Solve A Neurologic Mystery - page 4

RS is a 70 year old, lady 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.... Read More

  1. by   juan de la cruz
    Also, discharge planners, social workers, dietitians, pharmacists, physical and occupational therapists exist and are part of the ICU team along with the intensivist, other providers (NP, fellow, resident), and nurse.

    The patient wanted her independence and went home with 24-hour care which was arranged for her before she left. She was willing to pay for the service. PT and OT did asses her functional readiness to go home and felt that this was a reasonable discharge plan.

    We are an ICU team, hence, we were not responsible for her primary care. She receives primary care from a local physician who we got in touch with and updated of her hospital course. She left the hospital with a follow up appointment with her primary care physician. Neurology was involved in her case as a consulted service. They also wanted to see her as an out-patient.
  2. by   tinyonern
    Very interesting case. My first reaction was bladder infection caused mild confusion, which led to mis-taking meds, which led to NMS or serotonin syndrome, which led to... I never worked with adults (hospitalized) other than in psych, and part of that was in gero psych. Towards the end of my working career I worked telephonic disease management with the elderly, and one of the things I tried to stress was having a safety plan in place. It didn't have to be elaborate, just a phone call daily from a neighbor, someone checking if they didn't pick up paper, pull up blinds, or something that they did daily that would be noticed if they didn't do it. This person might still have gotten sick, but maybe it wouldn't have been 3 days before it was noticed. In my experience, many seniors want to remain independent, not be a burden, and many aren't willing to have strangers in their homes, but are willing to develop simple safety plans with neighbors.
  3. by   weirdscience
    Juan, this was a GREAT post. Please share more like this if you have the chance!
  4. by   judihh
    I have not a clue---- I myself am 71 and am not particularly fond of this scenario. Is she still smoking? Why is she not doing her own light housework? What does she do socially? Does she still drive? Is her only social life her 20 pack deadly friends? After she does improve she should be plugged into a stop smoking group. And her activity should be questioned and improved if need. As it is she is an accident waiting to happen. At the very least she should have a "life alert", as the next time she may be found DEAD!
  5. by   jstrawberry
  6. by   lamazeteacher
    It's good to know that there's now "turn teams" doing that very necessary aspect of patient care, in acute care settings, especially for COPD PATIENTS; and some discharge planning occurred when the patient was discharged. It seems that the plan was economically based ("the patient was willing to pay"). Was her family present to oversee coverage, however? Was the 24 hour care provided by an R.N. or uncertified aide? Did her family physician concur and order discharge meds, or was it assumed that her former regimen was adequate? What preventive plans to assure that rehospitalization or repeat performance would occur? One of the biggest costs for Medicare, is repeated hospitalization, largely based on assumptions that appropriate care and followup happen.

    To answer the impertinent question regarding my direct ICU experience, I haven't staffed ICU in the past few decades, and I have done Home Health Nursing after my advanced age caused physical limitations, which inspired me to change my role at work. One of the most neglected needs of nurses, is a pension plan. We work at different facilities according to opportunities to advance, and the work we do is full of stress. However age creeps in with destructive capacity, even though we have delayed those changes, considerably.

    When I was working in hospitals, I was an Infection Control Nurse and Nursing Educator, in the late '80s and early '90s. After that I worked to promote umbilical cord blood stem cell preservation. I believe that stem cell treatment will revolutionize medical and nursing care in the future. First, however it's necessary for innovative thinking and observation of disease process folks to get off their "high horses" and realize that "after the fact" care wastes time, lives, and money. It's quality of life that is essential as the objective for our profession. To that end, quality of nursing care is intrinsic!
    Last edit by lamazeteacher on Jun 22, '13
  7. by   Esme12
    I think that educating bedside nurses with case studies is important so that they can recognize the complications and symptoms of something so they can better care for their patients. While I have never worked at a facility the employed "turn Teams" and the bedside nurse was responsible for that is understood that these basic needs are performed as the standard of what else does the patient need....right now.

    We all know that at 3 am and the patient presents with some symptom or deterioration it is the nurse who call the MD and acts as their "eyes" and assess the patient for their needs and many times have I said wouldn't you like to order xyz? or wouldn't a xyz be helpful? so that when they ask can have an intelligent answer for them with rationale.

    Admittedly.....I have been a nurse for 35 years.....and I know very little about discharge planning for I have always left that up to the experts so that they could organize, brainstorm, and advocate for what the patients need at home.

    Unfortunately, is is all about money.....medicare restricts what it will pay for and why they will/will not pay for any govern treatment/care/therapy and unfortunately many of the elderly and disable just don't have disposable income to pay cash and the their quality of outpatient/home care is affected.
  8. by   MauraRN
    Quote from barrymedic
    Thinking about serotonin syndrome also. An over dose of her paxil may have caused it.
    I was thinking along the same line. SSRI overdoses are bears. On the other side of the coin, stopping her paxil or lorazepam can cause problems too. Paxil potentiates many other meds, including OTC/herbals. Could lead to the LOC, which led to the PNA, etc.
  9. by   emesibaja
    Just looking at ems data, one could speculate pulmonary edema related to possibly cardiomyopathy and kidney failure. Also over dose with ativan and ems giving narc an at scene could explained her agitation later.
    If she went into ARF weather is cardiac in origin or medicine or excessive fluid related that could explained her agitation due to build up of toxins or hypoxia causing ams.
    Ct ruled out stroke, edema could be due to fall, if she had an arrhythmia there is no test to test for it, cxr showed opacity so one could say bc her copd she had CAP aggravated by her copd and it got to the point that made her hypoxic and made it collapsed. Which her temp and wbc support that idea.
    Vs suggest pulm edema, cxr didn't show nothing bad so it has to be resp related supporting CAP, lactate wasn't to bad, her skin is warm so based on that we can assume she is not in shocked yet bc if she was her skin would cold among other symptoms, so that for not rules out ami.
    So most likely dx CAP that explains temp, wbc cxr findings and mental status.
    I would imagine md would order echo, bnp, ekg and trops that would rule out cardiac culprit.
    Cbc, bmp, repeat lactic, amylase, lipase, d dimers, blood gas and if a tlc is available a cvp and a mixed venous, that will provide a baseline metabolic picture it will also assessment major organs, cvp will assess fluid status and drive certain therapy , mixed venous will assess cardiac and tissue status .

    Blood cultute, u a cult and sputum cult
    Depending on cardiac work up results a cardiac cath might be needed .
    Since Ct was negative no masses were shown of pt did seized based on ct finding not rt nothing acute so they may order a neuro consult plus eeg.
    Also carotid us to assess blood to brain and possible tia.
    The results will drive medical and some or nursing care but normal icu care is require neuro checks, urine output, rhythm strip, vs, lung sounds, pulses, gi sounds and size since a decline in that will indicate worsening condition.

    Good case, it makes you think
  10. by   ives
    1) first thing that comes to my mind is the patient is post-ictal. The frothy sputum indicates either pulmonary edema but is also very common with seizures. She could and most likely has an aspiration pneumonia secondary to seizure activity. She has skeletal muscle breakdown secondary to being on the ground for undetermined amount of time. With her CPK of 20000 she probably was on the floor quite some time and will most likely have rhabdomyolosis.

    2) serial CPK levels every 12 hours, aggressive crystalloid hydration, renal consultation, loading dose of Phenytoin or utilize Keppra, control hypertension, keep patient sedated and allow for brain edema to decrease. Prevent hypertension, prevent acidosis, keep K on upper side of normal, monitor kidney function closely, antibiotics for aspiration pneumonia and begin feeding the patient via tube feeds as soon as possible.
  11. by   NRSKarenRN
    Don't know how i missed this thread when first posted in 3013. Great responses from members listing body system assessment, suggested labs/diagnostic testing and clinicalnursing considerations. Learned a new diagnosis today.