UPDATE 7/28 I have had a few days off. Day after this post, I go in to find my pt. up in a chair, talking to friends, lucid and cheerful; helped back to bed, a lot of pain, but only tylenol. Still, her wound is still weeping serous and dressing soaks out in 2 hrs. Still has a foley but UOP good. Anyway I go back tomorrow. First I spoke with a nurse friend and was suprised to learn she is still there.
SHE HAD TO GO BACK TO THE OR FOR AND I&D OF HIP, NO ANESTHETIC CEPT A SPINAL AND HAD HEMOVAC PLACED. So, the upshot is she is not draining more than 5 ccs in the drain a shift, cultures of the hip are pending again, and she was SO MUCH pain that night the MD was called and because she is on coumadin tx and has allergies to IBU, the only thing they could come up with was neurontin. Guess it worked well for her. Cant wait to see what tomorrow brings.
Okay everyone is stumped on this lady. Lets try and figure it out without me breaking any HIPPA's
Elderly
Hx. CHF, aneurism (which left her very slightly off)
broke R hip, came in and had ORIF
oriented and talkative at admit and up to day after
Meds: pca dilaudid, removed day two Heparin GTT removed day three, on Coumadin. Multiple bruises even on her pubic area. Has had three or four units of PRBC's. Percocet, removed day four, Onadestron schedule twice daily, PRN Vicodin .5-1 Q6, Lorazepam po or iv .25 Q4 only. Daily meds include Potassium and antibiotics, prevacid, doc, senna and Lasix.
Now, the pca, percs, some phenergren were all d/c'd because the pt began to have altered loc. She also panics and has a sense of doom and hyperventilates, thus the lorazepam. Often the pt is diaphoretic and states she is hot.
She is a COMPLETELY different woman then when I first saw her.
The wound is stapled and well approximated but weeps so much serous fluid that the dressing must be changed Q2H. She obviously has much pain when turning.
During the day she becomes a bit more lucid but is unable to get up with PT more than sitting up. When she is "sundowning" or whatever is happening at the eve/noc period, she is practically having to be restrained as she is so confused she doesnt even realize she has a broken hip.
Yesterday when I took her over she had had only lorazepam X2 and TYLENOL for pain. UGGGH. This is because she denies pain when you ask her and because her son did not want her to be so loopy as it scared him.
She was becoming more and more disoriented and anxious. I and the NTL consulted everything and did vitals.. O2 sats normal, temp normal, bp normal WBC normal, blood cultures and wound culture growing NOTHING. Gave her lorazepam X1 and her vicodin, .5 X2. She only got worse. LUO on shift (250)
Our thoughts - Pain, sundowning and ARF?? Other theories were sepis but the signs are not pointing that way. Small stroke, but grips equal, no noted drooping.
She had to have Narcan X2 for sedation and guess what, she snapped out of it a lot, but that was after 10 doses of percocet the day and night before. However yesterday she had had no meds all day and still became very agitated and disoriented.
SO, what more can we do? If its been tried I will let you know. If we find out what happened, I will let you know. 
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CRNI-ICU20
482 Posts
I would get a stat CT brain....if she was bleeding enough to cause some superficial bleeding over her pubic area, she may well have been anticoagulated enough to have bled into her brain....not all brain bleeds will cause pupil inequality, but depending on the area of the brain, could be the reason for her confusion and obvious mental status change...
I don't think this is sepsis, a simple lactic acid and/or CBC with diff would rule that out....
I don't think this is heart related...because she would continue to decline if it was her heart....not plateau as she seems to have done....and her blood pressure would have changed...
since she had a history of previous aneurysm, it would be my first thought that she "leaked" a little from anticoagulation therapy.....
What was her previous INR's???