NRNP 6540 Week 5 Atypical Presentation Note Example

Atypical Presentation Note: Two Days of Fluctuating Confusion in an 88-Year-Old Woman Whose Daughter Says She Is Not Herself

Student Name

College of Nursing, Walden University

NRNP 6540: Advanced Nurse Practice in Primary Care Adult Gerontology II

Instructor Name

Month Day, Year

Atypical Presentation Note: Two Days of Fluctuating Confusion in an 88-Year-Old Woman Whose Daughter Says She Is Not Herself

Baseline First

Before recording what is wrong, the note establishes what is normal for her. Her daughter, who visits daily, describes an ordinary day a week ago: V.P., an invented 88-year-old retired seamstress with mild hypertension and osteoarthritis, dressed herself, made tea and toast, did the newspaper crossword, walked with a cane to the mailbox, and talked on the phone with her sister in the evening. She has no diagnosis of dementia and managed her own pills from a weekly organizer.

Change From Baseline

Over the past two days she has been confused, mixing up her daughter's name with her sister's, unable to finish the crossword, and picking at her blanket. The confusion comes and goes: she is clearer in the morning and worse in the afternoon and evening. She has eaten little, stayed in bed, and been incontinent of urine once, which is new. She has not complained of pain, cough, or fever, according to her daughter, though she has seemed "short of breath going to the bathroom." Last week an urgent care clinic prescribed tramadol for back pain after she lifted a laundry basket; she has taken it three times daily.

Confusion Assessment Method, Item by Item

Acute onset and fluctuating course: present; a clear change from baseline over two days, worse in the afternoon. Inattention: present; she could not name the months of the year backward, stopping at October after two tries, and lost track of the conversation. Disorganized thinking: present; she wandered from the question to a story about her sewing shop. Altered level of consciousness: mildly drowsy but rousable. Features 1 and 2 plus either 3 or 4 are present, so the Confusion Assessment Method is positive for delirium (Inouye et al., 1990).

Examination

Beyond the checklist below: heart rate 104 and regular, blood pressure 118/66 without orthostatic measurement because she could not stand safely, no focal weakness or facial asymmetry, pupils equal and reactive, no neck stiffness, no rash, abdomen soft with mild lower tenderness from constipation, no calf swelling. She wears glasses and a right hearing aid, which were not in place when she was found in bed; both were put on before the cognitive testing.

Search for the Cause, as a Checklist

Delirium is a sign of an underlying problem, and in older adults it often has more than one cause (Inouye et al., 2014).

Infection, chest: temperature 99.5 F, which may be a fever for her given a usual temperature near 97; respiratory rate 24; oxygen saturation 90 percent on room air; crackles at the right lung base with dullness to percussion.

Infection, urine: urinalysis shows a few white cells. Bacteria in the urine of older women are common without infection, and a positive urine test should not be taken as the cause of delirium unless there are urinary symptoms or no other source (Nicolle et al., 2019); here there is a more convincing source.

New medication: tramadol started last week can cause confusion in older adults, especially at repeated doses.

Dehydration: dry mucous membranes; poor intake for two days.

Constipation: no bowel movement for four days, possibly worsened by tramadol.

Urinary retention: bladder scan shows 90 mL after voiding, not retained.

Pain: back pain present but not severe at rest.

Crackles at the right base, low oxygen saturation, fast breathing, and a low-grade temperature move pneumonia to the top of the list, with tramadol, dehydration, and constipation as contributors.

Disposition: Home or Hospital

Two paths were weighed. Treatment at home would require oral antibiotics, reliable fluid intake, oxygen saturation stable on room air, and someone with her around the clock. Transfer would bring oxygen, intravenous fluids, and closer monitoring, but also the risks hospitals carry for older adults with delirium: unfamiliar surroundings, disrupted sleep, and deconditioning. Her earlier statements matter here. At her last annual visit she said she wanted to be treated for illnesses that could be reversed and did not want to die in a hospital, but she also said she would go if needed to get better. Her daughter can stay with her tonight but not continuously this week.

Recommendation, agreed with her daughter: transfer to the hospital for treatment of pneumonia with hypoxemia, because her oxygen saturation of 90 percent and her poor intake make safe treatment at home unlikely without continuous support. Tramadol is stopped now. The hospital team is sent her baseline description, her advance directive, and a request for delirium prevention measures: family presence, glasses and hearing aids, a regular sleep routine, and avoiding sedatives.

References

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948. https://doi.org/10.7326/0003-4819-113-12-941

Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922. https://doi.org/10.1016/S0140-6736(13)60688-1

Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., Eckert, L. O., Geerlings, S. E., Köves, B., Hooton, T. M., Juthani-Mehta, M., Knight, S. L., Saint, S., Schaeffer, A. J., Trautner, B., Wullt, B., & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83-e110. https://doi.org/10.1093/cid/ciy1121