You are working in the critical care unit as a new graduate ACNP, on nights. You are the only provider on the unit that night, but you have a critical care MD, pharmacist, and hospitalist on call and available to you by phone.

Describe your assessment, interventions, recommendations, and referrals for the following patient. Support your answer with two or three peer-reviewed resources.

1. He is a 90-year-old male with mild dementia who underwent a total right hip replacement and a right-sided thoracotomy/chest tube placement earlier in the day due to a massive hemothorax from multiple rib fractures.
2. He fell down 13 stairs and remained on the floor for 13 hours before being found by his neighbor. He does not recall what happened to him or why he fell.
3. His noncontrast head CT is negative for intracranial abnormalities, but closed head injury/concussion is highly suspected. He has gotten more confused and combative as the night has gone on yet understandably is complaining of 10/10 pain in his hip and chest tube site.
4. The surgeon has ordered morphine 1 mg q. 4 hours prn pain and Tylenol 650 q. 4 hours prn. The patient’s family is very concerned and wants the patient’s pain addressed.
5. He is a full code and his VS are as follows: BP 160/75, HR 118, he’s in A-fib w/ RVR, RR 24, 02 sat 90% on 3 liters NC. This patient has COPD wearing 2 liters of 02 at home, hypertension, early stages of dementia, A-fib on ASA and metoprolol, and takes oxycodone 10 mg q. 3 hours at home prn due to debilitating rheumatoid arthritis.
   He has been without nutrition for over 24 hours and the bedside nurse says that he refuses to eat or drink anything or take his medications.