management and Documentation
- Continue regular behavioral assessments.
- Record medication efficacy, side effects, and any need for dose adjustments.
- Medications should be reviewed weekly, with periodic full psychiatric evaluation.
- Documentation must be updated with each medication use, and the necessity of continued medication should be reassessed regularly.
Chemical Restraints Consideration
Using PRN medications for acute agitation can be viewed as chemical restraint if primary purpose is to restrict a patient’s movement or behavior without therapeutic intent. In Mr. Z’s case, the use of medications is justified as a safety measure in response to acute agitation and risk of harm, aligning with ethical standards provided that the intervention is proportionate, limited in duration, and part of a comprehensive behavioral management plan.
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Discussion
A balanced approach combining pharmacological and non-pharmacological strategies is critical in managing BPSD. Non-pharmacological interventions include environmental modifications, engagement in activities, and behavioral therapies, which should be prioritized before medication use (Cohen-Mansfield & Billig, 2013). Pharmacotherapy remains essential when safety is compromised, with PRN medication plans tailored to individual risk profiles and monitored closely.
The decision to administer PRN medications must involve staff training, clear protocols, and timely communication with the healthcare provider. The use of medications as chemical restraints remains ethically complex; however, when employed judiciously for safety, and with ongoing reassessment, they can be justified.
Conclusion
Managing agitation in geriatric patients with Alzheimer’s disease requires a multifaceted approach that includes careful medication selection, vigilant monitoring, and a focus on non-pharmacological interventions. Clear documentation, staff training, and ethical considerations are paramount to ensure patient safety while respecting autonomy and minimizing restraint use.
References
- Cohen-Mansfield, J., & Billig, N. (2013). Nonpharmacological Management of Agitation in Dementia: A Review of the Literature. Journal of Clinical Psychiatry, 74(11), 1140–1146.
- Liperoti, R., et al. (2014). Pharmacological management of agitation and aggression in Alzheimer’s disease. Expert Review of Neurotherapeutics, 14(5), 625–638.
- Kurth, J. K., & Teri, L. (2020). Pharmacological Treatment Strategies for Behavioral and Psychological Symptoms of Dementia. Journal of Alzheimer’s Disease Reports, 4(1), 163–172.
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
- Reisberg, B., et al. (2008). Behavioral and psychological symptoms in dementia: a review. Alzheimer’s & Dementia, 4(4), 184–192.
- Herrmann, N., et al. (2015). Pharmacological Management of Behavioral Symptoms in Dementia. Canadian Journal of Psychiatry, 60(4), 146–154.
- American Geriatrics Society. (2019). Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674–694.
- Groenewald, C. B., et al. (2018). Pharmacologic Management of Behavioral Symptoms of Dementia. The Medical Clinics of North America, 102(4), 661–676.
- Husebø, B., et al. (2018). Nonpharmacological interventions for agitation and aggression in dementia: a systematic review. Clinical Interventions in Aging, 13, 1029–1044.
- Moysi, R. S., et al. (2021). Ethical considerations in the use of pharmacological restraints in dementia care. Bioethics, 35(2), 123–130.