Patient Assessment - Deep trouble - page 5
The aim of this "game" is to look at critical indicators in assessment. Some of the patients in the following scenario are in "deep trouble" but some may not be. Can you identify the ones in... Read More
Jun 16, '03Thanks for answering the paeds one for us Kids-R-fun.
He in all probability has a fractured larynx - they are rare but I have coem across a couple in my time. the keys re teh stroy -caught across teh throat - "clothes lined" by a branch while traveling at speed. The second is the hoarse voice and the third and most important is the stridor.
By the time stridor is audible in an adult they only have 20-30% of the airway patent in other wards they are 70-80% occluded. Stridor is always a danger sign. This patient will and should be taken immediately to threatre and a tracheostomy performed. Nebulised adrenaline may be given and in extreme circumstances I have seen helium oxygen mix used on upper airway obstruction but the botom line will be a trachy.
Jun 16, '03I was starting to worry as well! I have very little experience at admitting people, I have either watched others or on one placement they said here you do it and I missed big things.
I knew there was something wrong with both patients and I went and harrasessed a doctor, the nurse who was suposed to be supervising me wasn't interested, If either of these guys decide to sue, the and assessment forms were all completed by me, and she just countersigned without reading...
1. Admited for R&r (This was a private hospital). TPR and BP NAD. Only complaint a slight rash, Wife said she had changed washing powders and he was taking piriton. The guy looked zonked(Sorry no technical terms,) bu this cold have been the piriton, but was alert and able to participate in the assessment whenever his wife let him.
Two days later this gentleman went into renal failure and was blue lighted to the NHS, before this he was amitted to the private HDU, and I did get the Dr to do Bloods, none had been ordered, and I gave up my break to treck across to the NHS hospital to get instant blood gasses.
Next time I'll tell the wife to shut up, and drag an Rn in, even if it is screaming and kicking!
Can any of you guess what was wrong with this chap?
Jun 16, '03Piritin chlorpheniramine maleate, an antihistimine.
I don't have a PDR handy , but I imagine that the rash is from something other than a simple reaction. Rash is seen as an reaction to antihistimines but not renal failure.
From his "zonked" presentation I would say that he may have liver disease. The antihistimine, which he was showing a reaction to with the rash, built up from an inability to metabolize it fully, and the reaction to the antihistimine was manifested systemicaly as its serum concentration built up.
That's all I can come up with.
I'm late to class again .................crap.
Love this stuff.
Jun 16, '03I checked with the BNF and Piriton, chlorphenamine maleate/ chlorpheniramine maleate.
One of the main side effects is sedation, so I was thinking logically at the time.
Rash from washing powder --->o/c remedy--> Side effect--> lethargy (I thought of another word instead of zonked)
This was all the gentlemen presented with, and to be honest I gave a big clue with blood gasses, and the fact he went into renal failure.
I am going back to my work, and I'll post his diagnosis later.
WhisperLast edit by Whisper on Jun 16, '03
Jun 16, '03All blood gasses will tell you is that he is in metabolic acidosis. That can be assumed from renal failure since the kidneys produce bicarb to buffer. He is in no apparent distress, just lethargic, so I can't see the gasses giving you a respiratory indication..............unless his co2 was not compensating(<45)......then he is hypoventillated and not responding to the metabolic acidosis.
Jun 17, '03Quickly posting his diagnosis before I go to work,
The gentleman had Septicemia, he was 'zonked' as a combination between this and the sedation from the piriton. I wasn't happy to complete this assessment, and there was somehting about this guy I could just not put my finger on, when the Rn wasn't bothered I talked the doc into going and seeing him first, pushing him to the front of the queue, the blood gasses weren't that important on his admittence, but they did come back with slightly altered levels, enough to bumb the guy up to a higher level of care, by day one he was going down hill fast, diagnoises confirmed, and moved to a HDU bed, over night renal failure began to show, and Gentleman was starting to circle the drain... Blue lighted over to the NHS HDU/ICU, and treated for renal failure (1st stage).
He did make a full recovery, but he was in hospital for a long time... Now anyone that even gets an allergy from the sheets, if the RN won't listen I ring dermi. just to ask their advice.
Got to run
Jun 17, '03I am amazed at how much you guys know. Peeps - how come you know so much!!?? Although I suppose once something grabs my attention I can run with it - just haven't had much opportunity to at this stage in my degree. (although I can tell you a fair bit about impetigo - but you probably already know it!!!).
Jun 17, '03Whisper - Sepsis in the elderly can be very difficult to diagnose. What kind of rash did he have? When you said rash it did run through my mind that it could be anything from peticheal spots to a severe allergic reaction. The following flow chart shows how complex "rash" can be.
Although sepsis usually have a high temp there are cases especially in the elderly who do not evidence a high temperature. Often early shock (septic and hypovolaemic) can associated wth respiratory alkaloisis. But it depends on the stage of shock as to the effect seen in the blood gases.
Jun 17, '03Thanks for the link, it look really interesting, I am on my lunch break so I can not have a proper look at the minute.
The guy was elderly, about seventy five, and had no temp, on admittence. This patient scared me, him and another gentlemen have put me off assessments, I haventcompleted one since! I think I am building a phobia about them,
I think when I go back on a placement on the wards I will be okay as long as I have a good mentor who is willing to catch any mistakes.
BTW the pts rash was NOTHING like the pictures I have seen in books of sepsis, it was nothing remarkable, and looked like little more than heat rash, but I did measure and document i was just lacking the knowledge of what the problem was.
Reading this thread is helpful as I can see things I know, and more importantly the areas which I don't which gives me a chance to correct that. If I manage to qualify it will be in less than a year, which is very worrying and very daunting considering the amount that I don't know.
By the by, the other gentlemen I mentioned earlier we thought was a CVA, but it turned out to be some tropical disease, (which I was not told the name of) So even though we were looking at the wrong cause we were giving him the right treatment.
Jun 17, '03I]From Rachelkieran[/I]
Peeps - how come you know so much!!?? Although I suppose once something grabs my attention I can run with it - just haven't had much opportunity to at this stage in my degree.
How is it possible for someone with such a crappy education to pass boards when some associate degreed students from well known schools had to retake, then excel at a vocation I was never taught??
I bought books every time I wanted to know something. I took ACLS (although I was not required to) so I could learn what a code was about. It cost me $300 I didn't have but it was knowledge that I couldn't afford not to have. When I came across something I didn't have the answer to (which was often) I found the answer and beyond.
Anyhoo, you get the point.
I'm using the same strategy now that I'm completing prerequisites for BS in physician assistant. In A&P courses, for instance, we learned about renin released from the kidneys as a response to blood pressure. If you then follow renin around some very interesting reactions occur and some always surprise me. The first reaction occurs in the lungs............................One year of school and 5 years as a certified respiratory therapist and I never knew that:chuckle
Look around The clues for what you will learn next areeverywhere.
Jun 17, '03:roll
Hi guys!! I just wante dto say that I am a student and that I love reading these posts about the Patient Assesments. They are so interesting! I am learning alot just from reading them!! Keep em coming!! Katie
Jun 17, '03if i may make a request...
when including a list of drugs given to or taken by a patient, could we please use generic names so all may know what it is we're talking about? every country has different patent names for things and it can be very confusing to puzzle them out.
just my $.02 worth...
epiglottitis is becoming a rare thing and many paeds personnel have never seen it. this is due to the advent of the haemophilus influenzae b immunization that came on the scene about 15 years ago. it is still seen occasionally in the canadian northern aboriginal population and is caused by streptococcus pneumoniae. treatment is the same for both agents: intubation with or without ventilation, antibiotics, steroids and tincture of time. racemic epinephrine isn't much help, nor is heliox.
and on the topic of cases 4 and 5, absolutely the kid with all is the priority. febrile neutropenics are usually the only oncology patients we see in the picu other than post-op cranis. when they crump, they do it in a big way.