I am a 4th year nursing student. Currently I am doing my preceptorship at ICU.
Here is the patient's profile (has been modified for patient's confidentiality):
Patient X, male, 50 years old.
Dx: Hypertensive Emergency
Medical history: GIST (GI Stromal Tumor), metastatic to liver, lungs, and spine. Surgery in 2004 &2005. Pt. used morphine for pain control at home. Patient was on PO chemo trial since last month. One week ago, pt was brought to ER for increased BP (200/110), increased HR, altered LOC. Patient C/O loss of vision and increasingly confused during waiting period at ER. MRI revealed bilateral parietal and occipital edema. Pt was intubated and transferred to ICU for BP control.
At my shift:
Pt was extubated 5 days ago. Night nurse reported that pt. had an episode of coughingà BradyàSaO2 dropped to 86%, was put on 100% O2, SaO2 returned to 96% after. ABG showed PCO2=63. Pt was on 33% FiO2 when we start our shift. We drew another ABG 0730: PH=7.43, PCO2=52, PO2=80, HCO3=35. SaO2=96%.
During assessment, pt is not fully oriented, but follows commands, moving all ext., no pain. Pt is only on Diludid infusion for pain control, no sedation.
Pt's BP remains stable (MAP at 90's) while sleeping. But once pt is awake, he is agitated, tries to get off from bed, MAP shoot to 130 to 140, SaO2 drops to low 90's. We tried to re-orient the pt, get him on the chair, relaxation music, distraction..., but nothing worked. Pt. has to be restrained to keep him pulling all the lines and tubes. Family said he is never an aggressive person. During our shift, we had to give him a lot of Propofol and versed bolus to calm him.
My questions:
What are the possible causes for the agitation?
My interpretation of the ABG: Metabolic alkalosis with respiratory acidosis (I know the PH is fine, but the numbers are abnormal, right?) . But which one is compensating which one? Are the kidneys trying to compensate the respiratory acidosis?
Thank you for reading this long posting. I am just curious to know:heartbeat
Am I the only one that noticed that we are all saying that since the pt is getting Diprivan they would be inutubated, however after re-reading the OP it clearly states that they are giving Diprivan and Versed in what appears fairly large doses and this pt had been extubated 5 days prior! I would have to think that alone could be causing some of the issues at hand with confusion and agitation.
OP watch your back here many states prohibit RN pushing Diprivan and giving it to a patient that is not ventilated is a disaster waiting to happen...at least in my opinion.
ITA! I reread the OPs post multiple times...it sounds like they are giving Diprivan and Versed to a patient who is not intubated. IDK what the state's thoughts on that are, but that is against policy at my institution, except as conscious sedation for procedures (GI lab, TEE, etc).
Since the patient has mets to multiple areas, I'd be concerned about brain mets, which can cause personality changes, decreased LOC, agitation, or other CNS problems depending on the area affected.
Delirium can also lead to agitation, and can be aggravated by giving multiple opiates and sedative agents. It is better to switch completely to another opiate or benzo rather than to add another when the first is not working well.
I.E. Patient is on morphine and Versed for pain and sedation on the vent. The Versed is not keeping him very calm, so rather than adding Diprivan, you should stop the Versed and switch to Diprivan. Or try continuous drips of morphine and Versed rather than IV pushes. If the Versed still isn't working, then switch drugs.
Does this make sense? One sedative agent and one opiate at a time.
When we switched our policy to this (we do make exceptions when necessary) we had a decrease in our delirium rate.
Look, this patient has 20 reasons to be disoriented/confused(the MRI showed brain swelling for goodness' sake). The OP asked why the patient 'when awake' (and not being sedated with dangerous medicine) is agitated and pulling at things and trying to get out of bed. It's silly for people here on this thread to try and pinpoint a medical reason for it (like i said he has 20 different reasons to be confused)
The answer to her question isnt about what diagnosis is causing it (if it IS asking this, the question is misguided) But rather what motivation is driving his behavior. Ask any experianced nurse that works with alzheimers/dementia patients. The number one reason why these innapropriate behaviors escalate is because...they have to poop.
Constipation. As i said, anything else is a guess. A bowel movement emergency is as good a guess as any.
The patient did have a PRN order for propofol ( I think we should have re-assessed the order), and the resident who came to assess the patient gave the PRN order of Versed. I am not sure about the policy regarding propofol IV push for extubated patients. My preceptor told me that it wasn't a good practice at all, but there was no way to keep the patient under control at that point.
I went back checked the chart. The patient had a BM on the following day, but was still agitated, the night nurse had to call a Code white on him on that night... I had 3 shifts in the following week, the patient was still there (total ICU stay>12 days with >10 days post-extubation).
I think his ABG may relate to his Lung met. He had shallow breathing pattern with RR around 10-12/min. I will say--R acidosis with metabolic compensation (maybe a little over compensated?)
I think his ABG may relate to his Lung met. He had shallow breathing pattern with RR around 10-12/min. I will say--R acidosis with metabolic compensation (maybe a little over compensated?)
Good Job!
A rr-10-12 is normal and wouldnt account for a pCO2 in the 50's. (meaning it's another clue that he's not in a metabolic alkylosis with resp compensation)
Also, he wouldn't be considered 'a little over-compensated' because his pH is normal.
whipping girl in 07, RN
697 Posts
ITA! I reread the OPs post multiple times...it sounds like they are giving Diprivan and Versed to a patient who is not intubated. IDK what the state's thoughts on that are, but that is against policy at my institution, except as conscious sedation for procedures (GI lab, TEE, etc).
Since the patient has mets to multiple areas, I'd be concerned about brain mets, which can cause personality changes, decreased LOC, agitation, or other CNS problems depending on the area affected.
Delirium can also lead to agitation, and can be aggravated by giving multiple opiates and sedative agents. It is better to switch completely to another opiate or benzo rather than to add another when the first is not working well.
I.E. Patient is on morphine and Versed for pain and sedation on the vent. The Versed is not keeping him very calm, so rather than adding Diprivan, you should stop the Versed and switch to Diprivan. Or try continuous drips of morphine and Versed rather than IV pushes. If the Versed still isn't working, then switch drugs.
Does this make sense? One sedative agent and one opiate at a time.
When we switched our policy to this (we do make exceptions when necessary) we had a decrease in our delirium rate.