Hi! I work night time at a medical ward and lately have received a lot of intox patients. My colleague who tonight was working on the opposite ward (we are 1 nurse plus 1 tech per ward) received an alcoholic who'd been on a binge. I asked about delirium earlier during the night to check what was going on and they did have quite a lot to do with the patient who was agitated but they didn't mention it.
Forward four hours and they call me to see if tech on my ward could help out, after 20 minutes alarm goes off and patient is in cardiac arrest. I run to help and get the impression patient had had a 40 degree Celsius fever, hallucinations, agitation, cramps and basically all symptoms of DT. Suddenly asystole so no defibrillation went off. It left a sad feeling in my gut, how quickly have you seen delirium tremens develop? Was quite a young person. I have personally never seen DT. The ER doctor must've noticed something off but still put patient on the ward instead of ICU, shouldn't it be treated in ICU generally? My colleague must've given the doctor feedback during the night of condition.
Week before had unclear intox who also arrested but lived. Doesn't feel very good to receive patients who are this ill and can survive with ICU care.
Yeah. I'm sure it could've been. I'm certain they did check electrolytes (at the very least these) before sending pt to the ward. The resident who was on call has always to me seemed good at her job, if just a slight bit arrogant, but surely must've ordered those. There was 1 person in the room when the patient crashed but not sure what happened just before.
I feel a bit more certain of what I'm gonna do if I'm put in this situation myself as a nurse, thanks to you all :-) it will surely happen at some point. Especially the part of what kind of patient load per nurse would be most safe. Couldn't possibly handle someone like this safely while also caring for 17 others.
I bet we all have our horrible residents stories! I know one who turned and walked away during a cardiac arrest cause "it isn't my patient" (but was only doctor on the ward at the time).
Warms my heart to hear you percieve me that way, I try my very very best to be just that!
Yep. It's heavy. Why we are so often upset when they send us patients who are basically in need of ICU-type care. I mean I can't possibly or safely deliver that kind of care. I mean besides all the bedpans and diapers I also need to squeeze in the i.v. treatments and administration. I know other wards have maybe 24 patients but then it's 2 techs, not sure which would be least stressful. What kind of staffing do you have night time?
Yep. It's heavy. Why we are so often upset when they send us patients who are basically in need of ICU-type care. I mean I can't possibly or safely deliver that kind of care. I mean besides all the bedpans and diapers I also need to squeeze in the i.v. treatments and administration. I know other wards have maybe 24 patients but then it's 2 techs, not sure which would be least stressful. What kind of staffing do you have night time?
Intermediate care, which is the level this patient needed to be at, is going to vary a little bit by hospital. My PRN job says three patients is the max per nurses, my FT says four is the max for intermediate. The ratios don't change between day and night because the patient is in intermediate because he needs frequent monitoring/interventions. Someone aggressively withdrawing is going to be assessed q1h whether it's night or day, as an example. Intermediate also does usually have techs to help with the ADLs.
Even then, intermediate is heavy. I have mostly been working intermediate and my second job, and even with three patients, I don't sit down all night some nights. I can't imagine carrying a load the size you're carrying and taking care of intermediate patients, too.
Would you mind spelling out for me the names and meanings of the different levels of care in english? I understand the day to day speak well but not so accustomed to the different health care related words and acronyms, would be much grateful for it!
What's PRN or FT? q1h? I guess it's something x 1 hour. During the day our unit is split in 3 groups so 6 pt per 1 nurse and tech. But it's difficult then too, I was actually more stressed during daytime than on the night shift. I think at our icu or cardiac icu (what's the acronym/correct name for that in English?) they are 2 pt per nurse+tech both day and night.
If I get a patient in withdrawal I should then assess and re-asses using ciwa? Tried to find a translation or valid similar protocol in Swedish but haven't. I did find ciwa mentioned in a guideline report. I will definitely take a more aggressive stance towards the resident, having learned from this event and your knowledge. I would be distraught if a patient of mine died like this and it could've been prevented. I think this might, and rightly so, become a Lex Maria, that is that this event by law must be reported to the government and the clinic will be scrutinised.
Sorry for all the acronyms, I forget how we all use different types of language. PRN is just as needed, FT is full time - so those aren't different levels of care, they just differentiate how much I work at each facility. As far as q1h, "q" just refers to every, so I was saying you might have to do something every one hour for an intermediate level patient, which is why a patient like that has no business being somewhere that he/she cannot be easily checked on every hour.
Lab work is standard at the ER. As well as ecg. So I'm certain they did it. As I said not heard of that alcohol protocol though and I'm certain the doctor did not give such instructors to the nurse.
Yeah, acronyms can be a bit confusing for the swede here. We got our swedish versions :-) thanks for explaining. How many different levels of care do you have where you work/patient load per nurse on the different units? Curious about that, sounds like we have quite different system here. Surgery/ortho/oncology/medical units all have this heavy load.
We have three basic levels of care at my hospital - med/surg, intermediate, and ICU. We have at least 10 med/surg units I think, maybe 3 intermediate units, and 4 ICU units. The med/surg units have 6-8 patients per nurse, intermediate has 3-4 patients per nurse, and ICU has is 1-2 patients per nurse, depending on acuity. There is no hospital setting that would take 18 patients around here. That's more of a nursing home sort of ratio in my area.
I would love to take a look at documentation systems in other countries just for kicks, because I've always wondered if it's the documentation that makes US ratios so different from ratios in other countries. I could take a lot more patients if I did less documentation. I would estimate I spend at least 4 hours per 12 hour shift documenting in ICU, and more time on documentation than that when I float to other areas. How much of your shift do you spend doing paperwork?
Are you sure DT's were the cause of arrest? Withdrawal symptoms can occur in severe alcoholics even before their alcohol level reaches zero, but true DT's typically don't occur until a couple of days after the last drink.
It's not unusual to confuse "en extremis" symptoms with DT's, and the symptoms you describe could have just as easily described a patients in end-stage sepsis, meningitis, etc, which all would have been more likely causes of sudden cardiac arrest in this particular patient.
Specializes in Acute Care - Adult, Med Surg, Neuro.
Typical orders for the alcohol withdrawal patients we see would be seizure precautions, K & Mg checks (like q8h), bedside swallow eval, fall risk precautions, CIWA scale (with scores greater than a certain number triggering transfer to a higher level of care), & antipsychotic medications PRN for hallucinations/agitation. Those who have seized already or who have a history of seizures typically have cardiac monitoring ordered. There are orders for thiamine & folic acid replacement. Typical labs (BNP & CBC, U tox) are ordered. IV fluid replacements is ordered. Chronic alcoholics may also have liver function tests and ammonia levels checked.
For withdrawals I guess I usually see tremors, sweats, and increasing anxiety. The patient can be very restless. We usually give meds titrated until the patient is sleeping. I haven't had a patient with Delirium Tremens although I have received them as a step down from ICU after it has past. Long term alcoholics are at risk for coagulopathies, esophageal varices, encepholapthy, ascites, GI bleeds. I know patients who cirrhosis can decompensate rapidly. They are usually jaundice with a big ascites belly. Many of the patients I have see have very poor judgement and are huge safety / fall risks.
Not sure this answers your question but this is what I know. Is the patient a long term alcoholic with liver damage?
hybr1d
49 Posts
Yeah. I'm sure it could've been. I'm certain they did check electrolytes (at the very least these) before sending pt to the ward. The resident who was on call has always to me seemed good at her job, if just a slight bit arrogant, but surely must've ordered those. There was 1 person in the room when the patient crashed but not sure what happened just before.
I feel a bit more certain of what I'm gonna do if I'm put in this situation myself as a nurse, thanks to you all :-) it will surely happen at some point. Especially the part of what kind of patient load per nurse would be most safe. Couldn't possibly handle someone like this safely while also caring for 17 others.
I bet we all have our horrible residents stories! I know one who turned and walked away during a cardiac arrest cause "it isn't my patient" (but was only doctor on the ward at the time).
Warms my heart to hear you percieve me that way, I try my very very best to be just that!