So.....What's up with this patient?

  1. 0
    I sent a pt to the ER yesterday from out pt rehab.I was 1 of 2 nurses.No Dr was present as is the norm in non telemetry classes in this type of setting.

    The patient has,no major cardiac history other than HTN, hx of lap -chole ,obese but no other health issue begins decompensating. She had eaten 3hrs prior and on arrival to rehab is her usual bubbly self with BP128/82,RSR, consistent with baseline. IO min after exercise she felt weak , nauseous,diaphoretic,,numbness to hands,denies chest pain but has slight pain LUQ,repeating near syncope episodes and intermittent confusion
    .BP 240/128 ,RSR 60,.No SOB but RR about 18.. Sat on RA 88% , the 4L NC bumps her to 95%.Pt is 350 lbs ,has hx of panic attacks.Exercises usually 3-4x a week for 60 min minimum x 3yrs. She is fearful but not panicking.

    My first thoughts,stroke,low sugar/dry ,MI in that order. CS 102. FAST stroke protocol negative. ASA given.12 lead,no ST changes.BP now 218/108 RSR 71 RR 17.Upgraded to NRB. BP tapered down to 160/92 56 SB .EMS arrived, pt transferred to the ED.CS in ambulance 107,RSR 60 ,136/72,transient confusion,sluggish,co operative

    The center was close to our closing time.We do not usually go with pt to ER but we were concerned that she may have panic attack en route and also that this history,weight, or transient confusion may effect her diagnosis.

    So nurses ,with the information provided I am wondering....What do you think the pt issue was?,How would you have treated her? (please bare in mind that this is out pt with only 2 staff present )What do you think was the initial diagnosis by MD in the ED? Thanks ahead of time for your input.
    Last edit by Joe V on Nov 7, '12
  2. 14 Comments so far...

  3. 0
    Important fact I forgot to include,no headache throughout.
  4. 0
    Did you just get one EKG or serial? You said no ST changes but what about RBBB/Cor Pulmonlae? Home meds? Any Anticoagulants? I am assuming RSR means regular sinus rhythm
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    RSR with no ectopy on regular strip or 12 lead EKG. As mentioned she was given Aspirin.Pt took usual daily meds.
    Cor pulmonlae... wow ....Definitely did not come to my mind or certainly in those terms !! (I honestly just looked that up .I actually never heard of right sided heart failure in its latin form before ) . I thought I was stretching it checking both arm BPs for potential aneurysm but thanks though I learned something new. The only thing I could evaluate for right side was Pt had no SOB ,JVD, or visible edema and I did not listen to her lungs.
    I am a world away from being a cardiologist.I was just wondering in the same situation what would you and in terms of care and what diagnosis do you think MD made.
    When I arrived in the ED with pt the Dr on hearing that the woman had exercised looked at her weight and said ''probably just over did it . Lets watch a bit but you likely will rest up and go home ''.60 mins now since pt had 1st got dizzy and confused I hunted the Dr down. The only treatment so far was another 12 lead that was still normal..I said to the Dr you may be right she might just be "dry "but this is a normally very sharp woman and this concerns me. Maybe to shut me up or maybe the Dr. did already plan on this but she sighed and said "ok we will do bloods and head CT" The family showed up. I left doubting myself. Had I over reacted. Should I have given the aspirin. I had noted after doing the CS that she bled alot and later worried about a bleed. I also questioned is it possible this woman normally has very high sugars and 107 for her was too low. How many times have I told students treat the symptoms not the number. I also wondered why did I just go with instinct by raising O2 from nasal cannula to non rebreather when Sat was ok. A co worker (who is not a nurse )has said in the past "your offsite but stuck in an ICU head " As I went home all these thoughts surfaced. On Monday when I am back at work I can call the pt or her Dr. Meantime I am doubting,second guessing myself.
    Last edit by echoRNC711 on Nov 3, '12 : Reason: quotation marks
  6. 2
    First of all the ED MD was being a donkey's behind. My personal feeling on why obese people have a higher mortality is because they are under treated for real diseases and ignored "because they are obese". This patient especially needed a CVA/TIA/MI work up.

    Cor Pulmonale? usually someone knows they have Cor Pulmonale/right heart failure and it isn't "abrupt onset" as the result of exercise. Being off site you did the right thing and got her to the ED. I am curious, however, why you went with this patient? Did the ambulance not have paramedics or ALS (advanced life support?) It sounds like they were medics because you mentioned she was in Sinus rhythm during he transport. When the medics are present .....you are not covered to do anything except hold the patients had. I know you meant well......but the medics are perfectly capable of dealing with a panic attack and recognizing the patients problem and appropriate intervention.

    Anytime the EMS system is activated quickly is the BEST possible reaction to any situation for it gets them one step closer to appropriate intervention.....especially if she was having a CVA. If she "normally runs high sugars" this gives her a diagnosis of diabetes but you said she has no medical history so how/why would everyone "know" she had high blood sugars? If her only history is just lap/chole....why is she in rehab? I assume cardiac rehab as you have a cardiac monitor.

    Without seeing or knowing this patient at all ........my differential would be.....place the O2 if available and call 911. What I think was going on? My first thoughts would be maybe, Pulmonary emboli, TIA, CVA, Hypertensive crisis, a panic attack, and finally MI. What would I do if I was offsite with this case scenario......I would monitor the patient place O2 if available and await EMS arrival. I might consider OJ if I thought they could swallow or give SL nitro IF they had it on their person........ I would strongly encourage them to take their medicine. But await EMS arrival.

    So....you have an obese female with SOB hypoxia, confusion, numbness, tingling, marked HTN in an outpatient setting without an MD.........place the O2 and call 911 is the right action here.
  7. 1
    I was thinking acute Cor Pulmonlae in relation to a PE. Athought it does not really fit the symptoms it is good to rule out.
    Esme12 likes this.
  8. 1
    From a new RN= possible TIA, CVA, or PE. nitro SL, O2 (hx of COPD? - drive to breath ) and call 911. MD will probably follow a cardiac protocol- get troponin level, BNP, Electrolytes and all that good stuff including ABGs and EKG.
    echoRNC711 likes this.
  9. 0
    Thanks everyone .ChseZ,I see now where you are coming from, yes PE is a great call.I am impressed that you are a student and putting it all together already using critical thinking Skills.

    Esme12, Thanks you are always supportive.To answer a couple of your questions.I have absolute faith in paramedics who consistently impress me with their ingenuity and speed. My concern was more for a confused pt arriving in the ED who could not represent herself well.I personally feel no one should attempt to go to a hospital without an advocate and statistics would support me on that one. Would I have gone if the center wasn't closing,probably not.

    Cardiac rehab is a very different type of setting and nursing.Many pt have been with us in the preventative program for 10+ yrs.(which this pt was in ) For pts it is their own community in many ways. We visit pt at home or when they are in hospital,have attended their families weddings or pt funerals and watched their grandchildren grow.We, visit pt on break time/off time in case anyone is wondering. For a select few we are their health proxy which was the case in this situation and why I felt a greater responsibility to go on my own time to the ED with her.In this situation and thank you for validating it that "the Dr. was a donkey " so I am glad I went.

    Regarding the pt. Her family called me at home today. I had used my cell phone to let pt know that I had called her attending that she was in the ED (that's why they had my cell number ) They were a little unclear of the facts but were able to tell me that she had remained in a stupor for about 12hrs. CT was negative,first 2 CPKMB's were flat. (I'm not sure if a 3rd was ordered ) However they said they were" looking into her heart muscle for damage". Whether that meant she had had an MI and they weren't understanding I am not clear on yet. They were clear that the Pt was dx with hypertensive encephalopathy and was getting an echo done. I will get a clearer pic on Monday when I speak with her PMD.
    Simma: while I would love to have given the pt a little nifedepine or in hospital setting Nipride in an out pt setting without a Dr. you don't have those choices. Yes,there is a crash cart but if the situation progresses you have the problem of (other than using the defibrilator, inserting IV access) am I willing to intubate/run a code without the Dr. In this environment it is a clear "No ". This is beyond my scope. Stabilze and "bus to ED is my focus.
    I will keep you posted on her progress . Thanks again. Your help was much appreciated.
  10. 2
    It sounds like you took really good care of her! We forget how scary it can be without all our monitors, blood work, and x-ray down the hall. She was in good hands. One thing I would like to add if I may....don't ever give aspirin in a pt where stroke may be suspected. I did read that she was having LUQ pain, which can be suspect for MI. Giving aspirin is the right thing to do for that situation alone, but any stroke symptoms should never get it before a CT head is performed. There's no way to tell if it's a bleed. Now, I totally understand that it was a crazy situation and there were so many factors happening all at once. It's super scary and you were alone. You did a great job of getting her the care she needed and you shouldn't doubt yourself. You were able to think on your feet with the resources you had in a short time under stress. That situation can be daunting even in a hospital setting with tons of staff around. The B/P was definitely a concern. Strokes present with hypertension, but it could have been related to a number of different things. But, just for future reference, if you suspect any stroke-like symptoms in your pts, never, ever give aspirin. And concerning nitro..... Even if a pt is suspected of having an MI, I wouldn't give nitro unless I had an EKG first. If nitro is given to pt's with a right-sided MI, their BP can tank. In general, there should be a PIV if nitro is given. Plus, right MI's sometimes need fluid boluses rather than vasodilators. All meds should be given by EMS (other than aspirin and O2 on scene.)

    Her confusion is interesting. I thinking maybe related to episodic hypoxia or CO2 retention? Perhaps a nonspecific metabolic encephalopathy? But you did mention hypertensive encephalopathy. Was she able to get an MRI?
    Esme12 and turnforthenurseRN like this.
  11. 1
    Quote from hodgieRN
    It sounds like you took really good care of her! We forget how scary it can be without all our monitors, blood work, and x-ray down the hall. She was in good hands. One thing I would like to add if I may....don't ever give aspirin in a pt where stroke may be suspected. I did read that she was having LUQ pain, which can be suspect for MI. Giving aspirin is the right thing to do for that situation alone, but any stroke symptoms should never get it before a CT head is performed. There's no way to tell if it's a bleed. Now, I totally understand that it was a crazy situation and there were so many factors happening all at once. It's super scary and you were alone. You did a great job of getting her the care she needed and you shouldn't doubt yourself. You were able to think on your feet with the resources you had in a short time under stress. That situation can be daunting even in a hospital setting with tons of staff around. The B/P was definitely a concern. Strokes present with hypertension, but it could have been related to a number of different things. But, just for future reference, if you suspect any stroke-like symptoms in your pts, never, ever give aspirin. And concerning nitro..... Even if a pt is suspected of having an MI, I wouldn't give nitro unless I had an EKG first. If nitro is given to pt's with a right-sided MI, their BP can tank. In general, there should be a PIV if nitro is given. Plus, right MI's sometimes need fluid boluses rather than vasodilators. All meds should be given by EMS (other than aspirin and O2 on scene.)

    Her confusion is interesting. I thinking maybe related to episodic hypoxia or CO2 retention? Perhaps a nonspecific metabolic encephalopathy? But you did mention hypertensive encephalopathy. Was she able to get an MRI?
    Or a dissecting aneurysm and if it is ascending arch it would cause neuro symptoms. When I mentioned nitro it would only to encourage the patient to take their own med. When nurses are off site with MD's and monitoring capabilities...the best case scenario would be to activate the 911 EMS system and get tot he hospital ASAP.

    I'm guessing TIA/PE
    turnforthenurseRN likes this.


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