Instructions
Read the following case studies in your Bowles Case Study book. Answer the specified questions listed with each case study.
• Case 1.3 Physical restraints (Question 4 and 7)
o Restraint stats
https://www.crisisprevention.com/Blog/October-2010/Adverse-Effects-Associated-With-Physical-Restraint
https://atlanticquality.org/download/public/nh/nh-ny/508_restraint_alternatives.pdf
Case 17.1: Acute Confusion (Delirium) (starts on p. 205)
• If it is the Summer or Winter term, answer questions 3, 7 and 8
• question 7 resource
• https://consultgeri.org/geriatric-topics/delirium
• question 8 resource
• https://consultgeri.org/try-this/general-assessment/issue-13.pdf
Case 20.3: Hypersomnia (starts on p. 242)
• If it is the Summer or Winter term, answer questions 4, 5, 6 and 10
• question 4
o review text for physiological changes to the circadian rhythm of older adults
• question 6 resource
• Epworth Sleep Scale
• question 10 resource
• CPAP Instructions
Case 1.3╇ ■╇ Physical Restraints
J â•›oseph Deikel is a 78-year-old male admitted to a medical–surgical floor in an acute
care facility. Three days before, he had visited his internist for nausea, vomiting, and
a low-grade fever. At that time, he was provided with a prescription for promethazine
(Phenergan) suppositories and returned home. Mr. Deikel has a strong aversion to any
medications taken rectally and did not use the suppositories. The vomiting continued for
another 48 hours and was followed by dry heaves. He barely was able to get out of bed
at this point and had to hold onto furniture for support. His son found him lying on the
bathroom floor, and he was transported to the local emergency department (ED).
Abnormal findings in the ED include Mr. Deikel’s BP of 88/50, heart rate 114, temperature
100.1°F, oriented to person only, serum Na+ 128, blood urea nitrogen (BUN)
44, and creatinine 2.1. Intravenous fluids (IVF) of sodium chloride 0.9% were initiated
at 140 mL/hr along with orders for multiple cultures.
On the medical–surgical unit, Mr. Deikel felt the need to urinate and attempted to
get out of bed to go to the bathroom, and fell (no urinal had been provided). His son
left, and he was put into a posey vest restraint. When given a dose of intravenous (IV)
antibiotics shortly thereafter, he yelled out in pain as his entire arm with the IVFs had
a tremendous burning sensation, so as a means of “self-preservation” he pulled the
angiocath and tubing out. He now found himself with both wrists restrained.
Reviewing the events, it is apparent that Mr. Deikel, an elderly gentleman, was
dehydrated by several days of fluid loss, as evidenced by abnormal vital signs
and lab work, and thus became confused. The use of physical restraints described
in this scenario was unfortunately not uncommon in years past. Hopefully, this
will remain just that: a practice of the past. Use a document provided by the
U.S. Food and Drug Administration (2014) at www.fda.gov/MedicalDevices/
ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/
ucm123676.htm to assist with the following questions.
- When are full bedrails (aka, siderails) considered a form of
physical restraint? What can be a negative outcome of having
full bedrails up, surrounding a patient? - What psychological effects do you believe physical restraints can
have on a patient?
For Questions 3 to 7, use the Hartford Institute for Geriatric Nursing website at �http://
consultgerirn.org/topics/physical_restraints/want_to_know_more (Bradas, Sandhu, &
Mion, 2012). - What, if any, items listed under the definition of physical
restraints were unfamiliar to you? - After reviewing the section “Morbidity and Mortality Risks
Associated With Physical Restraints,” choose any two items
and discuss how physical restraints could lead to the specific
problem.
A thorough assessment of a client is the first step in planning an alternative to �physical
restraints of a patient in order to know whether physical or cognitive impairment exists,
as well as risks for injury, such as falling. In addition, presence of medical devices in
cognitively impaired patients can represent a risk factor, such as a urinary catheter,
nasogastric tube, peripheral/central IV access device, and other invasive items. Finally,
a diagnosis or presence of a psychiatric disorder such as drug withdrawal, posttraumatic
stress disorder, panic attacks, and so forth should be known. - Provide the name of the assessment tools and their primary
purpose in the “Try This Series” listing. - If physical restraints must be used, which of the following must
be implemented? Select all that apply.
a. Choose the least restrictive device
b. Ensure proper sizing and fit of restraint
c. Reassess the patient’s response at least every 4 hours
d. Release the restraint at a minimum every 4 hours
e. Renew orders every calendar day after evaluation by a
licensed independent practitioner - After reviewing the information for alternate care strategies,
which one(s) do you think might be the most challenging for
a patient who is agitated and why? - The use of physical restraints often presents an ethical dilemma
for nurses. Develop a statement to explain the conflict between
beneficence (nursing) and autonomy (of the patient) in regard
to restraints.
Case 17.1 ■ Acute Confusion (Delirium)
Sâ•›ara Garnet is a 78-year-old woman who is accompanied by her daughter, Megan,
to a preoperative visit for a scheduled total hip replacement. Sara had been active,
playing bridge and taking daily walks, until about 6 months ago when her hip began
hurting so much as to limit her activity. She states she had experienced sporadic pain
for years, but the hip started “giving out” on occasion, resulting in several falls. Sara is
in otherwise good health, though her daughter reports that she has noticed that Sara
has been having some difficulty with her short-term memory recently. She is able to
compensate for this loss by keeping an appointment calendar next to her phone and
using Post-it notes to help her remember messages and daily tasks. Sara has a history
of depression, which is treated with Celexa (citalopram), and hypertension, which is
treated with lopressor (metoprolol).
lily Arnse, RN, performs some presurgical cognitive screening tests, the Geriatric
Depression Scale (GDS), Mini-Cog, and Trails B. Sara’s score of 1 on the GDS indicates
that her depression is well managed with her current medications. She struggles
with three-item recall and the Clock Draw Test, as she is able to recall only two
of three items and cannot correctly position the numbers on the clock. She is almost
completely unable to perform the Trails B test. - Is Sara at high risk to develop postoperative delirium? What risk
factors does she have? - An evidence-based guideline for recognizing, preventing,
and treating delirium has been created through the Hartford
Institute for Geriatric Nursing. Review this guideline, which is
available at http://consultgerirn.org/topics/delirium/want_to_
know_more (Tullmann, Fletcher, & Foreman 2012). How can
Sara’s risk for developing delirium during this hospitalization
be reduced? - The Confusion Assessment Method is a valid and reliable tool
for assessing delirium. Go to the Hartford Institute for Geriatric
Nursing website, http://consultgerirn.org/uploads/File/trythis/
try_this_13.pdf (Waszynski, 2012), to view this tool. Describe
how to use the confusion assessment method (CAM) to make a
diagnosis of delirium.
Suggested Resources
American Association of Critical-Care Nurses. (2014). Delirium assessment and �management.
Retrieved from http://www.aacn.org/wd/practice/content/practicealerts/delirium-�practicealert.
pcms?menu=practice
Doerflinger, D. M. C. (2013). How to try this: The mini-cog. The Hartford Institute for Geriatric
Nursing. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_3.pdf
Greenberg, S. A. (2012). The Geriatric Depression Scale (GDS). Hartford Institute for Geriatric
Nursing. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
Heerema, E. (2014). The Trail Making Test and its use as a screening tool for dementia.
About.com Alzheimer’s/Dementia. Retrieved from http://alzheimers.about.com/
od/testsandprocedures/a/The-Trail-Making-Test-And-Its-Use-As-A-Screening-For-
Dementia.htm
Tullmann, D. F., Fletcher, K., & Foreman, M. D. (2012). Nursing standard of practice �protocol:
Delirium: prevention, early recognition, and treatment. Hartford Institute for Geriatric
Nursing. Retrieved from http://consultgerirn.org/topics/delirium/want_to_know_more
Waszynski, C. M. (2012). The Confusion Assessment Method (CAM). Hartford Institute for Geriatric
Nursing. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
Case 20.3 ■ Hypersomnia
M ack Dunlevy left his primary health care provider’s office with an unfamiliar
word, “hypersomnia,” written on a prescription pad. He sought help due to an
ongoing problem of being very tired and sleepy during the daytime. He is 67 years
old and retired from a manufacturing position 5 years ago. He has been a very active
man most of his adult life, but over the past 6 months he finds himself predominantly
sedentary.
Mack was divorced in his 50s and has dated Diane for more than 7 years. Diane retired
from the local university a year ago. Their relationship has experienced a lot of conflict
recently as Diane planned on the couple traveling, providing volunteer work, playing
with grandchildren, and generally being together the majority of the time once she no
longer worked. She gave Mack an ultimatum to seek medical help about his excessive
sleepiness or the relationship would end. Diane also gave him the nickname “Narc” as
she has repeatedly told him he is suffering from narcolepsy.
Based on the history taken by a nurse practitioner at the office, Mack’s health Â�status
was considered above average for his age group. He had two surgeries many years
ago, which included an inguinal hernia repair and appendectomy. His height is
68 inches with his weight at 200 pounds. He has never smoked, used tobacco �products,
or tried recreational drugs. When asked about alcohol use, Mack told the nurse practitioner
he had “one or two” servings of bourbon prior to bedtime. In actuality, since
his �relationship with Diane has been strained, he consumes double or more of that
amount. Mack believes alcohol helps him sleep better at night, which allows him to
stay awake during the day. This has not been the case, however.
Current prescribed medications include Flomax (tamsulosin) 0.4 mg orally daily,
Nexium (esomeprazole) 40 mg oral daily, and Lasix (furosemide) 20 mg orally every
other day. Medication used on a prn basis includes Motrin (ibuprofen) 400 mg orally
for occasional muscle soreness and Benadryl (diphenhydramine) 25 mg orally for
�seasonal allergy-based rhinitis.
- Describe how the as-needed medications listed could result in
daytime sleepiness. - What are age-related physiological changes affecting the
circadian rhythm of older adults?
The nurse practitioner who evaluated Mack at the office asked him questions
pertaining to hypersomnia using the Epworth Sleepiness Scale (ESS) authored by
Smyth (2012). Mack’s score was a “12.” - Go to http://consultgerirn.org/uploads/File/trythis/try_this_6_2.pdf
in order to interpret what this finding means.
Many other questions were asked at the office in an effort to find a cause for Mack’s
excessive daytime sleepiness. He was wearing a cotton button-up shirt, and the nurse
practitioner inquired about the neck size of this piece of clothing. Mack was quite
surprised at such a question but good-naturedly replied, “Why in the world does that
matter?” The nurse practitioner explained perhaps obstructive sleep apnea may be a
contributing factor for his hypersomnia. - Visit the Hartford Institute for Geriatric Nursing evidence-based
guidelines at http://consultgerirn.org/topics/sleep/want_to_
know_more (Chasens & Umlauf, 2012). What action is suggested
for optimizing the use of CPAP?
Mack experienced a dramatic improvement in his daytime sleepiness following treatment.
He began golfing, playing cards, and watching sports with his male buddies
once again. He and Diane enjoyed daytime trips, volunteering at their church, and
attending local events. Mack was so busy experiencing life again, he lost 15 pounds
and rarely thought about taking a nap in his favorite recliner.
Suggested Resources
Chasens, E. R., & Umlauf, M. G. (2012). Nursing standard practice protocol: Excessive sleepiness.
Hartford Institute for Geriatric Nursing. Retrieved from http://consultgerirn.org/topics/
sleep/want_to_know_more
Duffy, J. (2007). Sleep problems in older adults [Video file]. Healthy Sleep. Retrieved from http://
healthysleep.med.harvard.edu/video/sleep07_duffy_problems/wm-hi
Johns, M. W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness
scale. Sleep, 14, 540–545.
Lifetips. (2014). The difference between hypersomnia and narcolepsy. Retrieved from http://
sleepdisorders.lifetips.com/faq/120851/0/what-is-the-difference-between-hypersomniaand-
narcolepsy/index.html
Mayo Clinic staff. (2012). Sleep apnea. Retrieved from http://www.mayoclinic.com/health/
sleep-apnea/DS00148/DSECTION=risk-factors
Smyth, C. (2012). The Epworth sleepiness scale (ESS). Hartford Institute for Geriatric Nursing.
Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_6_2.pdf
Sample Solution