Need help figuring out what happened to this guy!?!?

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Specializes in NICU.

Ok at the end of my shift something very strange happened with my patient. My patient was a young guy who had been an alcoholic for quite some time. Was admitted with DT's and pancreatitis. He has been in and out of the hospital for a year. He is very debilitated... can't walk and is extremely weak. He was taken off the ventilator last week and moved up to my medical floor. He is A&O to person and place. He seems like all of this has made him a little slow but he knows what is going on. He has a PEG and we are trying to get him to start eating. He is swallowing fine....

He had a good day yesterday. He sat in the chair for 45 minutes and pretty much had a non-eventful day. He wears 2L NC... He is also diabetic.... Ok so at about 1800 I went in to hang an antibiotic and he seemed to be sleeping.. His tray still was sitting on his bedside table and he hadn't been set up to eat.. So I tried to wake him up. He was extremely lethargic and I was only able to get a response after doing a sternal rub. I quickly got a SQBS which was 120... vitals were fine... temp 98 BP 130/70 HR 88 RR 18 O2 sat 98%.... So i repeatedly stimulated him until he was able to tell me that he was tired... He knew who he was but told me he was at the bank trying to cash a check? I reoriented him.. and when I asked him how he felt he said crappy..... (the assistant had been in there 30 minutes ago to change him and said he was awake then).... All he had that day that would make him drowsy was 1 percocet at 1400

Well 20 minutes later I went back and he was out again.. This time I could NOT stimulate him to wake up... Sternal rub... nail bed stimulation...nothing! I got another nurse in there and we took vitals again and continued trying to stimulate him and couldn't... vitals were fine... The only thing he would do when we would stimulate him was flutter his eye lids.....

I immediately paged his primary physician who was in house... He ordered a stat ABG and said he was coming up right then.... Well I go back in the room to wait for respiratory... I tried stimulating him again and got nothing.... He looked bad too.. he was breathing good though.... So I'm standing in the hall waiting for the doc/respiratory.. They get there in about 3 minutes... Respiratory walked in the room with the MD.... The doctor calls his name and he opens his eyes and says. "what?" They look at me and say ... "he's fine.... he's awake!! why did you call us??" I AM SPEECHLESS!!!! I don't understand!! All I could do was swear up and down that he wasn't fine a minute ago.. Now he is alert and oriented and answering their questions!!!!! How can he go from completely nonresponsive to talking in 2 minutes... They drew the ABG and it was normal...

The doctor and the resp therapist made me feel so stupid for calling... Another nurse was with me and told them that he really was nonresponsive a minute ago... I am just so confused.. And I feel stupid for calling!! I really just don't understand what happened.....

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Seizure? although usually they don't snap out of the post-ictal state like that, do they?

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Maybe he was really sound asleep through your trying to rouse him.

:confused:

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Specializes in icu, er, transplant, case management, ps.

As he is a diabetic, did you check his blood sugar?

Woody:balloons:

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Specializes in Dialysis, Nephrology & Cosmetic Surgery.

This is not my area of expertise but you mention he is an alcoholic and I can remember from my nurse training - along time ago nursing a pt with hepatic encepholopathy and he would drift in and out of responsiveness. Is it possible that this would explain his response? Or another suggestion - again from limited experiene - if he has had any strong analgesia or sedation he may be numbed to painful stimuli such as sternal rub etc. He may have felt very drowsy and comfortable when you were trying to stimulate him and was not feeling pain from your attempts to make him respond. It may be that when the Dr came a spoke to him it was in a tone that demanded a response from this man? I have been with a friend when he was admitted following overdose of anagesia and he wouldn't respond to sternal rub but if I shouted loudly and with authority this was enough to induce a response. I may be well off the mark but this is the only thing I can think of.

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Specializes in Gerontological, cardiac, med-surg, peds.

Has anyone checked his serum ammonia levels?

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Specializes in nursery, L and D.

I was thinking increased ammonia levels too. Sounds like he is a prime candidate for liver failure.

Don't feel stupid for calling! NEVER feel stupid for taking care of your pts! You did what you had to do, and if you hadn't called and he was stroking, etc, then you know what would have happened!

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Specializes in NICU.

hmmm I'm not sure when his last ammonia level was.. I'm off until monday... but that is something to think about.... and yea his blood sugar was 120

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

My first guess would be ammonia levels also - however has his BUN/Creatinine been checked recently? Is he a chronic renal failure or perhaps new onset acute? People get used to a high creatinine after a while, but if it is new his "unresponsiveness" could be his body's way of handling the increased toxin load.

How about his intake/output? Is his urine more concentrated than before and with less output?

You said his ABG was normal, right? What exactly do you mean by normal? A PH of 7.35 CO2 of 45 HCO3 of 22 might all be normal, but compared to prior could show the patient is experiencing metabolic acidosis.

Finally, were his respirations shallow? Shallow respirations are usually a sign that the pt is experiencing some chemical form of sedation (whether narcotic, high CO2, high ammonia level, etc). If his respirations were "normal" depth, he might truly have been deeply asleep, with the decreased sensation normal for diabetics.

Hope this helps

Pat

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Specializes in nursery, L and D.

Let us know when you find out, should be interesting to see what is going on. Wonder if he has had any trouble since you have been off?

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ok so i love to watch the show mystery diagnosis, it sounds like poisoning, and signs of begining liver failure. has anyone done a full tox panel on him? the person on m>d> was being poisoned by his wife with rat poison. btw is anyone bring him food or drinks? let us know what happens!

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They look at me and say ... "he's fine.... he's awake!! why did you call us??" I AM SPEECHLESS!!!! I don't understand!! All I could do was swear up and down that he wasn't fine a minute ago.. Now he is alert and oriented and answering their questions!!!!! How can he go from completely nonresponsive to talking in 2 minutes... They drew the ABG and it was normal...

The doctor and the resp therapist made me feel so stupid for calling... Another nurse was with me and told them that he really was nonresponsive a minute ago... I am just so confused.. And I feel stupid for calling!! I really just don't understand what happened.....

It is really insulting that they did not take your word for it. They do that all the time and it makes me mad. :trout: I had a patient that was obviously having petite mal seizures for several days. Nursing reported it, doc denied it. Then another MD happened to witness it. Oh!!!! then the patient's attending suddenly believed it. Like I said, insulting but they do it all the time.:trout:

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