Case Study 7.3
Simone Walker
Lakeview College of Nursing
Nursing of the Gerontological Client
January 22, 2012

1. What might be the cause of Mrs. Stokes’s hallucinations?
     The cause of Mrs. Stokes’s hallucinations may be from adverse effects from taking/receiving morphine. Some adverse effects such as drowsiness, delirium, and myoclonus occur in direct relation to the dose which may be reversed by dose reduction (Chau, Walker, Pai, Cho, 2008). Mrs. Stokes is experiencing delirium from taking/receiving morphine. 
2. The nurse reports to her health care practitioner that Mrs. Stokes is having visual hallucinations. Based on the article, what treatments might the nurse anticipate to be ordered for Mrs. Stokes? 
       Since, Mrs. Stokes is already on a low dose of morphine. The health care practitioner is probably going to discontinue the administration of morphine and prescribed a different kind of pain medication for Mrs. Stokes. The nursing staff will continue to monitor her to see if the hallucinations return.   
Change in her pain medication, lowering her pain medication dose, treating her
hallucinations, or changing the route by which her morphine is administered

3. What other acute health problems might be the underlying cause of these hallucinations in Ms. Stokes?
      The other health problems that could be potentially causing her hallucinations are psychosis, delirium, dementia, Charles Bonnet syndrome, Anton’s syndrome, seizures, migraines, Peduncular hallucinosis, sleep disturbances, drug effects, tumors, inborn errors of metabolism, and Creutzfeldt-Jakob disease (Teeple, Caplan, & Stern, 2009).  (THOSE ARE THE MAIN ONES)
4. The physicians start Ms. Stokes on Quetiapine (Seroquel) to treat her hallucinations. What would you teach her and her family about this medication?
     Teach the patient and family: To rise slowly, prevent orthostatic hypotension, take medication as prescribed, follow-up is necessary, if drowsiness occurs avoid hazardous activities like driving, avoid over-the-counter medications unless prescribed by healthcare provider, notify prescriber immediately of fever, difficulty breathing, fatigue, sore throat, rash, bleeding or thoughts, behaviors of suicide (Roth, 2011).

 May take several weeks to be effective. Avoid drinking grapefruit juice. Side effects
that should be reported to the doctor include dizziness, fainting, drowsiness, and
constipation
5. Quetiapine (Seroquel) is also recommended for those with Parkinson’s disease; what is the rationale?
      “Neuroleptic medications (i.e., dopamine antagonists) are the mainstay of treatment for visual hallucinations due to primary psychotic illness. These medications are also beneficial for the management of delirium (in which hallucinations are thought to be due to release of endogenous dopamine), with intravenous haloperidol having the most evidence for safety and efficacy. Unfortunately, due to their dopamine-blocking activity, most neuroleptics will significantly exacerbate parkinsonian symptoms in patients with DLB or dementia associated with Parkinson's disease” (Teeple, Caplan, & Stern, 2009). 

 Quetapine (and clozapine) have a low affinity for dopamine receptors, and thus do
not exacerbate Parkinsonian symptoms.

6. Use the section on the causes of visual hallucinations to explain the hallucinations to 17-year-old Carol. 
     Explain to Carol on how it is difficult to determine how and why these visual hallucinations happen but science has some answers. Carol should be given information about visual hallucinations and explain the information to her and let her know about support groups that are out there for families dealing with family members having a family member having this condition or disorder.  

Either the lack of sleep or the pain medications or the time she was under anesthesia
may have caused her brain to be “irritated.” She is most likely to experience
these hallucinations when she is drowsy.
7. Carol says she understands, but wants to know what to say when her Grandmother says she is seeing bugs. What may be a therapeutic response?
      These are some of the things that you want to do when your Grandmother is hallucinating:
      Approach the person quietly while calling his or her name. Ask the person to tell you what is happening. Ask whether he or she is afraid or confused. Tell the person that he or she is having a hallucination and that you do not see or hear what he or she is experiencing. Talk with the person about the experience and ask whether there is anything you can do to help. Suggest that the person tell the voices to go away. Involving the person in other activities may help. Help the person find ways to handle the hallucinations, such as listening to music or watching TV. Do not hurry the person (Curtis, 2008).
8. Ms. Stokes asks whether she will have the hallucinations again. How would you respond?
    I would respond by saying that it is possibly for her to experience hallucinations again, but the medication she is taking can help control/prevent the episodes of hallucinations. She can write down the date and time, if she ever experiences hallucinations again and she can inform the doctor when she comes in for her follow-up visits.

 Because the source of the hallucinations has resolved, it is unlikely she will have
the hallucinations again. 

9. What precautions should be taken now that Ms. Stokes is back home in order to prevent further hallucinations?
Make sure she is taking her medications. That she is not taking any other medications that have not been prescribed by their healthcare provider. Have an exterminator come by to kill the bugs and prevent bugs from coming into the house. The daughter and granddaughter should come by more often to check on her and make sure is fine. The daughter can see about having a nurse come by once a week to evaluate her mom. 

   Make sure she gets adequate rest, balanced with activity. Involve her in family
activities. Avoid opioid pain medications.

        

References
Chau, D., Walker, V., Pai, L., & Cho, L. (2008). Opiates and elderly: Use and side effects. 
	Clinical Interventions in Aging: Dove Press. Retrieved from 
	http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/
Curtis, J. (2008). Helping a person who is hallucinating. Revolution Health. Retrieved from
	http://www.revolutionhealth.com/articles/helping-a-person-who-ishallucinating/aa48238
Roth, L. S. Mosby”s 2012 NURSING DRUG REFERENCE, 25th ed. Missouri: Elsevier, 2011
	& 2012.
Teeple, R. C., Caplan, J. P., & Stern, T. A., (2009). Visual hallucinations: Differential diagnosis
	And treatment. The Primary Care Companion to the Journal of Clinical Psychiatry.
	Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660156/