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  1. SafetyNurse1968

    Case Study: Unexplained Bruises

    If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. History of Present Illness: Ann is a 6 yo girl who is brought to the pediatric clinic. For the last week, her mother says she has been very tired, lacks energy, sleeps more than usual, and has not had much appetite. Upon assessment, you discover bruises on the little girls’ arms and legs that Karen can't explain. She says, "I had no idea those were there!" and looks embarrassed and worried. Past Medical History: Ann was full-term from an uncomplicated pregnancy and delivery. All immunizations are current. Ann had measles at age 3 yo. Family History: Ann has one brother, age 8 years, who is in apparent good health. The maternal grandmother died at age 55 from rectal cancer. Social History: Developmental milestones on target. Medications: None Allergies: NKDA General Appearance: Alert, interactive, pale, height and weight normal for 6-yr-old Vital signs: BP 108/68 HR 130/min RR 20/min T 98.7oF HT 41 inches WT 37 lbs What are all the possible reasons for these signs and symptoms? Do you remember normal values for pediatrics vital signs? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run?
  2. SafetyNurse1968

    Case Study: What’s Causing This Cough?

    If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint: Provided by caregiver: “My grandfather is confused and pretty sick. He was up most of the night coughing.” History of Present Illness: H.T. is an 82-year-old Hispanic male who is widowed and a retired grocery store owner. His 28-year-old granddaughter lives with him. He uses a walker and takes daily walks in the neighborhood with her. He can perform most ADLs, but his granddaughter prepares his meals. He presents to the clinic with his caregiver who reports that about a week ago, Mr. T. came down with a cold and had a runny, stuffy nose. He visited the curandero and has been drinking gordolobo tea with honey, lemon and a generous dollop of tequila. He appeared to be getting better, but then several days ago he developed a cough. Over the last two days, the cough has become worse and he can’t seem to catch his breath. He was confused last night and nearly fell getting out of bed. General Appearance: The patient’s age is consistent with that reported. He is well-groomed and neat, uses a walker for ambulation and walks with a pronounced limp. He is lethargic, frail and thin oriented to self only. Patient is coughing and using accessory muscles to breathe. Appears uncomfortable and in moderate respiratory distress. Past Medical History: Tobacco dependence x 60 years Chronic bronchitis for 10 years Urinary overflow incontinence for 10 years HTN x 5 years, BP averages 140/80 with medication Mild right hemiparesis caused by CVA 3 years ago Bipolar x 50 years Constipation x 6 months Influenza vaccination 3 months ago Family History: (+) for HTN and cancer, (-) for CAD, asthma, DM Social History: Lives with granddaughter in his home Smokes ½ ppd Some friends recently ill with “colds” Occasional alcohol use Medications: Atenolol 100 mg po QD HCTZ 25 mg po QD Aspirin 325 mg po QD Aripiprazole 15 mg po QD Combivent MDI 2 puffs QID (caregiver states patient rarely uses) Albuterol MDI 2 puffs QID PRN Docusate calcium 100 mg po HS Allergies: Penicillin (rash) Okay, super sleuths, what are all the possible reasons for a cough? What’s causing his confusion? I think the most fun way to play is to imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  3. If you think you know the correct diagnosis for this Case Study (CSI)... Do not post the answer here. Instead, post your answer in the Admin Help Desk. We don't want to spoil it for others who are late in joining us. In a few days, after the diagnosis is posted, Admins will announce the names of those who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You can ask questions and comments below. Chief Complaint “My son died a month ago. He was stationed in Afghanistan. I think I’m still in shock. For the last few weeks I haven’t slept well. I keep waking up in the middle of the night, my heart pounding, out of breath, and now on top of that I’ve been feeling nauseated. I even threw up yesterday. I wonder if I have the stomach flu. I’m just praying I don’t have another migraine coming on.” History of Present Illness A.W. began to experience shortness of breath and racing heart approximately two weeks ago, primarily at night. Nausea began two days ago with two episodes of emesis yesterday. Admits to burning pain in her throat that she attributes to heartburn. Ms. W. has been depressed and anxious since learning of her youngest son’s death. Ms. W. states she has been feeling more tired than usual, but attributes it to lack of sleep and stress over her son’s death. Most recent migraine was over a month ago. General Appearance Looks anxious. Eyes wide, blinks a lot, shoulders tense, diaphoretic, occasionally rubs stomach just under sternum. Pt appears female, skin is brown in color, appears stated age, looks slightly overweight with weight carried around the middle. Okay super sleuths, what’s going on here? What information do you need? What would you do first? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  4. SafetyNurse1968

    Case Study: I’m too tired to walk the dog…

    Chief Complaint “Over the last few months I’ve been increasingly exhausted. I thought maybe I just needed some time off, but now that I’m actually taking a break from work, I’ve been feeling worse than ever. This last week I haven’t even been able to walk the dog.” History of Present Illness T.K. is a 51 year old woman of mixed race who presents to her primary care provider with progressive fatigue, loss of appetite and mild nausea for the last 6 days. She has been at home for the last 5 days on leave from work but has been unable to take part in her usual activities including walking the dog and gardening. Her partner has insisted that she make an appointment with her primary care provider. General Appearance Looks fatigued: eyes and shoulders drooping, sighs deeply every few minutes, flat affect, moves slowly and with effort; pt appears female, skin is brown in color, appears stated age Past Medical History Broken clavicle from a fall from her bicycle, treated with surgery 10 years ago Latent TB, Positive PPD 4 years ago, treatment with isoniazid (INH) for 9 months High blood pressure, pre-diabetes and hypercholesterolemia for 2 years controlled with diet and exercise Mild depression diagnosed 4 years ago, treated with Prozac and counseling Family History Mother had Ductal Carcinoma In Situ 15 years ago Father had MI at age 65 One brother died from opioid overdose at age 21 One sister (age 45) with Graves disease Social History Born and raised in Asheville, NC Works in an insurance office doing medical coding, previously had been an RN, but quit R/T latent TB Partner teaches elementary school, no medical issues Drinks 1-2 alcoholic beverages per week, non-smoker, occasional cannabis use, denies other drug use Loves gardening and hiking with partner and dogs Tries to walk daily and follows low carb, low cholesterol, low salt diet Medications Prozac 40 mg PO daily for mild depression Acetaminophen 650 mg PO, every 4 hours PRN pain Loratadine 10 mg PO daily for allergies Benadryl 50 mg PO qhs PRN sleeplessness Multivitamin, Centrum, PO daily Allergies NKA Review of Systems (only abnormal systems are presented) Weight loss of 10 pounds in last month Salt cravings for several weeks until loss of appetite a week ago Several bouts of dizziness, one fainting spell in last 6 months Few aches and pains Very dry skin, subnormal turgor, sparse axillary hair, pigmented skin creases on palms of hand, elbows and backs of knees Breasts have very dark areolae, hyperpigmentation prominent along brassiere lines Moderately weak pedal pulses (1+) Vital Signs BP sitting, RA 96/72 HR 80/min RR 12/min T 98.7oF HT 5 ft. 8 in WT 170 lbs What else do you want to know? Feel free to ask questions and make comments below.
  5. SafetyNurse1968

    Case Study: My Stomach Hurts

    DIFFUSE ABDOMINAL PAIN “Mr. Halpert, what seems to be the problem today?” you ask as you scroll through his unremarkable medical history on your tablet. On paper he looks completely healthy. His heart rate is slightly elevated -- probably due to the pain --but all of his other vital signs are within normal range. He looks pale and slightly diaphoretic. His face is tight with pain as he says, “Please, call me Jim.” He groans and continues through a grimace, “Sorry about this. This is really embarrassing. I’ve been having pain for a few days. I thought it was just a bad burrito or something. I don’t normally come to places like this, but the pain seems to be getting worse.” Abdominal pain is the most common cause for hospital admission in the US. It represents a wide spectrum of conditions from food poisoning to appendicitis. Jim’s pain could be caused by something as mild as emotional upset over his annoying coworkers, or it could be as serious as a perforation of the gut that needs immediate emergency surgery. You’ve got plans for a barbecue right after work, and in fact, your friends have already started without you. They’ve been texting you to get moving and join the fun. The last thing you want this evening is a prolonged session with a patient. You know from experience that an efficient assessment is the key to clocking out on time. What questions could you ask to get to the root of the problem as quickly as possible? THE ROOT OF THE PROBLEM I’ll bet you’re thinking of one question, in particular, …one that makes you want your pathophysiology textbook. There’s a picture in there that will help. You know the one…it’s an image of a torso with a tic-tac-toe board drawn over it. Each quadrant has a list of possible problems related to…LOCATION! Before you click on either of the references below for help solving this problem, take out a sheet of paper and see how many possible problems you can list (no peeking!) A THOROUGH PAIN ASSESSMENT You feel Jim's forehead with the back of your hand, even though you’ve already taken his temperature. It’s cool to the touch. “Where, exactly is the pain?” Jim says, “In the middle, right here” and clutches his abdomen right above the umbilicus. “It’s up above your belly button?” You ask and he nods in affirmation. “Not down below.” You point to your own belly, circling the area below your umbilicus. He shakes his head back and forth. “Is it worse on either side?” You point to your right and left abdomen as you ask the question. “Maybe just a little bit worse on the left, but I’m not really sure.” He lightly pats his stomach with his left hand right below his breast bone. “On a scale of 0-10, with 10 being the worst pain you’ve ever had and 0 being no pain, what is your pain right now?” Jim thinks for a moment and then says, “I broke my leg playing football in college, and it’s nowhere near that bad. I guess it’s around a five or a six?” You feel a sense of relief that his pain isn’t severe. You know that in mildly ill patients watchful waiting and diagnostic evaluation is often the best approach. THE OPTIONS Here’s a list of the more common reasons for diffuse abdominal pain (we’re going to look at these first…though it is possible he could have typhoid fever, it’s not very likely!) Pancreatitis Gall stones/Cholelithiasis Gastroenteritis Peritonitis Gastritis Peptic ulcer What else do you need to know to narrow this down? Make a list of questions you’d like to ask Jim. HISTORY LESSON I’m hoping your list of questions looks something like this: Pain: location (check!), severity (check!), radiation, movement, onset, duration, severity, quality, exacerbating and remitting factors. Associated symptoms: fever, anorexia, vomiting, syncope, GI blood loss Medications: NSAIDs, prednisone, anticoagulants Psychosocial: Drug and alcohol use, prolonged stress Jim asks, “What do you think is wrong with me? Could it be food poisoning?” You respond, “That depends. Let me ask you a few questions to help me narrow down what it might be. First off, does the pain radiate at all?” Jim shakes his head back and forth. You continue, “Does it get worse with movement?” Jim replies, “No, not at all. It comes and goes. There’s nothing that really seems to make it worse… or better for that matter.” You continue, “You said it started a few days ago? Is the onset of the pain linked to anything you were doing?” Jim pauses to think for a moment, “I can’t think of anything. I guess I mentioned I went out for Mexican food with some friends.” You ask, “Did any of them get sick?” He shakes his head no. “Have you had any vomiting or diarrhea?” “Yeah, a little diarrhea, but I haven’t thrown up. I do feel a little sick to my stomach occasionally. I guess that means it’s not food poisoning, huh…It’s weird…I haven’t wanted to eat at all. Every time I try to eat something, I feel full right away. I guess that’s why I thought it was something I ate.” You add, “Food poisoning usually comes on pretty quickly with some fairly unpleasant side effects, but we’re not ruling anything out yet. Have you noticed any blood in your stool?” Jim turns slightly red and says, “No, I mean, not that I’ve noticed.” You ask, “Have you ever had anything like this happen before?” He shakes his head back and forth. You continue, “Try to describe the pain for me. What is it like?” Jim replies, “It's horrible!...but I don't think that's what you mean...” You give a sympathetic smile and say, “Is there any cramping? Is the pain sharp, or more like a dull ache, does it come in waves?” Jim responds, “No, there’s no cramping, no waves. My stomach is tender though if I press on it, it hurts. I guess the best way to describe it is kind of a gnawing or burning pain, if that makes any sense? And it comes and goes…and I have lots of indigestion like I said…no appetite and feeling nauseated. I’m just so tired…” You look up from typing in Jim’s symptoms to ask, “Tired of being in pain?” Jim answers, “Yes that, but also just tired all over. All I want to do is sleep, but I can’t because of my stomach.” You nod and pick up the tablet, “I hear you, it’s hard to be in pain for a few days. It’s good that you came in. I’m going to have the physician come in here in a sec, and she’s going to do a more thorough exam. I just have one final question.” What Is It???? There’s one question that will really seal the deal here. What’s one thing from this patient’s history that might give you a big clue to what is causing his abdominal pain and get you out of work on time? Stay tuned for the exciting conclusion! I’ll post the final puzzle piece of Jim’s history, and give you some diagnostic clues as well. Feel free to ask questions and make comments below.
  6. Hospice: 3 Ways Hospice at the end of life is focused on the whole person and their needs for symptom management, their psychosocial needs as relates to their significant others, and their spiritual care at the end of life. In these three case stories by a Faith Community Nurse, we see how hospice can be about much more than simply physical comfort at the end of life. A hospice team composed of nurses, aids, social workers, administration, chaplains and more, can play a part in helping the patient and family to the point of death and beyond. Hospice nurses work in different settings, often during the course of the same day, often visiting in a home, then in a nursing home, hospital or an assisted living facility. Sometimes facilities do develop a preference for one hospice agency over another, but according to the law, hospice agencies are to be presented fairly by case managers, physicians and others who have an opportunity to refer to hospice. 1. Hospice in the Nursing Home There are some nursing homes that resist hospice care. Since hospice services are included in Medicare, it is difficult to understand why there would be any resistance. Nursing homes often do a great job taking care of patients in rehab and those who are under long term care but most could benefit from expanding their care to include hospice expertise as the end of life approaches. (The Gerontologist, Vol 46, Number 3, p325-333) The FCN, Stephanie, caught up with Edward as he walked along the sidewalk with his walker outside the assisted living facility. After exchanging greetings and small talk about the weather, she asked him how his wife was doing. Mary had been suffering from Alzheimer’s Disease for several years and had experienced a recent decline with a significant loss of interest in her surroundings, as well as diminished energy, appetite and less recognition of her family and caregivers. The family had called in their Faith Community Nurse to discuss hospice but found that Edward was hesitant to take the step. As they walked along on the late summer afternoon, enjoying a cool breeze they talked about Mary’s condition. He said, “I think she would do better if she tried harder. She just needs more stimulation.” The couple had been married for over 60 years, and his longing for her, and the grief that he was already experiencing at the thought of her impending departure from this earth were clear. Mary lived at an adjacent nursing facility so they kept moving in that direction as they talked about the recent changes. “Edward, I know your family has been talking about hospice. Are you interested in talking about that? Are there any questions that I can answer for you?” “I don’t want to do that!” He exclaimed with a flash of anger. “I want to get her into rehab. That would help more than anything.” She let the topic go for the time-being as we finished the short walk and headed into Mary’s room. In subsequent days, as Mary continued to decline and spend more and more time asleep or unresponsive, the path forward became even more clear. His daughter said, “The facility is managing the end of life symptoms well, but we need hospice for dad. Hospice might give him the support he needs to change directions and let her go.” The daughter brought up the excellent point that sometimes hospice is as much for the family and the staff as it is for the patient. Sometimes there are minimal symptoms to manage, and physical problems are not the primary concern, making the support for the family a priority. Also, in a situation with a long-term resident of a nursing home, the transition to hospice can help everyone at the facility change directions to a more palliative care frame of mind with less interventional care considered. Hospice can assist the patient, the family and the facility in being on the same page. 2. Hospice in the Hospital Shirley had experienced a difficult year:a broken hip with a stay in a rehab facility, another fall with broken ribs and pneumonia, chronic pain from degenerative changes, diagnosis of atrial fib with anticoagulation therapy, a loss of mobility and function as well as a loss of many of the activities she enjoyed in life. Her husband, Carl, was a diligent caregiver, installing ramps, assistive devices, chair elevators and much more, to make their home navigable for her. In their mutual devotion they faced each day together, not without frustration but generally glad to have more time with each other. Their FCN provided support, helping to coordinate their congregation’s attention so they it decreased their sense of isolation and helped them to stay involved as much as possible. After a long stint in rehab, Shirley was finally getting out and about more and beginning to feel a little more like herself when one day she felt sick to her stomach, vomited blood and passed out. She was rushed to the hospital where she coded and was placed on life support. Her husband knew that she did not wish to have advanced interventional care but at the moment of crisis could not face “letting her go,” as the staff said. After several days on a vent with valiant attempts to prolong her life, it became abundantly clear that the end was near. The medical staff talked with Carl and the children who had gathered. They wept and mourned there in the ICU as respiratory therapy came to disconnect the ventilator. The FCN was with them and tired to provide information, assistance and support. Shirley continued to breathe after the discontinuation of life support so she was transferred to a hospice unit where their professional help aided the family during the time of transition. Shirley continued to receive optimal symptom management for respiratory distress before passing peacefully a few days later with the children and her beloved, Carl, standing at the bedside. Hospice in the hospital plays a strong role in helping make death easier and in bringing everyone together as they transition from the hyper-active interventional mode to the slower pace of accompanying someone who is on their final journey. The hospice team during this time can help the family who may struggle with how the whole end of life process has gone and who may worry about whether or not they have done the right thing in choosing hospice. 3. Hospice at Home The FCN got a call from the family. Arnold was ready for hospice care. After a 2 month battle with metastatic esophageal cancer, he and his wife were ready to change directions from interventional care to comfort care and hospice. His cancer, found in an already advanced stage, threw out complications faster than they could be addressed and brought under control so that he could qualify for any type of therapeutic regimen. After dealing with hypercoagulability that brought about ischemic pain in his feet to breathing problems related to tumor growth, they realized their time was too short to spend it in the cramped bays at the emergency room. He wanted to be at his country home, enjoyed the views from the front window, basking in the warmth of family and friends during whatever time he had left. While 27% of hospice patients are in a facility, 66% participate in hospice from their own home. (2013, National Hospice and Palliative Care Organization) Home care is truly the most common model of hospice care and when engaged early enough, allows for the time for the organization to fully deploy its range of helpful care options. After visiting with the family, the FCN let them know how to initiate hospice services with the company of their choice, smoothing the way for hospice care to come into the home after a referral from the primary doctor. Hospice at home, in the hospital or in the nursing home can serve the patient and family well as they look for ways to help everyone involved come to terms with the separation caused by death.
  7. BE A DETECTIVE I'm teaching nursing fundamentals right now, and one of the things I tell my students over and over again is the importance of observation. Assessment and inspection are two of the fundamentals of Fundamentals. I tell them the job of nursing will never get boring if you think of each patient as a mystery. "Try to be like Sherlock Holmes (yes, they still know who that is, much to my joy) or House (from the TV show) and solve the mystery". No matter what your patient says, I want you to think, "What's really going on here?" I'm going to tell you a true story (names and relationships have been changed to protect the innocent). It has a beginning, a middle, and an end, but I am leaving off the end, for now. Because I believe you can solve this mystery, I really do. So read on, and see if you can unravel the Mystery of The Dog in a Fedora. Ruth It's been a few years since this happened, and it concerns my cousin Ruth. I hadn't seen her in a few years - we live on opposite ends of the country, but out of the blue she called to ask if she could come to live with us for a few months. She was 18 and living a vagabond life, driving around the country in a PT cruiser with her dog, Mavis, exploring, meeting weird people, and working odd jobs. She had just finished picked oranges in Florida, and was looking for a break from living rough until a job opened up for her on the west coast picking apples. We weren't happy with our nanny, and I loved the idea of connecting with actual family, so we agreed she would stay for a few months and keep and eye on our four children, taking them places, keeping them safe, and bonding. The version of Ruth who showed up on our doorstep was thin for her 5'9" frame. She had cropped her hair short and dyed it purple. She has piercings and tattoos in odd places, but is a smart and very funny girl. I've known her all her life, and I trust her, despite her appearance. You might think from the description that Ruth is into drugs and alcohol, but I believe her when she adamantly denies using any mind-altering substances, because she lost her father at a very young age to suicide. Ruth is my cousin by a second marriage, and before her mom married my uncle, her dad had been an addict with a diagnosis of manic depression. When she found out he had killed himself, she hadn't seen him in years, but she had memories of him coming home drunk and high. The kids adored her, probably because at the time she was staying with us she was just a really big kid herself. One of their favorite things to do was take a fresh pack of markers and draw all over each other. I would come home from work and find Ruth with a pink mustache, lovingly drawn on by my 5 year-old daughter. I never knew what each of my four kids would have on their arms, backs, legs and tummies when I arrived home. One day it would be cartoons of dogs and cats, another day it would be an entire Shell Silverstein poem. We all thought it was hilarious, and it washed off in the bath. Ruth did a great job entertaining my kids, but a less than great job with the other duties of a nanny. She didn't wash the dishes, the guest room looked like a bomb had gone off in her suitcase, and the kids toys were always everywhere but in the toy box. You make exceptions for family members because you love them. SOMETHING ISN'T RIGHT As time went on however, I began to notice how tired RUTH seemed to be. She would sleep until 5 minutes before I needed her to watch the kids. She would go to bed the moment I got home. The kids started talking about how she was too tired to play. A neighbor called me one day to report my 2 year-old son was wandering in the front yard, alone, without any pants on. I called Ruth, who answered promptly, saying in a quiet voice that she was sitting down, leaning up against the front door frame, too tired to walk around with the little guy. His lower extremity situation was normal for him - he was a staunch nudist. It would have surprised me if his pants had been ON, but I was worried that the kids weren't getting the care they needed to be safe. That evening, after the kids went to bed, I knocked on Ruth's bedroom door. A faint murmur let me know she was awake and I entered the guest room. After moving aside a pile of clothing, I sat on the bed and said, "Ruth, what's going on?" She was quiet for a long time. Finally she mumbled "I'm just so tired...all the time." "Are you not sleeping?" "I feel like all I do is sleep, but it's never enough." I know teenagers need a lot of rest and sleep, but when it interferes with activities of daily living, my nurse radar goes up. I did a visual scan of Ruth and the room. She looked tired, with dark smudges under her eyes, and her skin was pale, but she was always pale, favoring the goth lifestyle of no sun at any time. I observed no signs of drug or alcohol use, but those could easily be hidden. "Is this normal for you? I mean, I haven't seen you in a few years, maybe this is how it is all the time?" She started chewing her lip, and looking at her chewed fingernails she said, "I feel like it's been for the last few months. I used to do stuff. I used to ride horses. I picked all that fruit." That was a good piece of evidence. She had successfully picked fruit all Spring - keeping a very physical job that was probably based on quotas. "What's changed?" I was trying not to pry too much, but it had to be done. "I went off the pill a while a go, and I've been bleeding a lot, on and off for a while now." Now we were getting somewhere! Sexually active, recently stopped birth control. "Are you bleeding a lot?" She shrugged and looked away. I could tell she was embarrassed. She shook her head indicating a negative. "Well you could be a little anemic, maybe you could try eating some spinach or broccoli. Heck, I could fry you up some chicken livers." She smiled at that, which was nice to see. "I'm a vegetarian, remember?" "We've got to figure something out - you have to be able to keep the kids safe, right? Do you need a few days off?" "No, I'll be OK. Sorry. I've probably just got a cold or something." "Keep me posted OK? Let me know if you feel worse, and just keep talking to me, OK?" "Sure." I left her then, sure that she went right back to sleep. I was worried about her. Her voice seemed flat and she didn't look like her usual cheerful self. Since depression runs in her family I wanted to keep an eye on her mood as well. "Ruth is her own person, as I am sure you know. Once she left home, she didn't want any more mothering. You know about as much as I do at this point." My aunt Nancy said in response to my phone call that evening. No insight was going to come from Ruth's mom, then. HALLUCINATIONS A few weeks went by, and I could tell Ruth was really trying, but I could also see that she wasn't feeling any better. She seemed listless, and tired, and had even stopped coloring my children. She was never one to chat much, but now she was practically silent. I decided to head into her room for another fact-finding mission. "So it seems like you aren't feeling any better. I see how hard you are trying. I'm worried about you. Are you feeling down?" As before, there was a long silence before the answer. "I'm having some weird thoughts." "What kinds of thoughts?" "I don't know. Just bad thoughts." "Ruth, you have to tell me what's going on. It's my job as someone who loves you to get you to open up. Please talk to me." Ruth took a deep breath and then said in a voice so quiet I could hardly hear her, "I'm seeing things." That wasn't what I was expecting. "How do you mean?" "When I lie down to go to sleep, I see lights on the ceiling. They move around. It's actually pretty cool." I didn't agree with that statement. "You're not taking anything, no drugs, no alcohol?" "Gross, no!" finally she showed a little spirit.She continued, with a small laugh in her voice. "There's a gray cat." "A grey cat." I repeated stupidly. We don't have a cat, much less a grey cat. "You've seen a grey cat around the property? "No, it just appears in my room, or in the kitchen sometimes." My whole body was tingling with this information. I was running through a list of things that could cause hallucinations, and none of them were good. Schizophrenia, tumors, brain injury, the list was not anything I wanted for my cousin. "I'm not sure I understand, Ruth. Are you saying you are seeing things that you know aren't really there?" I could see tears in her eyes as she looked away at the wall. "Yeah, I know it sounds crazy. Sometimes your dog comes in and sits down and she has a hat on. She's wearing a black fedora on her head." I sucked in some air and tried to get a handle on my thoughts. ETIOLOGY OF HALLUCINATIONS After doing some research, I was surprised that hallucinations in children are more common than you might think. An article I read states that most children ages 9-11 have had at least one psychotic-like experience, including hallucinations. There is an eight percent hallucination prevalence rate in children, however they tend to be transient and resolve spontaneously. In 50-95% of cases, after a few weeks or months.1 Causes of hallucinations include many organic problems, which I list below, but there are also some environmental factors I was unaware of including stress and anxiety, as well as childhood trauma. A positive relationship exists between hallucinations and sexual, physical and emotional abuse, but not parental death.2 Hallucinations are also related to drug use3 (LSD, psilocybin/mushrooms, mescalin/peyote), and a link has even been found between cannabis use and schizophrenia. Those who smoke cannabis are five times or more are more likely to develop schizophrenia, and researchers have found that if you are prone to schizophrenia, you are more likely to try cannabbis.4 Organic causes of hallucinations Schizophrenia Dementia Delirium Charles Bonnet Syndrome and Anton's syndrome (both involve vision issues.) Seizures (small, brightly colored spots or shapes that flash.) Migraines Peduncular hallucinosis (infarct of midbrain,) Sleep disturbances Tumors Inborn errors of metabolism Creutzfeldt-Jakob disease (a fatal, progressive neurodegenerative illness from prions.) Mood disorders (a significant relationship between hallucinations and suicidal behavior, those with MDD, and psychotic experience 14-fold increase in suicide plans or attempts.) HEADING TO THE EMERGENCY ROOM I will admit that I've seen things in the woods that I know weren't really there. I occasionally see things out of the corner of my eye after I've been running or biking for a long time. Once during an endurance race, I saw the little black dog I adored in college. She died many years ago, but we spent so many happy hours in the woods together. I don't think a trip to the ER is needed when I see things after pushing my body to its physical limits. Ruth, however needed to go. I questioned her further, "You said you are having bad thoughts. Is that what you meant, the hallucinations? Or is there something else? Are you having thoughts of harming yourself?" I know she's a cutter - I had seen the marks on her thighs under the very short dresses she wears, but the marks looked old and I hadn't brought it up, not wanting to pry into her private life at the beginning of the Summer. Now it was time to pry. Ruth replied, "I don't know." "Well I don't know either." I said with exasperation. I got up, went around to her side of the bed and gave her an awkward hug. She obviously didn't want it, but I was in full mom mode. "Can you promise me you won't hurt yourself?" Another long silence as I held her, and she did soften a little bit into the hug. She finally whispered, "No." OK then. I have never had to take anyone to the Emergency Room before. I called first, and they said to just drive up and bring Ruth inside, through the same doors that people with open head wounds, gunshots, and overdose travel. I called Ruth's mom while I was on the way, and she agreed I was doing the right thing. We didn't talk long because Nancy wanted to get moving on buying a plane ticket to come be with her daughter. Taking Ruth to the ER, not knowing if she would be admitted to the "psych ward" was one of the worst experiences of my life. Watching them wheel her away, not being able to protect her or keep her safe, and having to trust that the hospital would do the right thing - that was incredibly hard. SHE'S OK! Lucky for all of us, it all turned out OK. They kept her for four, long days. After her mom arrived, she went and camped out at the hospital so she could be there for each and every visiting hour. I begged Nancy to bring me copies of all the lab reports. I wanted to get as much information as possible. We talked at least three times a day. I kept telling her what to ask, and imploring her to take copious notes. "If they see you taking notes, they'll take better care of her!" I shouted into the phone. I love my profession, and I love being a nurse, but I know how easy it is for well intentioned, highly trained healthcare workers to make an error. I was determined to keep Ruth as safe as she could be. I'm going to stop here for a little while. I wonder what you think was going on with Ruth? I've given you the same information I had. I still feel so guilty for not figuring it out sooner. Why was my dog wearing a fedora? The rest of the story will be in part 2. References 1. Hallucinations in Children, Adolescents: Psychiatric, Medical Causes, Assessments and Treatment | Psych Central Professional 2. Visual Hallucinations: Differential Diagnosis and Treatment 3. Common Hallucinogens and Dissociative Drugs | National Institute on Drug Abuse (NIDA) 4. Marijuana use and schizophrenia: New evidence suggests link
  8. BACK STORY Read the full story HERE. A few years ago, my cousin Ruth came to live with us for the Summer and be a nanny to my four kids. While she was living with us she presented with increasing fatigue and listlessness. Eventually she admitted to having hallucinations, describing lights flashing on the ceiling as she tried to sleep, and of seeing our family dog wearing a grey fedora. She had always been pale and thin, she was a vegetarian, and she had recently stopped taking her birth control pills, which had led to intermittent bleeding for several months. In addition, she had a family history of suicide and manic depression. I suggested she try to eat more iron rich foods, and keep me posted on her fatigue level, but she didn't tell me much - typical of a teenager. Finally, we ended up taking her to the ER when she admitted to having thoughts of harming herself. I had considered anemia as the source of her fatigue, but when I questioned her about the amount of bleeding she was having, she had denied that it was excessive. In my experience anemia doesn't cause hallucinations, so when she started telling me about seeing our dog in a hat, given her family history, I started worrying about a mental health disorder, especially schizophrenia, which typically presents in early adult-hood.1 NOT THE USUAL SUSPECTS Ruth was in the psych ward for four days, and during that time they did a full history and physical, including a psychological evaluation, medication reconciliation and a wide panel of lab tests. Though they found signs of depression, that didn't explain seeing my dog in a fedora. What they did find was severe iron deficiency anemia. She had been bleeding longer and more heavily than she had previously admitted, and I could have kicked myself for not taking her to see a doctor sooner. This article is my penance for not picking up on it sooner. I review risk factors, signs and symptoms of the various types of anemia, as well as diagnostic tests and treatments, and there are great resources for further learning. I still don't think I would have put iron deficiency anemia with hallucinations - I have looked far and wide for case studies or research discussing a link between the two. I Googled anemia and hallucinations multiple ways and got nothing. I tried hypoxia and hallucinations as well. I looked on Google Scholar, PubMed and hematological websites, but found very little linking the two. There is an article about a woman with very low iron who thought she was infested with spider eggs (Delusional parasitosis secondary to severe iron deficiency anemaia).2I also found a link between mountain climbing and psychosis, but the authors haven't found a direct link between hypoxiafrom mountain climbing and hallucinations.3 There's also a link between Vitamin B-12 deficiency caused anemia and hallucinations. Some people diagnosed with dementia or Alzheimer's are actually suffering from B12 deficiency.4 Ruth wasn't a mountain climber, she wasn't vegan or lacking intrinsic factor or producing inadequate stomach acid. She was slowly bleeding to death. ANEMIA Anemia is common and affects one-third of the world's population, and more than 3 million Americans. Anemia is defined as any pathological condition leading to significant decrease in total body erythrocyte (Red Blood Cell) mass. Red blood cells (RBCs) carry hemoglobin, an iron-rich protein that binds and carries oxygen to tissues in the body. Anemia occurs when you don't have enough red blood cells or when your red blood cells don't work correctly.5 SAFETY Given the prevalence of anemia, you would think it would be easy to get all the information you need to know on the internet, but not so. I found myself longing for my old nursing school Med/Surg textbook. I found a lot of information for the layperson, describing signs and symptoms, but very little information on diagnostic lab values, and how to do a work-up on someone suspected of having anemia. As a patient safety specialist, I know that multiple organizations recommend up-to-date, easily accessible information be available to healthcare providers. It is often nurses who spot valuable details: patterns in vital signs, low lab values, patient behaviors, family stories, empty vitamin bottles found in a purse (can you hear the patient's voice? "oh, I didn't think it was important to tell the doctor about my vitamins!") When we have access to knowledge, we are better detectives, and have a better chance of keeping our patients safe. TYPES OF ANEMIA 5,6,7 Ruth had iron deficiency anemia, the most common type of anemia worldwide, affecting 10-30% of world population; in the U.S. 11% of women and of 4% men have iron deficiency anemia, but there are many other types of anemia.6 Iron deficiency anemia caused by a shortage of iron in your body. Your bone marrow needs iron to make hemoglobin. Without adequate iron, your body can't produce enough hemoglobin for red blood cells. It occurs in many pregnant women, and is also caused by blood loss - like Ruth's, from heavy bleeding. Ulcers, cancer and regular use of aspirin can cause it as well. Vitamin B12 Deficiency caused by a lack of folate and vitamin B-12.Both are needed to produce health red blood cells. A diet lacking in these nutrients can cause decreased RBC production. In addition, if your body doesn't make intrinsic factor, you can't process the vitamin - leading to pernicious anemia. Chronic diseases Cancer, HIV/AIDS, rheumatoid arthritis, kidney disease and Crohn's can interfere with production of red blood cells. Aplastic anemia Caused by underproduction of red blood cells due to infection, medication, autoimmune disease and exposure to toxic chemicals. Bone Marrow Diseases leukemia and myelofibrosis can cause anemia by affecting blood production in the bone marrow Hemolytic Anemia when RBCs are destroyed faster than bone marrow can replace them. It can be inherited or develop later in life, includes Sickle cell Anemia which is an inherited defective form of hemoglobin that causes RBCs to form a crescent or sickle shape - they die prematurely. Thalassemia A rare inherited blood disorder in which the body makes an abnormal form of hemoglobin SYMPTOMS 5,6,7 When you have anemia, your body tissues lack oxygen, so you may have one or more of the following symptoms: Tiredness Dizziness Weakness Headaches Pale skin Fast heartbeat Shortness of breath Pounding or whooshing in ears Craving for ice or clay (picophagia) Sore or smooth tongue Brittle nails Hair loss Difficulty concentrating Grumpiness Poor cold tolerance Decline in renal function Osteoporosis Sarcopenia (loss of muscle tissue) RISK FACTORS5,6,7 There are many risk factors for anemia: major surgery or trauma, menstruation (especially if periods are heavy) recently given birth, pregnant or breast feeding, GI disease like celiac, IBD, ulcerative colitis or Crohn disease, peptic ulcer, bariatric or gastric bypass, vegetarians, people who don't each iron-rich foods. DIAGNOSIS5,6,7,8 Diagnosis of anemia involves asking many questions. You will want to know: severity; rate of onset; the patient's overall health and oxygen demand; past medical history (menstruation, duration, frequency, flow, pregnancy, blood in stool, blood loss - acute vs. chronic); family history. You will also do a complete physical exam (Pallor, conjunctiva, oral mucosa, nail beds, palmar creases, orthostatic BP changes - intravascular volume shift), lab workup and medication reconciliation. LAB VALUES8,9 Diagnosing iron deficiency anemia is simple. Start with the CBC and look at the RBC count, and Hematocrit and Hemoglobin levels. If those are low, get an order for TIBC, iron and ferritin. A comprehensive list of lab values related to anemia is included, and where it's applicable I have included Ruth's values as well as normal values in parenthesis. Red blood cell size and color: with iron deficiency anemia, RBCs are smaller and paler in color Red Blood Cell count: how many RBCs you have. It's also known as an erythrocyte count. The test is important because RBCs contain hemoglobin, which carries oxygen to your body's tissues. Your tissues need oxygen to function. Ruth: 3.1x1012/L (3.9-5.2x1012/L) Hematocrit: the percentage of blood volume made up by RBCs. Ruth: 23.1% (34.9-44.5 % women; 38.8 - 50.0 % men). Hemoglobin: the oxygen carrying molecule found in RBCs. Lower than normal hemoglobin levels indicate anemia. Ruth: 7.0 g/dL (13.5-17.5 g/dL men; 12.0-15.5 g/dL women). Mean corpuscular volume(MCV): the average volume of red cells. It can be directly measured by automated hematology analyzer, or it can be calculated from hematocrit (Hct) and the red blood cell count (RBC) as follows: MCV in fl = (Hct [in L/L]/RBC [in x1012/L]) x 1000. Ruth 73 fL (78-102fL) Ferritin: a protein that contains iron and is the primary form of iron stored inside cells. The amount released and circulating in the blood reflects the amount of iron stored in the body. When your iron level is low, your body will pull iron out of storage to use it. A low level of ferritin usually indicates a low level of stored iron. Ruth: 4 ng/mL (12-156 ng/mL) Total iron binding capacity (TIBC): tells how much transferrin (a protein) is free to carry iron through the blood. If TIBC is high, more transferrin is free because there is less iron. Ruth: 550 mcg/dL (200-450 ng/mL). Serum Iron: The amount of iron in your blood may be normal, even if the total amount of iron in your body is low - which is why other tests are needed (like the TIBC and Ferritin levels). Ruth: 10 umol/L (10-30 umol/L)7 If it's not iron deficiency anemia, further tests are needed. Click on THIS link for more lab values and images of blood smears.9 And check out this Powerpoint based on Hazzard's Geriatric Medicine and Gerontology.8 It has flow charts for diagnosis, case studies, and a discussion of microcytic vs. macrocytic anemia (too much for this article!) TREATMENT5,6,7,8 Iron deficiency anemia: taking iron supplements (take on an empty stomach to increase absorption, don't take with antacids, take with Vitamin C, watch out for constipation) and making changes to your diet (red meats, leafy-dark green vegetables, beans, molasses, liver, grains). If the underlying cause of iron deficiency is loss of blood, the source of the bleeding must be located and stopped. In Ruth's case, she had to get back on contraceptives to lighten her heavy menstrual flow. She also had to take iron, and it takes a long time to get iron levels up to normal, unfortunately they can't be corrected overnight, and may take months to replenish. Vitamin deficiency anemia: Dietary supplements and increasing these nutrients in your diet. If your digestive system has trouble absorbing vitamin B-12 from the food you eat, you may need vitamin B-12 shots. At first, you may receive the shots every other day. Eventually, you'll need shots just once a month, which may continue for life, depending on your situation. Anemia of chronic disease: No specific treatment for this type of anemia. You have to treat the underlying disease. If symptoms become severe, a blood transfusion or injections of synthetic erythropoietin, a hormone normally produced by your kidneys, may help stimulate red blood cell production and ease fatigue. Aplastic anemia: Blood transfusions to boost levels of red blood cells. You may need a bone marrow transplant if your bone marrow is diseased and can't make healthy blood cells. Anemia associated with bone marrow disease: Medication, chemotherapy or bone marrow transplantation. Hemolytic anemias: Avoiding suspect medications, treating related infections and taking drugs that suppress your immune system, which may be attacking your red blood cells. Depending on the severity of your anemia, a blood transfusion or plasmapheresis may be necessary. Plasmapheresis is a type of blood-filtering procedure. In certain cases, removal of the spleen can be helpful. Sickle cell anemia: Administration of oxygen, pain-relieving drugs, and oral and intravenous fluids to reduce pain and prevent complications. Doctors also may recommend blood transfusions, folic acid supplements and antibiotics. A bone marrow transplant may be an effective treatment in some circumstances. A cancer drug called hydroxyurea (Droxia, Hydrea) also is used to treat sickle cell anemia. Thalassemia: Blood transfusions, folic acid supplements, medication, removal of the spleen (splenectomy), or a blood and bone marrow stem cell transplant. REFERENCES Schizophrenia Facts and Statistics Delusional parasitosis secondary to severe iron deficiency anemia Mountain Climbing Can Actually Cause Psychosis, And We Don't Know Why https://www.hsph.harvard.edu/nutritionsource/b-12-deficiency/ Iron deficiency anemia - Diagnosis and treatment - Mayo Clinic Iron-Deficiency Anemia | National Heart, Lung, and Blood Institute (NHLBI) Laboratory Evaluation of Anemia
  9. It's 11:34 a.m. The triage complaint is listed as possible stroke, with dizziness and facial droop listed as secondary complaints. A fifty-six-year-old female still in her street clothes is partially curled up on her right side scrolling through her phone. Patti arrived six minutes ago via private vehicle, walked in from the parking lot, and was brought to the room in a wheelchair. She doesn't appear to be in any acute distress, moving freely while repositioning herself on the gurney, breathing easily, with good skin color, and strong fine motor skills going into the phone-work. Her husband is leaning back in his chair at the bedside with his left ankle crossed over his right knee, reading a magazine. Nothing in this room conveys a sense of urgency. "The triage note says, 'possible stroke.' Can you tell me what happened today that brought you to the hospital?" I slide on a blood pressure cuff and a pulse oximetry clip as we talk. "I've been having headaches for a couple of months. But they've been worse for maybe two weeks now. And I've had some dizziness too." Her facial movements are symmetrical. She speaks clearly, without difficulty. Her vital signs are all within normal limits. "The note also says, 'facial droop'. Can you tell me about that?" The husband takes over. "She was just sitting at the table after breakfast this morning about nine o'clock. The left side of her face kind of pulled to the left, and she was having a hard time talking. It happened twice, about ten minutes apart, and it only lasted for a minute or two both times. She's had seizures so we didn't know if it was a seizure or what? Her face just pulled to the left." His description of pulling to the left doesn't sound like the "facial droop" described in the triage note. "Can you demonstrate how it looked to you?" The husband uses the muscles in his left cheek to pull the left side of his mouth laterally toward his ear." The patient adds, "I was having a hard time swallowing and I couldn't talk." "Any new or different medications recently?" "No," they say in unison, shaking their heads. About an hour later, we have normal findings on her EKG, chest x-ray, CBC, CMP and coagulation labs. Her repeated vital signs are also normal, and she's in a sinus rhythm with no ectopy on the monitor. She breezed through her NIH stroke scale with no neuro deficits. I'm headed to the room to let them know her CT has been read as "no acute intracranial findings." Intuitively, the husband's recreation of her face pulling to the side is still dogging me when he suddenly bursts through the privacy curtain, running toward me. "She's doing it again." Patti's sitting up at a ninety-degree angle, gripping both side rails. She's clearly anxious now; her eyes are wide, and she rocks rapidly back and forth. She's still in a sinus rhythm, but her heartrate is up to 110, and she's breathing fast. Her lower jaw is pulled laterally as far to the left as it can go, confirming the husband's choice of words in his description that "her face just pulled to the left." Somewhat relieved, I feel her tight muscles displacing her lower jaw radically to the left. "Can you move your jaw?" She shakes her head and tries to talk, but her voice is throaty, and her articulation is predictably muddled. "Is there anything else that feels wrong to you right now, other than your jaw being locked off to the side like this, making it hard for you to talk?" She looks at me and shakes her head, mumbling a garbled "no." "Patti, I can see you're really anxious. This doesn't look like a stroke or a seizure. I think it's a much lesser evil. Try to relax while I get the doctor in here to look at you." Dr. Spicer agrees that her presentation is consistent with a dystonic reaction causing a spasm of her jaw, lips, and tongue muscles. She's allergic to Benadryl, and, after considering Cogentin, he gives me a verbal order for 0.5 mg of IV Ativan. Her symptoms resolve rapidly, and, instead of being sleepy, she's just loopy enough to be happy and fun as we process her admission and move her to the observation unit. Patti's case is interesting for a couple of reasons. In looking for a potential cause, the most likely culprit appears to be her carbamazepine. They said 'no' when I asked about any new medications, but it turns out that her husband had changed jobs two months ago, forcing a change in insurance and doctors. The new doctor took her off Dilantin, which she had taken for years without incident, and put her on carbamazepine. The headaches had started a few days later, but they hadn't made the connection between the medication change and the headaches until we explored the timing together. Usually, a dystonic reaction happens after the first dose of a new medication or after an increase in dosage, neither of which applied in Patti's case, unless she had accidentally taken extra medication. We add a carbamazepine level to her labs, and the result comes back a little over the high end of the therapeutic range. Acute dystonic reactions are relatively rare in our flow of ER patients. Acute dystonic reactions to carbamazepine are also rare. Carbamazepine is sometimes prescribed to treat dystonia from other causes. The real key to the story was the husband's description that "her face pulled to the left." More specifically, just her jaw pulled to the left, but he was accurate in describing something that didn't sound like facial droop. (Try looking in the mirror and alternate between using your facial muscles to pull only your cheek or your jaw laterally. It's easy to see how he got his description.) It's unfortunate for Patti that she became one more causality of a system which forces changes in medical care because of a change in employment. The good news: there's no facial droop, no stroke, and no seizure. The simple longer-term fix for drug induced acute dystonic reactions is to discontinue the offending agent.
  10. You are a new graduate nurse on your second rotation in a 30-bed medical ward. It is 0800hrs during a morning shift, and you have been allocated the care of a 70-year-old female, who has been on your ward for the last week, recovering from an acute infective exacerbation of chronic obstructive pulmonary disease (copd). Past medical history: ischaemic heart disease (ihd) and severe copd (with type ii respiratory failure). When assisting the patient with breakfast you notice she has become increasingly breathless, only speaking in single words, and not interested in eating. A set of observations are taken: SAO2 88% on np at 2l/min bp 160/90, hr 144 resp rate 45 b/min, and Temperature 37.2. auscultation of the lung fields reveals wide spread expiratory wheeze bilaterally. lab results: abg uec's fbc ph 7.33 na 144mmol/l hb 155 g/l pa02 55 mmhg k 4.5 mmol/l wcc 11 x 109/l pac02 70 mmhg cl 109 mmol/l plt 400 x 109/l hc03 36 mmol/l urea 8 mmol/l creat 90 µmol/l Questions 1. Using the information given in the (above) case study start by prioritizing and justifying your immediate care of this patient? 2. You also need to interpret both clinical and lab results, and 3. what physiological processes may be responsible for the abnormal clinical or lab results?
  11. juan de la cruz

    Case Study: Fever

    The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in the hospital will be portrayed in an attempt to stimulate discussion on ways to approach his care not only from a nursing standpoint but also to understand the complexity of his care from the perspective of other disciplines who will be involved in his care particularly his medical management. Background History Rolando is a 19-year old college student who is the son of first generation immigrants from the Philippines. His parents are divorced and he lives with his mother in a coastal town close to where he attends college. He decided to skip the fall semester and live with his father in California's Central Valley region to help him run a small business. He presented to his family physician with complaints of productive cough for about 7 days and feeling warm and flushed. He said his phlegm looked white in color and not excessive. He appeared healthy and has no medical history other than having had his appendix removed at age 14. The physician prescribed him Azithromycin and cautioned him to seek further care if his symptoms do not improve. He recalls having some tests done at the clinic but was not sure what they were. Three days later, Rolando was feeling worse. He feels he is warmer and may have a high fever, is having chest discomfort with coughing while not expectorating any phlegm, and is experiencing joint pains and muscle aches. He has no appetite and is feeling weaker. His father was concerned and brought him to the nearest ED at a community hospital setting. Social History His social history is notable for being a college student with an undecided major. He admits to drinking alcohol occasionally but denies binge drinking, he does not smoke, he admits to having smoked marijuana in the past but not recently. He has a girlfriend in college and is sexually active. You are Rolando's first contact in the ED as the triage nurse. After gathering the above, you obtained the following data Subjective complaints: "feeling warm, headache, little short of breath". Temperature 39 C, HR 112, RR 32, BP 110/65, O2Sat 88% on room air Neuro: AOx3, moving all extremities, pupils equal and reactive. CV: EKG showed Sinus Tachycardia with no ST changes, no murmurs were heard on auscultation, no edema in extremities. Pulm: Harsh breath sounds bilaterally but no accessory muscle use. He does breathe fast as you noted in his respiratory rate. Skin: Warm and flushed, you notice what looks like a red rash in his bilateral shins. Rest of the system exam is WNL. Questions How would you triage Rolando and what tests would you expect to be done in his case? What would you tell the next ED nurse who will take care of Rolando once you determined the appropriate ED treatment area he should be treated at? What concerns do you have about what is likely the reason for his symptoms?
  12. juan de la cruz

    Case Study: "A Case of Bad Blood"

    CJ is a 65-year old female who tripped and fell inside her home landing on her right side. She felt immediate excruciating pain in her R hip and couldn't manage to get herself off the floor. Fortunately, she had a mobile phone in her housecoat pocket and she was able to call her son who arrived in her home within ten minutes. She was taken by ambulance to the ED where an x-ray revealed that she had sustained a hip fracture. CJ is otherwise healthy aside from a medical history that is notable for HTN and hyperlipidemia that are adequately managed with oral medications. CJ was seen by an Orthopedic Surgeon who recommended surgical intervention to repair her fractured hip. She was cleared medically to undergo surgery. CJ was taken to the OR for an ORIF and was intubated for general anesthesia. She had significant blood loss from the surgical procedure and required blood transfusions during the case. At the conclusion of her 3-hour surgical procedure, she had received 3 Units of PRBC's. Additional 2 Units of FFP's were ordered because her surgical drain had significant output. CJ was transferred to the ICU intubated because she was slow to wake up from anesthesia. The nurse received report from the Anesthesiologist that CJ already received the first unit of FFP and the second unit is half-way transfused. After receiving the second unit of FFP, her nurse noted an acute onset of oxygen desaturation to 75% and tachycardia. She was triggering the high peak airway pressure alarm on her ventilator. The nurse and respiratory therapist noticed copious amounts of pink, frothy secretions coming out of her oral endotracheal tube. Her FiO2 and PEEP were increased to 100% and 10 cmH2O respectively in order to maintain oxygen saturations above 90%. Chest x-ray was immediately obtained and showed bilateral pulmonary infiltrates with a normal cardio-mediastinal silhouette. The Intensivist is concerned that CJ suffered a Transfusion Related Acute Lung Injury or TRALI. Background As nurses working in critical care, transfusing blood products is a common role we perform. While blood product transfusion reactions come in many forms, a distinct type of blood product transfusion reaction known as TRALI is a rare but life-threatening condition that we must be aware of because it is the leading cause of transfusion-related mortality described in the range of 40-60%. The true incidence of TRALI is difficult to estimate not only because cases of TRALI are under-reported but also because of previous disagreements among clinicians as to which cases meet the criteria for this diagnosis. Pathophysiology The exact mechanism of TRALI is not well understood, however, experts accept the two-hit mechanism which involves: Neutrophil sequestration and priming - patient has intrinsic condition that causes neutrophil sequestration and priming in the lung microvasculature. This happens before the blood transfusion. Neutrophil activation - when patient receives blood product, factors present in the blood product causes the recipient's neutrophils to release cytokines that damage the lung microvasculature leading to pulmonary edema. Neutrophil Activation Can Happen in Two Ways Immune mediated - via anti-HLA antibodies and anti-HNA antibodies in the donor blood Biological response - biologically active lipids present in WBC's, platelets, and red blood cell breakdown. TRALI Diagnostic Criteria In an effort to standardize this clinical diagnosis, a consensus by the National Heart Lung and Blood Institute of the National Institutes of Health defines TRALI as new acute lung injury (ALI) or ARDS occurring during or within six hours of blood product administration. Conventional criteria for the diagnosis of ALI/ARDS as defined by the Berlin Criteria Acute onset Bilateral infiltrates on chest x-ray PaO2 to FiO2 ratio (P/F ratio) less than 300 with a minimum PEEP of 5 cmH2O Etiology must not be fully explained by cardiac failure of fluid volume overload Possible TRALI The above clinical diagnosis is made using strict criteria that only implicates the blood product transfusion as the culprit in the development of ALI/ARDS. In cases where the development of ALI/ARDS coincide with blood product transfusion but other confounding events exist such as aspiration, infection, or trauma, then a diagnosis of Possible TRALI is preferred. TRALI vs TACO A similar presentation of transfusion related respiratory insufficiency is Transfusion-Associated Circulatory Overload or TACO. In order to distinguish from TRALI, TACO is associated with rapid blood product administration in the setting of fluid volume overload and compromised cardiac function. The mechanism for pulmonary edema is of a hydrostatic process in nature, that is, elevated pressures in the pulmonary circulation causes fluid to shift to the extravascular space into the lung parenchyma. Nursing Care Planning Nursing diagnoses that may apply to TRALI include: Impaired Gas Exchange related to alveolar fluid accumulation as evidenced by dependence on mechanical ventilation with increased oxygen and PEEP requirements. Anxiety related to difficulty breathing and increased respiratory effort as evidenced by inability to maintain adequate oxygen saturation without mechanical ventilator assistance. Treatment Treatment for TRALI is supportive. Transfusion should be stopped immediately if TRALI is suspected. Follow your facility protocol in terms of triggering blood bank evaluation of a transfusion reaction. It is important that cases of TRALI are reported and confirmed to protect future recipients of the donor blood. In many cases, patients are profoundly hypoxemic enough to require intubation and mechanical ventilation. Traditional ARDS ventilatory strategies are employed. Hemodynamic monitoring is indicated as some patients develop hypotension and must be supported with fluid resuscitation and/or vasopressors. Education and emotional support to patients and families are important. The clinical course of TRALI has been described as short with quick resolution in mild cases to as long as 40 hours in severe cases though longer periods have been reported. Prevention It should be noted that cases of TRALI have declined significantly in recent years due to efforts at prevention. Blood donors implicated in TRALI cases should be deferred from future blood donation. Also recall that the mechanism thought to trigger TRALI partly involves immune mediated antibodies present in the donor blood particularly anti-HLA and anti-HNA antibodies. Some specialty laboratories in the US have the capability for neutrophil antibody testing to detect the risk of reaction from donor to recipient though this testing is expensive and still not widespread. More importantly, blood products donated from multiparous women and individuals who received multiple blood transfusions in the past have been found to contain the antibodies implicated in TRALI. As a consequence of this finding, most centers preferentially obtain blood products from male donors and screen female donors in order to eliminate the possibility of donation by multiparous women and individuals who has a history of receiving multiple blood transfusions. Lastly, blood transfusions must be utilized with reasonable indication and with thorough consideration of its risks. Further Reading Transfusion medicinel Transfusion-related acute lung injury surveillance (2003-2005) and the potential impact of the selective use of plasma from male donors in the American Red Cross [PDF] TRALI Risk Mitigation for Plasma and Whole Blood for Allogeneic Transfusion
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