ACE.D triptych

Ertha Williams


Ertha Williams is 74 years old, retired, and living with her husband Henry. Henry and Ertha had one son who was killed in the war 10 years ago. They have a daughter-in-law, Betty, who is a nurse, and one grandson, Ty. Ertha and Henry have experienced a lot of change in the past year. Henry was hospitalized with COPD and became more and more concerned about Ertha because she was experiencing frequent memory lapses. They were recently able to get an apartment in an assisted living facility. Neither of them can drive.


Ertha describes her journey over the past year. She talks about Henry's hospitalization and says she doesn't know what she will do if she ever loses her Henry. She relates that she has some good days and some bad days, and gets very anxious and cries when she recognizes she is confused and realizes that she has forgotten some important life events. Ertha tries to describe what it's like to know she is getting confused and forgetful and how it feels to be so dependent on others. She is hoping the doctor can give her some medicine to help her get better. She says she likes the new apartment and she gets to go in the van a few days a week to a nice center where they have a lot of activities.

Scenario 1 Scenario 2 Scenario 3

The staff at the assisted living facility has noticed that Henry covers for Ertha a lot. Henry admits to the staff that his concerns about Ertha are increasing. He says that recently he has had trouble convincing Ertha to bathe and change her clothes and he doesn't sleep well because he hears Ertha up at night wandering in the apartment. He has put chairs in front of the door and uses the chain lock so Ertha doesn't get out. Ertha's physician prescribed a sleeping pill, Ambien, but it hasn't helped. Henry has been giving her Benadryl during the day when she is "anxious." During the scenario the nurse will visit Henry and Ertha in their apartment and will do several assessments including the Mini-Cog, review Ertha's medications, applying the Beers Criteria, and explore what additional care options can be provided at the assisted living facility and what is available in the community.

It is six months later; Henry passed away three months ago. Ertha is more confused, cries frequently, and looks everywhere for Henry. She is not eating well and has lost weight. The nurse at the assisted living facility does not feel she meets their guidelines any longer and will need a higher level of care. She asks Ertha's daughter-in-law, Betty, to come in to discuss a move to a long-term care, skilled nursing facility. During the scenario Betty reports that Ertha calls her frequently every day, forgetting that she has called earlier. The nurse will repeat the Mini-Cog and administer the geriatric depression scale. At the end of the simulation the nurse will be expected to contact the primary care provider and use SBAR to report Ertha's behavior and the results of the assessment. The nurse will also discuss her medications and request a transfer order.

It is four months after Ertha's transfer to the long-term care facility. She is even more confused, going into other patient's rooms looking for Henry and stealing items. She recently began striking out at other residents, and staff finds food stashed under her mattress. She has been taking two antidepressant medications, an anti-anxiety agent and Aricept for the past four months but there has been no improvement. During this scenario the nurse will review Ertha's medications and assess her using the SPICES tool to determine if she should be moved to a behavioral health unit for Alzheimer's patients. She will report her findings, using the SBAR communication tool, to the primary care provider.

Finish the Story Assignment


Learners have now seen Ertha at three snapshots in time. What do they think her life will be like three months from now?

Author Information

Jeanne Cleary, BSN, MAN, RN
Ridgewater College
Willmar, MN


The Ertha Williams unfolding case content was reviewed in 2019.