John Kelly _ Acute Delirium UNFOLDING Reasoning_2021 John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure

History of Present Problem: John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!” Personal/Social History: John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife. He is a nonsmoker and has a glass of wine 2-3 times a week with dinner. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance:  History of: o Osteoarthritis o Asthma o Dementia (early stage) o Heart failure  1 day post-op (r. hip arthroplasty)  Prescribed 5 mg oxycodone P.O.  Agitated, combative and resistant behavior o He insists he is at home and yells, “you get the hell out of my house or I am going to call the police”  Increased risk for activity intolerance (weakness/fatigue) and injury or fall  Disrupts patient’s ability to function independently  Acute confusion  Dementia is a risk factor for acute delirium  Narcotics/opiates and comorbidities can cause behavior disturbances  Significant distress to patient and spouse RELEVANT Data from Social History: Clinical Significance:  Retired, married, independent and socially active  Religious (Catholic)  Indicates patient is able to complete ADL’s with full/complete independence  May want spiritual or religious services involved in pt. care  Religious/spiritual practices are adequate coping methods Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details P: 102 (regular) Quality: Tenderness to palpation over incision site R: 18 (regular) Region/Radiation: Right hip BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but does not appear to be in acute discomfort based on assessment O2 sat: 95% room air Timing: Unable to verbalize