This is a case study involving an elderly female with complex medical history who presented with altered mental status of unclear etiology. The patient in this case is unable to give a history.
There are no reliable sources who witnessed the events leading to patient presentation making it more difficult to ascertain the etiology of her condition. The author hopes to elicit a discussion of her case among peers in critical care nursing.
Background / Social History
RS is a 70-year-old female who lives independently in a first-floor apartment in the city. She has no close relatives but has neighbors who know her very well and check in on her from time to time. She hires a cleaning lady that does her house cleaning and laundry every week. Her nearest relative is a niece who lives in the same state but is 8 hours away by car.
Past History
Her medical history includes anxiety disorder, hypertension, hyperlipidemia, COPD, and mild kidney insufficiency.
She has a 40 pack/year history of smoking.
She has no known allergies.
Medications
Paroxetine 20 mg daily
Lorazepam 1 mg daily as needed for anxiety
Losartan 100 mg daily
Amlodipine 10 mg daily
Simvastatin 40 mg daily
Tiotropium 18 mcg inhaled daily
Albuterol MDI 2 puffs 4 times a day as needed
Present History / CC
On the day of her ED admission, her niece had been calling her phone and had been unable to get hold of her. Her niece called a neighbor who stated that she has not seen RS in 3 days. Concerned about RS's condition, the neighbor knocked on her door and heard no response. Luckily she was able to open the door as it was unlocked. Upon entering the living room, the neighbor found RS lying unconscious on the floor. She had frothy secretions from her mouth and had urinated on herself. She immediately called 911. She was intubated at the scene by EMS responders for airway protection due to her altered mental status.
Vital Signs
BP 180/100
HR 110
RR 32
T 38.5 C
O2sat 88% on RA prior to intubation
Diagnostic Studies
In the ED, RS pertinent labs showed a WBC of 15,000 mm3, a lactate of 2.5 mmol/L, and CPK of 20,000 U/L. Neurologic exam was significant for agitation and inability to follow commands with sedation wean. She was hyperreflexic with increased muscle tone. She is moving all her extremities equally and has no abnormal pupillary response. She is sedated on Propofol. CV exam reveals sinus tachycardia with BP of 110/50, her skin is warm to touch. Respiratory exam reveals rhonchi in upper lung fields with moderate white secretions via ET tube
ABG: 7.36, 38, 82, 19, -3, 100% on ACVC: 16X400, FiO2 of 0.5 PEEP of 5.
CXR reveals mild cardiomegaly, a hyperinflated lung silhouette and mild RLL opacity.
Non-contrast CT Scan of her brain showed focal vasogenic edema in the basal ganglia.
The remainder of the exam revealed normal findings.
The ED was particularly busy that evening so RS was immediately transferred out to ICU without further testing in the ED. Because of her complex medical condition, she was transferred to the MICU under your care as her primary RN.
What thoughts run in your head that could possibly explain what caused RS's presentation?
What further testing would you anticipate?
How would you care for RS as her nurse?
For this exercise to be fun and informative, answer in the following manner:
List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why.
Tests you would anticipate.
Interventions you would provide as the bedside nurse and why.
Note: This is an actual case and the outcome is already established.
I love this kind of stuff, very interesting. I was thinking thyroid storm along with Rhab. Thanks for the presentation. It's great to see how other nurses think.
This is really, really good. In my line of duty, we can almost always look closely at the link between how patient presents, and meds that may or may not have been taken appropriately--between BP meds and Lasix you can pretty much set your clock by some of the presentations.
I spend lots of time educating on BP meds (no, by finishing the bottle last week doesn't mean you are cured) and Lasix (I know you don't want to pee every 5 minutes, yet, here we are...).
This was awesome.. took some time to really focus in to analyze the situation and possible scenarios but it was almost an adrenaline rush to find the right answer. Thanks! I look forward to more of these case studies!
Specializes in Psychiatric Nursing/Case Management.
I was thinking Serotonin insufficiency syndrome. All of the bedside things that have been mentioned sounds about right. I could love to see what her Serotonin levels are. I am more psych and less medical. I am really leaning towards the fact that she aspirated and CVA due to the hypertension that was experienced upon EMS arrival. My two cents.
My vote was for CVA induced seizures, electrolyte imbalance due to dehydration, HTN due to lack of meds.
This lady needs to be in an assisted living facility upon discharge, with low dose ASA and monthly reevaluation of her status, unless she died.
At the very least, a medalert pendant would bring help quickly.
Her meds need supervision, so Home Health Nursing Care is indicated, if she refuses to go to Assisted Living.
This is scary for me, as I also am in my 70s, live alone with no close friends or family around. I use only my cellphone, which I forgot to recharge a few years ago, and when I woke up one AM, I was very weak & dizzy. I couldn't access 911 and kept falling asleep until 4PM, when my dog's urgent need to go out galvanized me, and I went to the stairs leading to my front door on hands and knees, slid diwnstairs on my behind and opened my front door for him. A young boy returning home from school had his (charged) cellphone, called 911 and then his mother who is an RN. She gave me support while we waited, and took my (normal) VS. As I suspected, I'd had another gastric bleed, due to having taken Aleve for chronic knee pain many years ago.
When I got to the ED at the local hospital, the paramedics gave my history to a nurse whose shift was over, and she didn't relay it to anyone. So it was 4 more hours that I waited alone, sleeping in the ED, before any nurse or doctor saw me! That meant that I was without my meds or fluids for 24 hours, before care was provided. No beds on telemetry were available, so throughout the night I was 1:1'd by a nurse who was able to get an order for an IV and 3 transfusions. However the supervisor who should have accessed the blood didn't have a key to the lab...... Also no one thought to get immediate radiographic discovery of my bleeding site....
Obviously it hadn't been my day....
I'm heartened by the clever responses to this case study. I wonder however what nursing care was provided......and what discharge planning was done if this patient survived. I did, miraculously, and was sent home without orders for Home Health Nurse follow-up, or any difference in my physical circumstances. Since I'm from Canada and keep in touch with my nursing school buddies and family, they were horrified by the seemingly primeval lack of care I had.
Perhaps a look at where nurses at this site see possible improvements to care, it might make things better for seniors requiring aftercare upon discharge. Do Discharge Planners no longer exist?
While it was of greater interest of participants in this discussion, it seems that ICU Nurses are, as usual, trying to "one up" the doctors.
They have the responsibility of diagnosing patients, and it seems that in the setting wherein this occurred, they weren't sharing their opinions. Also it seems prudent to me that the non invasive head scan should have preceded the LP, as the answer was found in that.
As nurses, we can be on the lookout for patients' wellbeing. So I would have intervened to inquire about the order of diagnostic tests, and suggest that the LP follow a negative MRI of the patient's brain. Since seizure(s) had occurred, the LP might reflect residual effects of that, but the MRI would more likely reflect the etiology of it.
Nursing is about care of the patient, yet I heard no measures for comfort, turning or positioning in the responses. Even observing for neurological changes, such as pupilary reaction and size.... Seizures generally result in headache, yet no ice applications were utilized. I understand that doctors' zeal for coming up with the diagnosis and treatment plan is intrinsic for them. However we are nurses, whose job it is to observe, follow doctors' orders, and report effects of treatment and changes in condition. There wasn't much reflection of those things being done, other than reporting when the patient began "following orders". I would have liked to know what those "orders" were, and what the response was.
When I worked effectively in clinical care, I was asked why I hadn't pursued a medical career. My answer always has been that nursing is my calling. I enjoy doing things for patients, especially those tasks that bring relief of pain and move them forward to recovery from illness. If we're not doing that, then we're performing something other than nursing.
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Esme12, ASN, BSN, RN
20,908 Posts
Hey you left out the MRI result!!!! LOL.
Great case......Thanks!