*GREEN* (F)
MRN: 132719
Admitted: 12/5/04
Red Cross, M.D.
12/5/04 23:45
Patient received in post op recovery at 2330 following Managuided Closed-Field Relocation and Internal Fixation of RFL #.
All obs in normal range.
Shivering ++ but normothermic.
RFL plaster cast in situ.
Patient rousable by voice, confusion and disorientation apparent. Patient reoriented.
Patient states that she remembers a "guy" telling her that he was going to "make me a mare" before being left alone in the forest. See hospital internal incident report #1357032 and interagency mandatory reporting tool report #F3479-432 for followup.
Nil pain or distress noted. Patient is resting comfortably ATOR.
Goodcheer, RN PACU
13/5/04 00:30
Patient transferred to ward.
Patient rousable to voice, remains confused and disoriented.
Non-compliant with hoof grip assessment, all other RFL vas obs normal.
IDC in situ and draining well, for removal mane as per Dr Stone
Cloudy Skies, RN
13/5/04 06:42
Post op obs completed, nil abnormalities.
Patient slept soundly overnight and was cooperative with care. Patient alert and pleasantly confused this morning, somewhat oriented but remains vague.
Patient aware of her disorientation and responded to queries by reading her ID bracelet. Green is very impressionable and when introduced to nursing staff claimed she was also a nurse.
IDC removed, tip sighted; awaiting void post removal.
Patient denies pain ATOR.
Cloudy Skies, RN
13/5/04 08:37
Patient appears anxious and requests assistance will all ADLs. Assisted patient with toileting (PUIT) and shower. Patient cries and states “I’m sorry for being so useless, I’m wasting all your time.”
Reassured patient and returned patient to bed.
Patient ate all breakfast items, requested assistance claiming she didn’t know how to use cutlery. Patient returned to sleep after breakfast.
Redheart, RN
13/5/04 11:25
Woke patient for interview with Lunar guards, Social Worker and myself in attendance.
Green reports that her name is Green (read from her ID bracelet) and answers all other questions about her life and family with “I can’t remember”, additionally stating “Maybe I wasn’t even alive then”.
When questioned about being touched inappropriately Green became distressed and denied emphatically that such a thing could ever happen. Patient was asked why she was crying and stated “You all have the wrong idea and I can’t fix it.”, “If I tell the truth you’ll all think I’m crazy.”, and “None of this is real anyway.”
Further questioning is to be postponed until Green’s mental state improves as per social worker.
Redheart, RN
13/5/04 11:32
Attended interview of Patient by Lunar guard. Interview was terminated by myself after it became apparent that Green could not answer questions in her current mental state and was becoming distressed by the subject matter.
Full report: #548596
Not to have visitors without prior approval.
Dayglow, Social Worker
13/5/04 12:14
Miss Green referred to me by Dr Red Cross.
CTB results noted and concur with report findings, nil abnormalities.
Continue with neurological observations qShift
Monitor any behavioral changes
Withhold regular Morphine, to be given PRN only.
Will review patient tomorrow
Dr Azure Light, Neurologist
13/5/04 15:48
Regular morphine withheld as per Dr Azure Light, patient denies pain ATOR.
Green seems hesitant to speak and STML is apparent; green claims she cannot remember speaking with Lunar guards when queried. Patient claims to have seen me “years ago” but I have not met Green before today; indicates disorientation to time and pony.
Patient resting in bed ATOR.
Redheart, RN
13/5/04 23:35
Observed patient to be resting in bed throughout shift.
Care provided as per care plan.
Patient complained of pain and PRN morphine given.
Patient asleep ATOR.
Tenderheart, RN
14/5/04 06:32
Patient observed to be sleeping for long periods overnight.
Care provided as per care plan, obs stable.
At about 0330 Green was found to have wandered into another patient’s room and introduced herself as the patient’s nurse. Green appears to have imprinted on nurses as her herd and is imitating things she has heard nursing staff say and do in an attempt to integrate herself with the group.
Green startles easily to unexpected physical contact and struck her RFL against the wall when approached by RN to return her to bed. Patient denies pain/injury but appears teary. Patient states “I’m so tired”.
Returned patient to bed by levitation, patient remains asleep ATOR.
Cloudy Skies, RN