what should i have done.

[heyimnew911]

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.

[elkpark]

Obviously this guy has some issues going on and could benefit from a psych eval.

A psych eval for what? Acute withdrawal is a medical condition, not a psychiatric disorder. Seizures are a medical/neurological condition, not a psychiatric condition. If you are talking about his prior noncompliance and substance ?abuse issues, that may be appropriate at some point, but it's impossible to do any kind of valid evaluation or discussion of those issues while he is acutely delirious.

[Coffee Nurse, BSN, RN]

As a disclaimer, I don't work with adults, but it seems to me you can't have it both ways here: either he's A&O enough to "refuse assessment," OR he's altered enough to justify medicating without consent. Not both.

[elkpark]

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.

You say you "could not" assess him for possible hallucinations, but then comment that he was talking randomly and "saw things not present." That's your assessment right there -- he was having visual and, probably, auditory hallucinations. Why would you not score that? If people are not responding to your questions about hallucinations, but behaving as if they are seeing, hearing, feeling things that are not there, then, yeah, they're hallucinating.

[NurseBlaq]

So have you spoken to the director?

[heyimnew911]

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.

thanks... i was not aware of the protocol and to call the MD. i thought i was to score and give medication based on that # that is it. 0.5 mg ativan for 8, 1 mg ativan for 12.... etc... (those aren't the actuall #s, just an example). they tried a psych eval, but he ignored it or wasn't oriented enough to understand. or consent

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.

i did ... she told me not to call anybody and it was OK, since he has a history of seizures. i asked her about transfer and she said "no... and why does he need to be monitored.?"

also, he is FULL CODE.

As a disclaimer, I don't work with adults, but it seems to me you can't have it both ways here: either he's A&O enough to "refuse assessment," OR he's altered enough to justify medicating without consent. Not both.

this was the report i got. as time went on ( i had the patient for 3 days) i started FORCING assessments. just like how i was slipping medication into food.

You say you "could not" assess him for possible hallucinations, but then comment that he was talking randomly and "saw things not present." That's your assessment right there -- he was having visual and, probably, auditory hallucinations. Why would you not score that? If people are not responding to your questions about hallucinations, but behaving as if they are seeing, hearing, feeling things that are not there, then, yeah, they're hallucinating.

i meant like, listen to lungs, heart, etc... i couldn't complete a head to toe accurately. i guess those weren't important at this point.

[elkpark]

i meant like, listen to lungs, heart, etc... i couldn't complete a head to toe accurately. i guess those weren't important at this point.

I was referring to your comment in which you said, specifically in reference to his CIWA score, that you couldn't assess him for hallucinations because he wasn't responding to your questions, but that he appeared to be hallucinating. I was questioning why, if you could observe that he appeared to be having auditory and visual hallucinations, you wouldn't include that in his CIWA score, regardless of whether or not he said he was hallucinating.

[canoehead, BSN, RN]

Sounds like a hot mess. If he's catatonic, or close to it, you should be able to do an assessment. Same if he's post ictal. Anyone in withdrawals HAS to put up with an assessment in order to be scored for prn meds, and they all are uncomfortable enough to want their prns. You can trade ice cream/treats for cooperation too.

I wouldn't go near slipping refused meds in food, unless the patient is declared incompetent, and I have a physician order.

If my patient's condition changes, or I've got life threatening vitals, I call the doc. Doesn't matter if I called an hour ago, or the charge nurse says not to. Call and if they don't want you calling again they can give you parameters letting you know what they DO want to be called for. If you are concerned, and your senior nurse doesn't guide you in a way that sounds reasonable, check in with another nurse on the floor that you trust. Just to put your heads together and see if there's an idea that could be tried. Keep asking for help until you are comfortable, and go up the chain of command. It's better to make the call and be overprotective than to have the patient crump and your boss asks why you weren't more attentive.

[Alex_RN, BSN]

Do you feel bad because you could not help him in a meaningful way? I used to feel that way. I finally realized that there was nothing I could do in my 12 hours that could make any change in a patient's multiple decades of aggressive hardcore substance abuse. If I can get someone to take a shower and maybe get some thiamine into them, it is a win. I still try, though. I just don't beat myself up about it.

I would never slip meds into food, though.

[dream'n, BSN, RN]

I'm confused. You say that the patient was combative enough to refuse assessments, vitals, etc., but on your 3rd shift he was practically vegetative. That right there would have put me on the line with the Dr. right away. Sometimes you have to push..."This patient is a full code and not receiving any treatment Dr such and such. I am not comfortable with this." If the client was now at a decreased LOC, why didn't you call for labs, etc. When I worked Med-Surg, I believe that a score of 16 on the withdrawal assessment necessitated a transfer to ICU for an Ativan drip. And a blood pressure of 70/40? Why didn't you call for that? That's not a normal blood pressure by any stretch of the imagine. The seizure could have been related to his seizure history, but maybe it was due to worsening encephalopathy or drug withdrawal. I would have called the Dr or a Rapid Response.

If I were you, I'd have that meeting with management BEFORE my vacation. I wouldn't be able to relax until I spoke with the supervisor. I'm worried that this patient may have had a very bad outcome.

[joyla163]

I wrote that in regards to the OP mentioning that the patient was refusing all vitals/labs/assessments. Patients can only refuse if they have the capacity to do so. If psych deems the patient incompetent to make medical decisions (at least for the time being while he is experiencing delirium), than he would no longer be able to refuse assessment/treatment. Once he is becomes more oriented, which should happen faster if he is getting appropriate medical treatment, than they can re-evaluate competence and allow him to have a more active role in the plan of care.

I understand that withdrawal and seizures are a medical issue. But you cannot just have a patient that is admitted to the unit lay there without being assessed or treated for these problems. The most important thing psych would be able to establish is if the patient has capacity to refuse at this point in time.

[elkpark]

I wrote that in regards to the OP mentioning that the patient was refusing all vitals/labs/assessments. Patients can only refuse if they have the capacity to do so. If psych deems the patient incompetent to make medical decisions (at least for the time being while he is experiencing delirium), than he would no longer be able to refuse assessment/treatment. Once he is becomes more oriented, which should happen faster if he is getting appropriate medical treatment, than they can re-evaluate competence and allow him to have a more active role in the plan of care.

I understand that withdrawal and seizures are a medical issue. But you cannot just have a patient that is admitted to the unit lay there without being assessed or treated for these problems. The most important thing psych would be able to establish is if the patient has capacity to refuse at this point in time.

Mental capacity to make informed decisions is a general medical decision, not an exclusively psychiatric decision. Any attending physician, in any specialty, can determine that the person lacks the capacity to make a informed decision about something like refusing treatment at the present time, and that's all it takes to be able to override his rights and preferences (which is kind of scary, by itself, but that's another conversation). It doesn't have to be psychiatry; in fact, if you look at the literature on capacity, a lot of articles make the point that the person probably best qualified to determine capacity is the individual's PCP, because that person (presumably) knows the individual, and her/his baseline, better than any of the providers treating her/him in the acute hospital setting. In the case of someone who is in acute alcohol withdrawal delirium or DT, it's usually a pretty simple, obvious determination to make. If it's just too difficult for the primary attending to figure out (), then it might be appropriate to consult psychiatry.