Case study...

  1. 6 So this isn't a specific case study nor does it come from a single patient... it's an amalgamation of cases with a bit of poetic license tossed in... but it may still be helpful...

    Please, experienced nurses, forgo the urge to post before the learners have the opportunity... by all means, though, chime in to respond to them (and to correct me as needed).

    Here's the scenario...

    Pt found down on the sidewalk by EMS... No hpi available... GCS=5 on their arrival, improves to GCS=12 by arrival to ED...

    Pt is a 30-something, well-developed male... uncooperative but not combative... strong odor of alcohol... vitals are WNL, FSBG=120...

    We have venous access, airway is intact, PERLA 4 but sluggish, moderate hematoma R occiput...

    Basic trauma labs have been drawn...

    Docs say, "we need to get him to the scanner...", what do you say/do... Questions, thoughts, concerns?
  2. Visit  ♪♫ in my ♥ profile page

    About ♪♫ in my ♥

    From 'my house'; Joined Aug '07; Posts: 5,962; Likes: 11,058.

    30 Comments so far...

  3. Visit  emtb2rn profile page
    5
    Had that guy tonight.....
  4. Visit  Jayjormom profile page
    3
    Ha me too. Mine was alert enough to urinate all over the cabinets and floor of my ambulance. I really hate dealing with intoxicated patients who are buttholes. Oh how I yearn to get out of ems.
  5. Visit  smf0903 profile page
    1
    "Amalgamation"...such a great word, and it rarely is used

    Was pt actually drinking? I'm not sure if "strong odor of alcohol" means he in general reeks of etoh or patient-opened-mouth-to-exhale-and-curled-my-hair. Would you do a second FS? (I may be totally over thinking this) 30-something, well-built is unlikely to be a type 2 diabetic but could be a type 1 with BG on the downslide, which could be bad if he's in scanner and BG tanks (again, may be over-thinking this)

    Can the increase in GCS be indicative of epidural bleed? Frequent reassessment (GCS) to see if there is change in neuro status. I am thinking that with any head trauma there must be a "hope for the best but plan for the worst" way of thinking.

    Looking forward to responses on this thread
    SeattleJess likes this.
  6. Visit  Esme12 profile page
    3
    Quote from Jayjormom
    Ha me too. Mine was alert enough to urinate all over the cabinets and floor of my ambulance. I really hate dealing with intoxicated patients who are buttholes. Oh how I yearn to get out of ems.
    Yes well...remember where EMS brings them...to the emergency room. You will still have to deal with them...except they will be detoxing and even more unpleasant. ((HUGS))
    Everline, SeattleJess, and chare like this.
  7. Visit  Esme12 profile page
    3
    Quote from smf0903
    "Amalgamation"...such a great word, and it rarely is used

    Was pt actually drinking? I'm not sure if "strong odor of alcohol" means he in general reeks of etoh or patient-opened-mouth-to-exhale-and-curled-my-hair. Would you do a second FS? (I may be totally over thinking this) 30-something, well-built is unlikely to be a type 2 diabetic but could be a type 1 with BG on the downslide, which could be bad if he's in scanner and BG tanks (again, may be over-thinking this)

    Can the increase in GCS be indicative of epidural bleed? Frequent reassessment (GCS) to see if there is change in neuro status. I am thinking that with any head trauma there must be a "hope for the best but plan for the worst" way of thinking.

    Looking forward to responses on this thread
    There are keys to your concerns. ANY patient that is altered you check the blood glucose. Why are you concerned about blood glucose in someone who had alcoholism?

    There are keys in the scenario...
    Pt found down on the sidewalk by EMS... No hpi available... GCS=5 on their arrival, improves to GCS=12 by arrival to ED...

    Pt is a 30-something, well-developed male... uncooperative but not combative... strong odor of alcohol... vitals are WNL, FSBG=120...

    We have venous access, airway is intact, PERLA 4 but sluggish, moderate hematoma R occiput...
    Why would you be concerned about a hematoma in the occiput region.
  8. Visit  ♪♫ in my ♥ profile page
    3
    So the guy's clearly at risk for a TBI... also at (low-but-not-zero) risk for c-spine injury... also, without knowing HPI, abdominal trauma cannot be ruled out... docs want to get a CT STAT.

    Problem is, you've got a uncooperative drunk dude... will you be able to get a CT if he won't hold still? Then there's the issue of him sitting up and falling/rolling off the CT table...

    This patient isn't safe to go to CT... nor will the CT be effective anyway... gotta hold still... newbie docs aren't so cognizant of simple risks like this.

    So, give him some sleepy meds... a whiff of ativan, a pinch of haldol, and a bit of fentanyl... guy is pretty still now... probably is safe to go to CT... probably... sometimes they're nighty-night right up until you start sliding them to the table... then up they come. Also, sleepy meds and booze... and possible TBI... airway is a risk... but not to the level of intubation... but needs O's... NR was in place at 15L... (pre-ox in case he needs to be tubed... and help him out since he's a little sonorous at times).

    So, think through how you get this guy safely to CT and back again... could wake up and start resisting... needs the mask left in place... apparently drunk as a skunk... Needs a CT head, CT spine, CT/contrast abd/pelvis...

    You're the nurse... you're doing the transport... what should you be thinking about? What do you need with you? What precautions should you take?
    emtb2rn, Esme12, and SeattleJess like this.
  9. Visit  smf0903 profile page
    4
    [QUOTE=Esme12;8008663]There are keys to your concerns. ANY patient that is altered you check the blood glucose. Why are you concerned about blood glucose in someone who had alcoholism?

    There are keys in the scenario...Why would you be concerned about a hematoma in the occiput region.[/
    QUOTE]

    BG concern would be because the liver is dealing with the etoh and not putting out glycogen/glucose to keep BG from getting too low.

    I think the hematoma in occiput region would be of concern because it's pretty darn close to the goodies of the brain...swelling at occipital region could push on cerebellum which could push on brainstem and interfere with respiration, HR, etc. If the swelling is bad enough, couldn't the brain herniate through the foramen ovale? I don't know if the path of least resistance is inward toward middle of brain or downward toward cerebellum and spine?

    You're the nurse... you're doing the transport... what should you be thinking about? What do you need with you? What precautions should you take?

    As for transport of patient, hmm...well I would be thinking of my "what if" he gets rowdy on the table/during transport, I'm not sure what (or if there is a) protocol is for this: Are you able to take sleepytime "just in case" meds with you (since he already has a line in)?? Is restraint an option?? (I hate throwing restraint in there because it has been drilled and drilled and drilled into us that restraints are absolute last resort...plus I would think a drunk guy coming to while he's strapped down would not equate to quiet and cooperative).

    I would definitely have PPE stuff with me since drunk=spewing bodily fluids. Aspiration would be a concern for patient. I'd have something for him to throw up in as well.
    annie.rn, emtb2rn, Esme12, and 1 other like this.
  10. Visit  Esme12 profile page
    2
    Pretty good. This guy was found face down with a o=would to the back of the head. Did someone hit him?. YOU think C-spine. YOu see a hematoma in the occipital region you think possible brain bleed and basilar skull fracture. What do you look for in a basilar skull fracture.

    You are right about the brain and vitals functions on the brain stem.

    IN transporting you always think airway...have an ambu bag. Oxygenation...Non re-breather. If the patient had sedation to chill hi out I would ask for a PRN to carry with in my pocket. I would also carry narcan and/or mazicon just in case everything caught up with the patient. I would have soft wrists just in case. A pulse ox and a monitor are a must.
    Everline and ♪♫ in my ♥ like this.
  11. Visit  AmyRN303 profile page
    1
    Quote from Esme12
    Pretty good. This guy was found face down with a o=would to the back of the head. Did someone hit him?. YOU think C-spine. YOu see a hematoma in the occipital region you think possible brain bleed and basilar skull fracture. What do you look for in a basilar skull fracture.

    You are right about the brain and vitals functions on the brain stem.

    IN transporting you always think airway...have an ambu bag. Oxygenation...Non re-breather. If the patient had sedation to chill hi out I would ask for a PRN to carry with in my pocket. I would also carry narcan and/or mazicon just in case everything caught up with the patient. I would have soft wrists just in case. A pulse ox and a monitor are a must.
    Battle's sign (raccoon bruising) and test any possible CSF for halo?
    Esme12 likes this.
  12. Visit  ♪♫ in my ♥ profile page
    4
    Quote from ♪♫ in my ♥
    So, think through how you get this guy safely to CT and back again... could wake up and start resisting... needs the mask left in place... apparently drunk as a skunk... Needs a CT head, CT spine, CT/contrast abd/pelvis...

    You're the nurse... you're doing the transport... what should you be thinking about? What do you need with you? What precautions should you take?
    Quote from smf0903
    As for transport of patient, hmm...well I would be thinking of my "what if" he gets rowdy on the table/during transport, I'm not sure what (or if there is a) protocol is for this: Are you able to take sleepytime "just in case" meds with you (since he already has a line in)?? Is restraint an option?? (I hate throwing restraint in there because it has been drilled and drilled and drilled into us that restraints are absolute last resort...plus I would think a drunk guy coming to while he's strapped down would not equate to quiet and cooperative).

    I would definitely have PPE stuff with me since drunk=spewing bodily fluids. Aspiration would be a concern for patient. I'd have something for him to throw up in as well.
    IN transporting you always think airway...have an ambu bag. Oxygenation...Non re-breather. If the patient had sedation to chill hi out I would ask for a PRN to carry with in my pocket. I would also carry narcan and/or mazicon just in case everything caught up with the patient. I would have soft wrists just in case. A pulse ox and a monitor are a must.
    Two paramount thoughts... patient safety and getting the scan done.

    Before I leave the CT suite, I prod him a bit... looks like we've got a chance of him holding still and I don't think he'll leap off the table.

    Just in case though... wrist restraints... and a talk with a student accompanying me about what we're going to do if he comes up.

    Also, since this drunk guy will be laying on his back in the CT suite, with limited mobility... suction connected, turned on, and right next to his face.

    The patient ends up not holding still in the scanner... the doc doesn't want to give me the meds I need to put him down... the CT tech and myself play the safety card... doc wants to try a little morphine (which wasn't going to do squat)... as we're standing around waiting for pharmacy to clear the order the doc finally comes to her senses...

    "Let's take him back and intubate him."... Rocuronium... the ultimate restraint.

    Thanks for listening.
    outrunningzombies, AmyRN303, emtb2rn, and 1 other like this.
  13. Visit  GrnTea profile page
    0

    This is a thread that is billed as an invitation to develop a nursing plan of assessment and care, but is almost 100% focused on medical diagnoses and assessment.

    Therefore you will perhaps understand why I sit here and yell, "NURSING!!! NURSING!!!"
    Last edit by Esme12 on Jul 10, '14 : Reason: PM sent
  14. Visit  ♪♫ in my ♥ profile page
    2
    Quote from GrnTea
    This is a thread that is billed as an invitation to develop a nursing plan of assessment and care, but is almost 100% focused on medical diagnoses and assessment.

    Therefore you will perhaps understand why I sit here and yell, "NURSING!!! NURSING!!!"
    Well, I don't do the whole nursing diagnosis thing.

    For me, the salient points were...

    How do you get an intoxicated patient to and from the scanner safely?

    I suppose one could do the "risk for injury," "risk for ineffective ventilation," etc... I just don't approach it that way.

    I just think, "what could go wrong and what will I do?" and "what is the likelihood of this going bad?"

    I think I've approached it 100% from a nursing perspective... though I don't mind the medical stuff since, IMO, nursing and medicine are not the separate entities that so many proclaim so vociferously.
    eagle78 and dudette10 like this.

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