Hello,
I have a patient in their late 70’s in a SNF short term rehab. He has been in and out of the hospital since March for emergency gall bladder surgery, stent in liver and then diagnosed with end stage renal failure – he has been on dialysis since that time. No prior other major medical other than major deconditioning from back problems. It appears his kidneys are now starting to function again and will know by end of week if dialysis will be discontinued. The patient was making significant progress with rehab, walking up to 50 yards with assist, and the had a set back three weeks ago He started having confusion, some mumbled speech and refusal to cooperate with rehab, etc. It took several requests for urinalysis, staff had difficulty obtaining, and results came back negative. Requested again, another delay for 5 days and results came back positive but NP wouldn’t prescribe antibiotic for another 6 days until sensitivity report. Thus over 3 weeks of symptoms with no antibiotic. Patient just completed antibiotic treatment yesterday but continues with escalating delirium, remains non cooperative with rehab and is somewhat combative – very unlike his personality prior to a month ago. Patient may also be dehydrated as he refuses to drink but DON doesn’t want to give him IV fluids due to dialysis fluid restriction (he is allowed 1500ml day). Pt had severe constipation last week but that is resolved. Per recommendation from the nurse at dialysis, the NP agreed to remove him off five meds last week that may increase confusion (pain pills, anti depressant, muscle relaxer, antihistamine). Vitals remain normal. The NP does not take initiative or have any urgency but I’m thinking the patient should have a repeat urinalysis to check UTI status, blood panel, hydration and be examined by physician. The administrator of the nursing home says “this is normal and it’s the transition before a patient goes from rehab to full time skilled nursing care”. What are your thoughts?