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.
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