6 months later . . . Henry passed away three months ago. Ertha is more confused, cries frequently, and looks everywhere for Henry. She is not eating well and has lost weight. The nurse at the assisted living facility does not feel she meets their guidelines any longer and will need a higher level of care. She asks Ertha’s daughter-in-law, Betty, to come in to discuss a move to long-term care, skilled nursing facility. During the scenario, Betty reports that Ertha calls her frequently every day, forgetting that she has called earlier. Person providing report: Day shift nursing supervisor Situation: Ertha has shown some marked deterioration since Henry died 3 months ago.

S​‌‍‍‍‌‍‍‌‍‌‌‌‍‍‌‍‍‌‌‍​cenario #2: 6 months later . . . Henry passed away three months ago. Ertha is more confused, cries frequently, and looks everywhere for Henry. She is not eating well and has lost weight. The nurse at the assisted living facility does not feel she meets their guidelines any longer and will need a higher level of care. She asks Ertha’s daughter-in-law, Betty, to come in to discuss a move to long-term care, skilled nursing facility. During the scenario, Betty reports that Ertha calls her frequently every day, forgetting that she has called earlier. Person providing report: Day shift nursing supervisor Situation: Ertha has shown some marked deterioration since Henry died 3 months ago. She is unkempt, more confused and agitated, cries frequently, and looks everywhere for Henry. We called her daughter-in-law Betty and she will be here shortly. Background: Ertha was diagnosed with major neurocognitive impairment, Alzheimer’s vs. Vascular etiology, about 2 years ago. Other than that, she has been healthy, except for arthritis pain that is relieved by acetaminophen. She has hypertension that is controlled with atenolol, and she is taking rosuvastatin for her hyperlipidemia. She had a bout of depression several years ago when her son died while serving in the war. She and her husband Henry moved into the facility four months ago; Henry passed away 3 months ago. Assessment: Ertha is not eating well. A staff member has to go and get her and take her to the dining room. She can’t sit at the table very long and eats very little. Other residents have tried to be supportive, but she cannot socialize. Ertha had clear deficits on the Brief Evaluation of Executive Dysfunction when it was done a few months ago, but we think she is worse. Her living space is very messy and she only comes out of her room when we go to get her. Dr. Rivers prescribed fluoxetine and trazadone and increased the dose on her rivastigmine transdermal patch a few weeks ago, but it has not helped. We now have staff administering her medications, but we all feel that Ertha needs a higher level of care now. We called our long-term care facility and there is a room available. Recommendation: Get some vital signs on Ertha and do a Mini-Cog™. Meet with Betty and help her see that Ertha needs more care than we can provide in assisted living. If she agrees, we can move her tomorrow. Dr. Rivers will be waiting for your call and is prepared to write a transfer order, so call as soon as you finish your visit. You now visit Ertha in her room and assess her. Ertha is up wa​‌‍‍‍‌‍‍‌‍‌‌‌‍‍‌‍‍‌‌‍​ndering in her room; the room is messy and papers are all over. She cries and keeps repeating herself throughout the scenario. Betty: “I can’t believe how thin she is and how sad! I got real busy at work after taking time off for the funeral and getting Henry’s affairs in order, so I haven’t been here in 2 weeks, but I’ve been calling almost every day.” Ertha: “I’m looking for something…Where is Henry? He never leaves me…Stop bothering me.” Which of these initial steps should the RN take? Select all that apply. a. Introduce yourself b. Verify Identity of Ertha c. Ask Ertha what she is looking for. d. Tell Ertha that Henry will be here in a little while. e. Make a comment to Ertha about how much Henry loved her. Correct Answers: A, B, E Ertha remains agitated. You administer the mini-cognitive assessment again. Compare these results to the result from 6 months ago. 1. Ask Ertha to remember 3 words: Banana, Sunrise, Chair 2. Ask Ertha to draw clock: Makes attempt to draw clock 3. Ask Ertha to repeat 3 words: When asked to repeat 3 words, she says, “Word, word, word! How would you like it if I was asking you all of these questions?” Nursing Interventions: You ask Betty what has worked in the past to calm Ertha down. Betty: “Ertha likes music, especially the hymns they play in church. And Henry used to rub her back and that seemed to help her be calmer.” What nursing interventions should be applied to Ertha? Select All that apply. a. Put on calming music. b. Offer back rub. c. Give her a task, such as folding washcloths. d. Orient to reality. e. Administer the Aricept for the agitation. Correct Answers: A, B, C Betty: “Can’t we try some new medications? Provide education regarding the purpose of medication. Explain to Betty that while medications can help, they cannot increase her level of functioning. What is your recommendation for further care for this client? • Move to long-term care vs Stay in Assisted living with extra help • Provide structured schedule vs allowing client to choose daily activities • Provide protected environment vs allowing client freedom to walk outside • Nutritional consult vs. allowing client to choose own diet Correct answers: • Move to long-term care • Provide structured schedule • Provide protected environment • Nutritional consult Answer following questions 1.Discuss the safety issues you considered when implementing care for this patient. 2.What measures did you implement to ensure safe patient ca​‌‍‍‍‌‍‍‌‍‌‌‌‍‍‌‍‍‌‌‍​re? 3.How would you assess the quality of care provided?