I'm wondering if there would be any interest in a "case study" that would take a patient from presentation and through treatment. There would not be any right/wrong - just an exchange and hopefully an opportunity to improve all of our abilities to critically think and be able to work through patient complaints, history and interpret the data. Also, we can look at treatment - so anyone up for it??
Brief example:
You are working in adult ED triage 74 year old female patient presents ambulatory with minimal assistance to the ED at 1500 c/o fever and feeling bad. Patient has 2 very concerned daughters and this is the 4th ED visit this week - (the other visits were at other ER's - but, the family volunteers that they were idiots working in the other ED's --- so we came here instead). Pt does not appear in acute distress.
Patient is alert but confused. (Family states this is near normal for her).
Vital Signs:
BP 104/64 HR 104 RR 22 SaO2 95% on RA Oral Temp 100.6F
History:
Hypertension
AMI 3 years earlier - placed 2 stents.
GI bleed 5 years ago -required 6 unit transfusion
NIDDM
GERD
Osteo-Arthritis/Chronic Pain
Hysterectomy at age 43
Basal cell carcinoma removed 2 years ago
Medications:
NKDA (does "break out" from adhesive tape)
Lisinopril
Atenolol
Prilosec
Plavix
Baby ASA
Duragesic Patch
Metformin
Now what? How do you proceed? Questions?
Anyone interested in participating in case studies?
Monitored bed d/t heart history, generalized discomfort, and recent electrolyte imbalance.
I'd hope to see a CBC, PCM, Mg,cardiac enzymes and EKG (no cp/sob in an elderly diabetic female with a history of CAD w/ n/v, generalized weakness), U/A and CXR. Consider lipase/amylase in light of recent c/o of abd pain.
I don't agree with giving her a gram of Tylenol for a 'fever' of 100.6; why are we rushing to treat a low grade fever if she isn't uncomfortable?
What constitutes the 'foley cath if warranted'? If she can't void?
Can the chg nurse work on moving any of the ICU holds out pdq?
Specializes in Flight, ER, Transport, ICU/Critical Care.
Hey I'll get to it -
?'s
* Th patient had IM Phenergan not IV - it was at the PCP's office 1 hour PTA in ED. But, she did get 50mg of it.
* Patient did not smoke, drink.
* No edema, strong pulses x 4
* FSBS 170
BED PLACEMENT: Sent to a general room - the primary nurse also had an evolving MI that was having pain/hypotension and active GI bleed that had blood hanging. The primary nurse was a little busy, so triage wanting to get back told the charge RN about the "old lady abdominal pain" and went back to her post in triage.
The charge nurse had one of the paramedics "get started" with IV and to go ahead and place a foley. Primary nurse told of patient while in process of hanging blood on the GI Bleed patient and was told that the paramedic was getting started.
Charge RN had completed patient assessment noting only diffuse abd pain x 4 quads with palp and normal bowel sounds. Remainder of patient assessment was unremarkable as charted by charge nurse. Charge RN did give the 1 gram tylenol PR (even did a occucult as negative for blood) and help paramedic insert foley (which revealed 200ml of foul smelling, milky amber colored urine). Charge RN left IV access to paramedic. Patient on dynamap with q 15min. NIBP, HR and Sao2. - Vitals were unchanged.
After 15 minutes trying to gain IV access/obtain labs the tearful paramedic notifies primary RN and Primary RN enters patients room. The daughters were beyond hostile. The medic that was caring for this patient had phenomenal IV and people skills - they had actually pushed the paramedic into the wall (accident?) in getting on the other side of the bed after medic failed IV access/even butterfly lab access after 4 attempts.
Patient still does not appear distressed. Sleeping and more difficult to respond - but, 50 mg of IM Phenergan might do that. A calm explanation that we had to get IV access and obtain blood to further assess their mom (our patient). The "daughters" let the RN try IV access again but they actually held the nurses arm as she tried to place IV to ensure "that you don't gouge our mommy". Primary RN was not successful.
Finally, after 45 minutes after ED arrival the MD makes it to the bedside. Yeah, the triage orders stand - he adds urine c&s, adds a 12 lead (just because) and soothes the daughters. He agree's that it looks like patient may have UTI and may need admission and we are waiting other ED records (request sent on arrival). The patient has never been to our facility. He thinks care is going in the right way - his exam was not significantly different. He asks us to "step up" the labs and IV. Right --- hadn't tried that.
IV team attempts without success (they tried once and family refused other attempts). The primary nurse went to the MD to consider the options - central access (consent has been placed on chart and tray in room) would you do an arterial stick for labs? or well, we are out of options and feeling a bit battered. MD's gives some snide remark and goes to see another patient.
The medic (who should be a saint) offered to go ahead and get the EKG - because it was ordered.
TALKING POINTS
1. When you have family that is clearly interfering with care (but may have some rights to make decisions for the patient)
2. How do you deal with these folks? Reason isn't working. Care is being delayed and compromised.
3. The workload of the primary RN is a real situation daily for many RN's. Even experience, sixth sense and dumb luck - can make it a minefield. Any tips for management?
But, at this point we have "nasty" urine, presentation that "matches" and the primary nurse has no "labs" cooking and is waiting on the MD to intervene.
Oh, we have gotten records for 2 of the ED visits. Urine was leuko + and + 4 bacteria.
EKG was no acute findings. WBC was 17, Hgb 10 and Hct was 30. K+ 2.0 nothing else notable. Was given IVF, IV Levaquin, IV 10meq Kcl runs x2 and d/c to home to force fluids, PO levaquin, Klor-Con 20 and Zofran ODT. And f/u with PMD.
So here we are an hour in? And not making much progress. Difficult access, difficult family, difficult ER doctor- some days!!!!
Now what? Oh yeah, they just gave a 18 week pregnant with lady partsl bleeding to this patients primary nurse. AMI, GI Bleed, Elderly altered a bit with abdominal pain, and threatened AB in 38 year old (IVF conceived) patient. Well, at least this nurse still has one room open.
And we wonder why nurses are not given special powers, capes, magic bracelets, telepathic power and the ability to be invisible. Hmmm....
Looks like it's compensated v-tac. Time for some amniodirone, really need that K+ level! We can work on the UTI later. I suspect she will also be getting some runs of K+. Told you from the get go she needed a monitored bed!
I had a feeling the 12 lead would change everything. Nice.
So I'm assuming (and yes, I know what happens when I do that) her clinical picture has changed. Looks like multi-focal v-tach to me. the 2 big questions I've got now are:
Is she responsive?
Pressure and pulse quality?
ACLS: defib and cpr vs. dccv vs. iv mg+/vent suppresant (amio or lido). The iv mg+ probably needs to be given right away, some will worry about depressing her respiratory drive but if you're checking DTRs then you have to almost double the loading dose after you lose the reflexes before you knock out resps.
Oh yeah.....have you "gouged their mommy" enough to get an IV yet?? forgot about that small point!
RNREMT- take it easy, don't put the cart before the horse. She has been talking and walking - yes she has been "a little confused", feels weak, etc... if she has a pulse and a BP, you don't need to "knock down" her resp. drive and intubate her. Treat the patient, not the monitor.
Assuming nothing has changed since the OP's last update, then we need to move fast, but she is "tolerating" this V-tac. I've seen it a few times in my carreer, I know a man who lived 2 days in v-tac while having a pulse, and decent pressure - before we were able to break it (this was 13 years ago).
A loading dose of Amnioderone, followed by a drip - if that does't work, we always have the old standby lido. Have the crash cart at the ready, move fast. Get runs of K+ ready too. Needs to have AT LEAST two IV sites, AT LEAST 20's, 18's would be better. If you can't get an IV, the doc should start a central line and/or art line. In a pinch, you can give meds through the Art Line, time to move fast.:heartbeat That rapid HR is my adrenaline charged pulse! lol
Specializes in Flight, ER, Transport, ICU/Critical Care.
Well guys - this is the good part.
I think that the initial decision to place the patient in a general bed and "give" this patient to the RN with 2 other sick patients was IN HINDSIGHT - not the best idea. No obvious reason to have this patient take the last monitored bed. (But I did like RNREMT-P's idea to at least get a six second strip - a paramedic action for sure but it would have changed the entire course of this case. ) But, at the time - other than the complicated "family" it looked fairly straightforward.
I think that the entire ER staff involved in her care acted in a reasonably prudent manner - given presentation, history, VS, etc.
I think that placing that foley with the "icky" urine, fever and diffuse abd pain kept all from looking further.
No excuse, but a difficult family was a key factor in delaying this patients proper treatment.
Families are given far more "leeway" in some facilities - we cater to most all demands, complainers and disruptive folks all too frequently are given priority and accommodated with whatever they "want". Any ideas how to effectively deal with these type of issues? There is a great lesson here.
Had the 12 lead been obtained before the tylenol was given/foley placed/IV access-labs attempted - I am certain that the "daughters" would have had been less inclined to direct the care of mommy. But....
The problem we have now is this ----
* That pesky 12 lead.
* NO IV access (the consent for central access was still on chart)
* and the smart mouth MD (who suggested that we work on it - well, his attitude is resolving fairly quickly).
Now,
* After the screaming from the paramedic stopped.
* The primary RN screamed for the doctor. He was in a room in the back of the ED, but the other ER doctor did "drop everything else" and assisted in getting this patient out of the general room and into a resuscitation room.
* The patient is now in the resuscitation room. The patient still does not have venous access. The patient has been placed on high flow O2, monitor, NIBP, SaO2. We are well over an hour into her "care" at this point.
Patient Condition:
* Remains sleepy, will awaken - but seems more confused. (Initially, felt by all to be caused by the monster IM Phenergan dose given at her doctor's office PTA) We got distracted!
BP: 100/58 HR: 80 RR: 12 SaO2 97% (on NRB) Monitor Rhythm looks like V-tach in LeadII.
* The daughters have been corralled as the patient is taken into the resuscitation room (amazing how fast one got opened!) and are following the primary RN into the med room as the primary nurse is urgently pulling drugs out of the pyxis. They are told in no uncertain terms that "mommy is sick and may not survive". They are asked, again, if there is anything else they can think of that they may not have mentioned? Also, they are informed of the now emergent need for access and NOW give consent to "do whatever you have to do" (that gouging problem was eliminated by the possibility of death). The primary RN notes to the daughters that central access will be necessary and that "mommy" will most likely be put on a "breathing machine" if she survives.
However, although the 12 lead is small (even the link) - lets review.
What metabolic condition can cause EKG changes like this one???
Patient presentation does not correlate well with presumed v-tach.
CONSIDERATIONS:
Patient has a obvious problem that is renal in nature.
Patient was hypokalemic less than 48 hours ago.
Was given supplemental potassium IV (and by Rx).
The super astute paramedic has started "going through" the medication bottles that were brought in by the family. All appear to correlate with the prescription instructions - except the Klor-Con it has 2 tablets left. (Original RX was for 30 with BID dosing) Hmmmm......
NOW
The charge nurse now has a 20g in the patients foot. Although there is no blood return it flushes easily and is patent.
The primary nurse is back at the bedside with an armful of meds - where the MD has done an arterial stick and FINALLY obtained labs and ABG's (that are being rushed by folks from their respective departments as STAT ).
The decision is made to start pushing meds through the "patent" peripheral IV in the foot?
No labs back yet.
IV access in the foot.
MD's (both) and lots of help at the bedside.
The 12 lead EKG is being looked at by everyone. (Surprise :) )
A decision has been made to treat prior to labs returning -
From what you've said, she may be hyperkalemic rather than hypokalemic, due to too many klor con missing from the bottle. There is still the possibility of hypokalemia due to N/V and diarrhea though. We really do need labs. The treatment of LOW K+ is simply giving K+.
If K+ is elevated, and with her possible renal failure, we could give Insulin 5-10 u and D50W 1-2 amps over 30 min. This will cause K+ to shift back into the cells from the intracellular fluid.
Sodium bicarb is another potential option, but I would hold on this one due to the fact that we don't know the rest of her electrolytes - and this treatment is contraindicated with hypernatremia and hypocalcemia.
Kayexalate is another option, but may be too slow working as it is giving PO.
Best option, INHO is Insulin/dextrose and amnioderone.
We don't have to intubate yet, but she has been compensating with this V-tac, and is now beginning to decompensate - so we do need to move fast.
I know the immediate concern is the EKG with recent changes, but as noted they are not terminal changes. HyperK+ from the Clor-Kon and urosepsis explains everything else.
) But, at the time - other than the complicated "family" it looked fairly straightforward.
robred
101 Posts
Monitored bed d/t heart history, generalized discomfort, and recent electrolyte imbalance.
I'd hope to see a CBC, PCM, Mg,cardiac enzymes and EKG (no cp/sob in an elderly diabetic female with a history of CAD w/ n/v, generalized weakness), U/A and CXR. Consider lipase/amylase in light of recent c/o of abd pain.
I don't agree with giving her a gram of Tylenol for a 'fever' of 100.6; why are we rushing to treat a low grade fever if she isn't uncomfortable?
What constitutes the 'foley cath if warranted'? If she can't void?
Can the chg nurse work on moving any of the ICU holds out pdq?