Need help figuring out what happened to this guy!?!?

[TigerGalLE]

Ok at the end of my shift something very strange happened with my patient. My patient was a young guy who had been an alcoholic for quite some time. Was admitted with DT's and pancreatitis. He has been in and out of the hospital for a year. He is very debilitated... can't walk and is extremely weak. He was taken off the ventilator last week and moved up to my medical floor. He is A&O to person and place. He seems like all of this has made him a little slow but he knows what is going on. He has a PEG and we are trying to get him to start eating. He is swallowing fine....

He had a good day yesterday. He sat in the chair for 45 minutes and pretty much had a non-eventful day. He wears 2L NC... He is also diabetic.... Ok so at about 1800 I went in to hang an antibiotic and he seemed to be sleeping.. His tray still was sitting on his bedside table and he hadn't been set up to eat.. So I tried to wake him up. He was extremely lethargic and I was only able to get a response after doing a sternal rub. I quickly got a SQBS which was 120... vitals were fine... temp 98 BP 130/70 HR 88 RR 18 O2 sat 98%.... So i repeatedly stimulated him until he was able to tell me that he was tired... He knew who he was but told me he was at the bank trying to cash a check? I reoriented him.. and when I asked him how he felt he said crappy..... (the assistant had been in there 30 minutes ago to change him and said he was awake then).... All he had that day that would make him drowsy was 1 percocet at 1400

Well 20 minutes later I went back and he was out again.. This time I could NOT stimulate him to wake up... Sternal rub... nail bed stimulation...nothing! I got another nurse in there and we took vitals again and continued trying to stimulate him and couldn't... vitals were fine... The only thing he would do when we would stimulate him was flutter his eye lids.....

I immediately paged his primary physician who was in house... He ordered a stat ABG and said he was coming up right then.... Well I go back in the room to wait for respiratory... I tried stimulating him again and got nothing.... He looked bad too.. he was breathing good though.... So I'm standing in the hall waiting for the doc/respiratory.. They get there in about 3 minutes... Respiratory walked in the room with the MD.... The doctor calls his name and he opens his eyes and says. "what?" They look at me and say ... "he's fine.... he's awake!! why did you call us??" I AM SPEECHLESS!!!! I don't understand!! All I could do was swear up and down that he wasn't fine a minute ago.. Now he is alert and oriented and answering their questions!!!!! How can he go from completely nonresponsive to talking in 2 minutes... They drew the ABG and it was normal...

The doctor and the resp therapist made me feel so stupid for calling... Another nurse was with me and told them that he really was nonresponsive a minute ago... I am just so confused.. And I feel stupid for calling!! I really just don't understand what happened.....

[PageRespiratory!]

But they can never seen to ignore the "hold the arm above the head and drop it" technique...

HAHA! It's incredible how well that works!! A good friend who's been a medic forever taught me that years ago.

[Mulan]

?psych, maybe he was choosing to ignore you?

my thought as well

[Kim O'Therapy, BSN, RN]

I had thought about him ignoring you also. I'm a student and would appreciate someone explaining the arm above the head thing. Thanks.

[EmmaG, RN]

I had thought about him ignoring you also. I'm a student and would appreciate someone explaining the arm above the head thing. Thanks.

One way to tell if someone is faking unresponsiveness. Hold their arm up over their head and let go. It's amazing how their arm will fall to the side

[GrumpyRN63, ADN, RN]

I'm suspicios he may have been ignoring you,maybe some visitors slipping him something, nice to run a tox screen to rule that out

[Daytonite, BSN, RN]

I worked for many years on medical units and had lots of alcoholics in various stages of liver disease as a result of it. Alcoholics are without a doubt a most interesting group of people to work with. On one hand they can be the very sensitive and caring people and on the other vicious and devious. My first thoughts in reading your post was that he probably had some build up of acetone in his system which would account for the confusion and somnolence. Or, it could have just been him pulling a little wool over your eyes since alkies are well known for having psych and behavior issues, including manipulative behaviors. I would look into his medical record and see what else is going on with his liver. The liver is a funny thing and cirrhosis can manifest itself in a number of different ways. Devoted alcoholics at the end of their drinking days who have cirrhosis can have manifestations that are behavioral in nature. It's sad to see, but they chose the lifestyle and we're left to deal with the results of it when they are hospitalized. You have to understand that maintaining a life of continual drinking involves psychological and psychiatric "fooling" of the self and others around them to justify doing it. With these patients, stopping drinking doesn't stop their treatment. Many require long-term psychiatric and psychological intervention as well.

Next time try waving an ammonia capsule under his nose. No one can ignore smelling one of those and reacting to it!

[Bugaloo]

I agree with the other nurses. Sounds as if his ammonia levels are off, or kidney failure. Also, when their liver function is screwed up, they will act like this. I would have called the doc too, so do not feel stupid. You did the right thing.:)