Seriously! We were at a lost at work last night. Pt is A&O X 4. But keep asking where her baby is, she needs a pamper to change baby, and keep pointing and talking to people that's not there. She's even tried to get out of bed a couple of times even though she can't walk. However, she knows phone numbers (and remembers to press 9 to dial out), she knows her name, time, day, where she is, the floor she's on, and her room number! She knows what she's eaten, how much, and even her blood sugars and amounts of insulin. She's a young lady (in her 50's), negative for UTI and no change in her medication regimen! Someone mentioned that she's "faking" but I don't think so but if she is, she's doing an awesome job. I'm a new nurse, but even the seasoned nurses are at a lost for words!
Thanks everyone! But to answer some previous questions, all of her lab work are WNL, her vitals are stable, awesome blood sugars. She was admitted to the hospital to have the AKA, and yes I work at a hospital.
Thanks everyone! But to answer some previous questions, all of her lab work are WNL, her vitals are stable, awesome blood sugars. She was admitted to the hospital to have the AKA, and yes I work at a hospital.
if all patho has been r/o, then it's time for a psych eval.
Not to offer medical advice, but there are a few things you may need to look into.
Jumping to a psych eval should be a LAST resort; a lot of factors can effect her neurologic status, and you absolutely need to rule out any medical condition before passing this off as psych.
As far as the A+O x4; this is not a reliable scale to assess her mentation. Even dementia/delusional patients know their name and birthday, and if they can read the poster on the wall or the papers kept at bedside, they can probably figure where they are and the date PDQ. The problem is that she is acutely delusional - be sure this is acute, maybe this was her baseline prior to admission? If so, lean towards psych.
Recent AKA and she is trying to walk? Something is going on here. I would first check her labs first - you would be surprised how loopy people can get with a low Na or Mg. UA, BUN, Phos, H+H, etc. Anything out of the norm, you want to correct to see if this may be contributing to her mental status.
Since labs are WNL, how recent was the AKA? One of the big concerns after AKA is developing blood clots; assess for potential CVA or PE leading to an acute/chronic hypoxia. Due to the nature of these, many other signs/symptoms develop and you would probably be working that up by now.
ETOH. The worst withdrawals I have seen have been ETOH. Completely changes people. Meth, Heroin, Coke, Nicotine, etc., are severe but not nearly as drastic or symptomatic as ETOH. This may be reflected in VS and other assessment data as well, keep a close eye on her and see if anything starts changing for the worse.
Was she admitted for the AKA? Possibly after an ulcer that developed? Has anyone followed up on possible infection or Sepsis? Septic patients also tend to have a drastic swing in mentation as well. Check her Lactic Acid, VS, see if blood cultures were drawn and resulted.
Is she dehydrated? Sometimes people overlook hydration status, particularly after surgery.
As far as getting out of bed; perhaps not a matter of not understanding AKA, maybe she is restless from something else going on. Any underlying acute conditions that may be contributing? Maybe a med that she took at home and got lost in the admission paperwork? When everything else is normal, go back to the basics: is pain under control, is she constipated, is her nutrition adequate, has she obtained any rest/significant sleep in the hospital? Sometimes, its just that simple. And do not underestimate the patient - thoroughly scope her room and be sure she does not have meds from home with her! This happens more often then you think, particularly with someone confused. If she is doubling up on meds, she may be causing this on her own.
She may need some scans as well - Head CT, EEG, Chest/Pelvic CT, X-Rays. Make sure it is not something organic in nature (i.e., a tumor, underlying cancer)
There are so many factors that can effect one's frame of mind. Please Please Please - do not assume it is psych or she is "faking" until you have the proof! A psych consult may not be a bad idea, but you can have this ordered WHILE you are looking into other causes. Some people do have legitimate pysch issues that may present this way, but it is nominal compared to medical causes and factors.
Please follow up on this, I would love to hear how this turned out.
Not to offer medical advice, but there are a few things you may need to look into.
Jumping to a psych eval should be a LAST resort; a lot of factors can effect her neurologic status, and you absolutely need to rule out any medical condition before passing this off as psych.
As far as the A+O x4; this is not a reliable scale to assess her mentation. Even dementia/delusional patients know their name and birthday, and if they can read the poster on the wall or the papers kept at bedside, they can probably figure where they are and the date PDQ. The problem is that she is acutely delusional - be sure this is acute, maybe this was her baseline prior to admission? If so, lean towards psych.
Recent AKA and she is trying to walk? Something is going on here. I would first check her labs first - you would be surprised how loopy people can get with a low Na or Mg. UA, BUN, Phos, H+H, etc. Anything out of the norm, you want to correct to see if this may be contributing to her mental status.
Since labs are WNL, how recent was the AKA? One of the big concerns after AKA is developing blood clots; assess for potential CVA or PE leading to an acute/chronic hypoxia. Due to the nature of these, many other signs/symptoms develop and you would probably be working that up by now.
ETOH. The worst withdrawals I have seen have been ETOH. Completely changes people. Meth, Heroin, Coke, Nicotine, etc., are severe but not nearly as drastic or symptomatic as ETOH. This may be reflected in VS and other assessment data as well, keep a close eye on her and see if anything starts changing for the worse.
Was she admitted for the AKA? Possibly after an ulcer that developed? Has anyone followed up on possible infection or Sepsis? Septic patients also tend to have a drastic swing in mentation as well. Check her Lactic Acid, VS, see if blood cultures were drawn and resulted.
Is she dehydrated? Sometimes people overlook hydration status, particularly after surgery.
As far as getting out of bed; perhaps not a matter of not understanding AKA, maybe she is restless from something else going on. Any underlying acute conditions that may be contributing? Maybe a med that she took at home and got lost in the admission paperwork? When everything else is normal, go back to the basics: is pain under control, is she constipated, is her nutrition adequate, has she obtained any rest/significant sleep in the hospital? Sometimes, its just that simple. And do not underestimate the patient - thoroughly scope her room and be sure she does not have meds from home with her! This happens more often then you think, particularly with someone confused. If she is doubling up on meds, she may be causing this on her own.
She may need some scans as well - Head CT, EEG, Chest/Pelvic CT, X-Rays. Make sure it is not something organic in nature (i.e., a tumor, underlying cancer)
There are so many factors that can effect one's frame of mind. Please Please Please - do not assume it is psych or she is "faking" until you have the proof! A psych consult may not be a bad idea, but you can have this ordered WHILE you are looking into other causes. Some people do have legitimate pysch issues that may present this way, but it is nominal compared to medical causes and factors.
Please follow up on this, I would love to hear how this turned out.
Clot was my first thought :)
And can't agree more with not assuming someone is faking just because the presentation is unusual...that can kill people. And IF there is some malingering going on= crazy folks die, too
I've seen people act this way when taking steroids.....prednisone. Don't know why this happens but it seems to be pretty bad and scary when it does. Steroids really mess with people sometimes.
Specializes in Med-Surg/Neuro/Oncology floor nursing..
I was thinking if she didn't bring her own stash of pharmaceuticals than something going on in the brain like a tumor, bleed, clot or swelling. I had brain swelling and knew my name, place, phone numbers but I kept asking for my father(who had been dead for 7 years at the time). OR I agree with some others..she's putting on a one woman show and you guys are the audience.
Specializes in Med-Surg/Neuro/Oncology floor nursing..
I've seen people act this way when taking steroids.....prednisone. Don't know why this happens but it seems to be pretty bad and scary when it does. Steroids really mess with people sometimes.
OH YEAH... steroids can make you change definitely. After I had brain surgery I was put on decadron and it made me a different person. It made me extremely angry, hungry, agitated and just a big pain in the ass.
I also forgot to suggest...maybe syphilis that traveled to the brain? A lot of people might not even think this because she's in her 50's but STI's do not discriminate..and what makes it worse is that people don't even think to check because of age..and the patient has it and it goes untreated and it spreads.
We were at a lost at work last night. Pt is A&O X 4. But keep asking where her baby is, she needs a pamper to change baby, and keep pointing and talking to people that's not there. She's even tried to get out of bed a couple of times even though she can't walk. However, she knows phone numbers (and remembers to press 9 to dial out), she knows her name, time, day, where she is, the floor she's on, and her room number! She knows what she's eaten, how much, and even her blood sugars and amounts of insulin. She's a young lady (in her 50's), negative for UTI and no change in her medication regimen! Someone mentioned that she's "faking" but I don't think so but if she is, she's doing an awesome job. I'm a new nurse, but even the seasoned nurses are at a lost for words!
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Dazglue, ADN, BSN, MSN, RN
380 Posts
Thanks everyone! But to answer some previous questions, all of her lab work are WNL, her vitals are stable, awesome blood sugars. She was admitted to the hospital to have the AKA, and yes I work at a hospital.