What happened to my patient???

[just keep swimming]

I have a patient who has a history of a cardiac arrest in our unit 6 months ago. I got her back from that and she has been doing well....until today. At the end of her run she began to call out a PCT's name. She seemed agitated (she only speaks Russian so its hard to know whats going on with her most of the time) so we began to rinse her back fearing that her pressure was dropping. The last pressure we got was 101/42 at 1300. By 1303 she began yelling this PCT's name kind of rhythmically while throwing her head back. At this point she was fully rinsed back but was not focusing and was thrashing about in the chair. As her pressure was normal for her before rinseback my guess is it was not a hypotensive seizure. I was unable to get anymore vitals on her as she was moving around too violently. Here are the different things I saw from her in the five minutes before the ambulance arrived.

1) no response to my voice or commands,

2) jerking back and forth from body fully extended to body pulled up in fetal position (no it did not resemble a grand mal seizure)

3) cyanosis that was getting worse with every minute

4) not diaphoretic

5) some right sided facial contortion (mouth pulling down on right side) with each time the body extended

6) each time the arm on the left extended, wrist turned in with fingers facing toward forearm as if posturing

7) blood glucose 112

The paramedics said they were going to sedate her in the ambulance, and when I called the ER to check on her status, they said she was sitting up calmly in a chair

She has an extensive cardiac history including CHF, the previously mentioned cardiac arrest, and a fib, is not diabetic, is in her 70's, currently has staph bacteremia

I'm driving myself crazy trying to figure out what was going on and how she could be okay so soon after....and get this....my wonderful NP sat in the back office and listened. When I asked why he didn't come out and help me assess the situation he said "oh, you're a good nurse. you can handle anything, I'm never worried when you're here" Gee thanks, but no thanks! could've used some help!

Anyone have any ideas as to what was happening?

[traumaRUs, MSN, APRN]

Breath holding spells?

[just keep swimming]

She was dc'd from the hosp the next day with a diagnosis of waxing/waning dementia. I really don't agree that this is all that was going on. I've seen this woman 3 days a week for 5 years and this was not her! Oh well, I guess I just keep a close eye on her and hope her doc is there to witness it next time since he probably thinks I was over reacting.

[Guttercat, ASN, RN]

Staph bacteremia and a history of A-fib... prime candidate for a heart valve vegetation ...and threw a clot, resulting in a TIA.

That'd be my first guess given the symptoms, or, perhaps a PE.

[just keep swimming]

Those were my thoughts too but she was discharged without any real diagnosis. Thanks for the validation though!

[Guttercat, ASN, RN]

Those were my thoughts too but she was discharged without any real diagnosis. Thanks for the validation though!

Did they work her up for these? Any echocard done, or R/O PE?

I'd run it by the nephrologist (again).

Endocarditis as we know, requires a more intensive approach to treatment than "simple" bacteremia.

I'd hate to see her with a destroyed valve...

Good for you for questioning. Good post, too.

[just keep swimming]

She actually has a history of endocarditis which would make her more susceptible to getting it again. The problem is that this nephrologist already thinks I overreact because a couple of weeks ago I had a patient whose phos came back at >1. I rechecked it stat to another lab and it came back at 1.2. Called the nephrologist who was reluctant, but ended up having the pt go into the hospital. The patient went in and had his phos drawn in the ER and it came back at 3.2. Mind you this was 2 days later, I had already told the patient to stop all binders, sensipar and increase dietary phos intake. The doc is the one who was dragging his feet on the whole thing. Now he thinks I was nuts for worrying about that lab value (close to the same result from 2 different labs) and now this.

The worst part is that it doesn't even look like nephrology saw her in the hospital, at least not from the summary they sent me.

Thanks for your support, I need to just keep pushing because I know what I'm doing and I need to stop worrying about what the docs are going to think of me.

And no there was no cardio workup or R/O of PE however if it were a massive PE she would not have recovered like that with sedation and the PE would have to be pretty bad to produce those symptoms, I think...

[Guttercat, ASN, RN]

She actually has a history of endocarditis which would make her more susceptible to getting it again. The problem is that this nephrologist already thinks I overreact because a couple of weeks ago I had a patient whose phos came back at >1. I rechecked it stat to another lab and it came back at 1.2. Called the nephrologist who was reluctant, but ended up having the pt go into the hospital. The patient went in and had his phos drawn in the ER and it came back at 3.2. Mind you this was 2 days later, I had already told the patient to stop all binders, sensipar and increase dietary phos intake. The doc is the one who was dragging his feet on the whole thing. Now he thinks I was nuts for worrying about that lab value (close to the same result from 2 different labs) and now this.

The worst part is that it doesn't even look like nephrology saw her in the hospital, at least not from the summary they sent me.

Thanks for your support, I need to just keep pushing because I know what I'm doing and I need to stop worrying about what the docs are going to think of me.

And no there was no cardio workup or R/O of PE however if it were a massive PE she would not have recovered like that with sedation and the PE would have to be pretty bad to produce those symptoms, I think...

As far as Phos, better safe than sorry, esp. if the patient was symptomatic.

And I totally agree, you can only do what you can do.

As an acute/inpatient dialysis RN, I'm not surprised the nephrologist didn't see her, especially if she was on observation status, and was discharged soon after admission.

So she has a hx of endocarditis, has bacteremia, and A-fib... I can't imagine it wasn't something that was at least considered...maybe just send a short note to the Nephrologist with the data?

Good luck, and great job on being a patient advocate. I like RN's like you. :)

[just keep swimming]

Thanks!