what should i have done.

Published

patient 77 year old JOHN DOE:

admitted for: encephalopathy (related to meth, benzos, opioids is what i gather)

hx: COPD, hight blood pressure, stage 3 kidney disease, unspecified seizures, (etoh,meth, opiods, benzo, abuse)

long story short, i had a this patient transferred up (med/surg) after spending a night in the ICU.

sleeps all day. refusing labs, vitals, ... basically, nobody touches him because he could be violent. though i was able to get vitals and start an IV on him. he is there detoxing. no medications or fluids. i'm to "monitor" this patient.

1) i'm a new graduate. so... what do i monitor for?

2) i noted a continuous seizure like activity on-off for a couple of minutes, gave the PRN ativan and he went back to sleep. i do not know what type of seizure. patient displayed arm tremors, upward gaze to right, and drooling. patient has a history of seizures but not taking any medication.

i had this patient for 3 days and this was new. should i have called the MD?

i got a disturbing text message from my director wanting to talk to me about this patient. i've got a 2 week vacation, but this is bothering me.

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Specializes in Med/Surge, Psych, LTC, Home Health.

Re: seizure... MD should have been notified if seizure activity was new.

You gave the Ativan, seizure stopped, then what? You said he went back

to sleep... after the seizure and then the Ativan, did you note that the

patient was back to his previous level of consciousness? Or did the patient

never regain that while you were with him?

Probably yes, you should have notified MD as soon as you were able.

Could have signaled worsening of the encephalopathy, worsening of

withdrawal... All things you were monitoring for.

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Specializes in Critical Care; Cardiac; Professional Development.

This wasn't really an appropriate assignment for a new grad. Detoxing is nasty business with so many ways to go sideways. Always remember to reach out to your more experienced colleagues when you don't feel comfortable that you have a grip on what you are watching for. Contacting the MD would have been appropriate.

In this kind of patient, you monitor for changes from baseline. You don't have to fully understand what those mean to be able to recognize they are happening and to act on them, so don't intimidate yourself too much - the critical thinking comes with time and at your stage, recognizing changes is a good place to be. Some of those things would be:

Increasing agitation

Decreasing LOC

Changes in neurological function

Changes in breathing/oxygenation

Decreased urine output

Elevating BP/vital signs

Tanking BP/ vital signs

Even if your facility doesn't use it and even if alcohol isn't involved, the CIWA tool can be useful in helping you identify some of the things you watch for in this type of patient. Likely they already have some baseline functional issues, so getting a good report on what baseline is/has been is important. Review charting for when the patient came in, how he has been in the ICU and what improvements or consistencies made them feel he was stable enough to step down.

Good for you for asking about this. Hopefully your manager is taking a mentoring approach to this rather than punitive.

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Re: seizure... MD should have been notified if seizure activity was new.

You gave the Ativan, seizure stopped, then what? You said he went back

to sleep... after the seizure and then the Ativan, did you note that the

patient was back to his previous level of consciousness? Or did the patient

never regain that while you were with him?

Probably yes, you should have notified MD as soon as you were able.

Could have signaled worsening of the encephalopathy, worsening of

withdrawal... All things you were monitoring for.

patient has a history of seizures, on no medication because of noncompliance. unless it is "slipped" into drink or food. so new in the hospital setting, but not new outside. seizure stopped and patient did regain "baseline LOC", though the patient was altered to begin with; 10 hours later. so a less vegetative state.

This wasn't really an appropriate assignment for a new grad. Detoxing is nasty business with so many ways to go sideways. Always remember to reach out to your more experienced colleagues when you don't feel comfortable that you have a grip on what you are watching for. Contacting the MD would have been appropriate.

In this kind of patient, you monitor for changes from baseline. You don't have to fully understand what those mean to be able to recognize they are happening and to act on them, so don't intimidate yourself too much - the critical thinking comes with time and at your stage, recognizing changes is a good place to be. Some of those things would be:

Increasing agitation

Decreasing LOC

Changes in neurological function

Changes in breathing/oxygenation

Decreased urine output

Elevating BP/vital signs

Tanking BP/ vital signs

Even if your facility doesn't use it and even if alcohol isn't involved, the CIWA tool can be useful in helping you identify some of the things you watch for in this type of patient. Likely they already have some baseline functional issues, so getting a good report on what baseline is/has been is important. Review charting for when the patient came in, how he has been in the ICU and what improvements or consistencies made them feel he was stable enough to step down.

Good for you for asking about this. Hopefully your manager is taking a mentoring approach to this rather than punitive.

his agitation lessened, but that was because he was almost catatonic when i came on shift. this wasn't his baseline the past 3 days i've cared for him. this seizure-like activity was abnormal even though he has a history of seizures. i've been the only person assessing him. his blood pressure was 70/40 (all else normal) when i left shift. i'm not sure if it was the librium because it never tanked that low prior even with the medication. his CIWA score was 23. it would be higher because i could not assess his tacticle, auditory, or/and visual hallucinations due to him not answering me. he did talk randomly and saw things not present.

after his stay in the ICU, absolutely no monitoring was done for the following 3 days. labs, vitals, etc... i did request the patient be chemically or physically restrained and all medication switched to IV so we could treat him. but no doctor did it.

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Specializes in Critical Care; Cardiac; Professional Development.
patient has a history of seizures, on no medication because of noncompliance. unless it is "slipped" into drink or food. so new in the hospital setting, but not new outside. seizure stopped and patient did regain "baseline LOC", though the patient was altered to begin with; 10 hours later. so a less vegetative state.

his agitation lessened, but that was because he was almost catatonic when i came on shift. this wasn't his baseline the past 3 days i've cared for him. this seizure-like activity was abnormal even though he has a history of seizures. i've been the only person assessing him. his blood pressure was 70/40 (all else normal) when i left shift. i'm not sure if it was the librium because it never tanked that low prior even with the medication. his CIWA score was 23. it would be higher because i could not assess his tacticle, auditory, or/and visual hallucinations due to him not answering me. he did talk randomly and saw things not present.

after his stay in the ICU, absolutely no monitoring was done for the following 3 days. labs, vitals, etc... i did request the patient be chemically or physically restrained and all medication switched to IV so we could treat him. but no doctor did it.

I am a little confused how you could be the only person assessing him and I am probably misunderstanding you somehow. Can you clarify on that? You obviously can't be there 24/7. How did the other shifts assess him? What did their report and charting tell you?

What you are saying just has insufficient management written all over him. Was an EEG done? Why wasn't he on anti-seizure medications if he had a history of seizing? Why was he catatonic? What was the discharge plan? All questions that I would be asking were I his nurse.

Come back and let us know what your manager had to say. I hope you documented your communication with the physicians.

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Yikes. Yes, definitely call for a seizure. Who cares if at home he is non compliant with his seizure meds? He's in the hospital now and seizures can be dangerous. If the doc knew, he would have likely added more withdrawal meds or iv antiseizure medications.

Also his sbp was 70 and his mental status was altered? And you still didn't notify the doc? Maybe he was severely dehydrated if he was too altered to eat or something else was going on.

This sounds like a really scary situation and you may need additional direction on when to call the doc.

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I am a little confused how you could be the only person assessing him and I am probably misunderstanding you somehow. Can you clarify on that? You obviously can't be there 24/7. How did the other shifts assess him? What did their report and charting tell you?

What you are saying just has insufficient management written all over him. Was an EEG done? Why wasn't he on anti-seizure medications if he had a history of seizing? Why was he catatonic? What was the discharge plan? All questions that I would be asking were I his nurse.

Come back and let us know what your manager had to say. I hope you documented your communication with the physicians.

"patient refuses to be assessed" etc... documented everywhere. majority of nurses/assistants do not want to get near him because he sometimes is combative. i'm a male. i did my own vitals, physical (as best as i could), i was slipping medication into food (i know this isn't ethical, but ... yeah...), and i place an IV when there was none.

an EEG was done, previous admission 4 months ago. he was on seizure medication, but he did not take it. the charge nurse told me not to slip medication into his food, but i did it anyway. MD did not want to give me a IV equivalent. I have no idea why he was catatonic, hence i reported it because it was a change of status from baseline. discharge plan was to have him sent to a shelter because he is homeless.

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If his CIWA score was 23 he should have already been getting PRN ativan along with a librium taper. Usually facility policy is to notify the MD for 2 consecutive CIWA scores greater than __ (we use 8). So the MD should have been notified prior to the seizure activity that there was an issue. Also, seizure activity while admitted warrants MD notification. Even if they aren't ordering anything new, they should be aware of changes in the patients status. Detoxing patients can go south quickly, it's important to get ahead of the withdrawal so that you can anticipate/manage potential complications.

All of that being said, your co-workers share much of this blame. "Patient refusing assessment" works if the patient is A&O and competent to make medical decisions. Obviously this guy has some issues going on and could benefit from a psych eval. Your co-workers could have used a little team work (1 distract while 1 assesses) to help avoid this episode.

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Yes you should have notified the MD as it was new change of status. You did give the correct Med but should be watching that vitals don't change. Was Librium being given? If meds aren't given for a detoxing pt then things like seizures, rhythm changes, etc will happen.

Did you not have a Charge or more experienced nurse to ask? Your charge nurse should have helped you through this One.

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I'm shocked at the "slip medication into his food" when the patient is non-compliant. This not only violates the ethical principle of autonomy, but I believe it constitutes battery.

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Specializes in Medical ICU.

This pt sounds inappropriate for med surg. Especially with a CIWA score of 23. Reason being, that high of a score triggers more frequent assessments and is very difficult to manage on med surg. What was his code status? I come from med surg and we had a pt similar sounding (etoh, encephalopathy, resisting care although not violent per se) and the docs were basically just letting her sit there, full code, not giving any meds, fluids, anything. Our big question was how can you let this pt lay here like this and not do anything and she is a full code?? We actually got the director of medical affairs involved when no doctor would listen to us, and then things started to happen. So for your pt in particular, things to remember for next time, if you start an IV and you're able to, try to grab some labs. Even if they aren't ordered, you can let the doc know you obtained them and see if they want them...I would have grabbed a tube for a cmp/bmp, a CBC, and an ammonia level...I wonder what his ammonia level was bc that could also be contributing to his catatonic state and violence. Then document that you did the iv/labs, called the doc, suggested labs, and what the response was. Document everything you suggested and what the response was. I definitely think you should have called about the seizure. Sometimes I see people not call a doc bc previous nurses were reporting "everyone knows about it" but really...can you be sure? The worst that can happen is the doctor gets snippy with you but at least you've done your part, let him/her know, and documented it. The slipping meds into foods, he is not alert and oriented and so you do what you have to do, especially if he needed lactulose eventually if his ammonia level was high...I'd be pouring that into some applesauce or something! When a previous person said it violates the principle of autonomy...he was not alert and oriented I gather? We crush meds and put them in food all the time to get people to take their meds, even when they are confused. This is common.

Anyway my advice here, to summarize, is document document document, go up your chain of command when you feel something isn't right or the pt isn't getting what they need, don't assume the doctor knows something and don't be afraid to call them, don't ever be afraid to ask questions. You were right to question this pt.

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Specializes in Critical care.

I agree with Kelly- this patient was far from appropriate for a med surg floor.

Was anything done about a BP of 70/40? The MAP for that BP is 50- we are ok with lower BPs in the icu as long as the MAP is ok and/or the patient is asymptomatic. I wouldn't have been ok with a MAP of 50 (we are ok with greater than 60, sometimes 55), especially in a patient as lethargic and not with-it as you described.

I chart to cover my behind. I will always notify or page the doctor and chart as such- "Dr. Green aware patient's of BP of 70/40. Suggested fluid bolus and maintenance IVF. No new orders at this time" or something similar to that. If I've paged and I'm waiting for a call back I'll state that "Paged Dr. Green to notify that pt's BP currently 70/40- awaiting call back with no new orders at this time".

I've come in and taken over care of patients with vitals that I'm not ok with. I trust the nurses I get report from and that the doctors and residents are aware of the abnormal vitals, but I like to check in with them and reiterate my concern and ask what the plan is. I then chart as such, because I know I'll be the first thrown under the bus if something happens.

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