NRP Session

Worst Shift Ever

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Intro

It's one of those days on L5 where everything that could go wrong, does go wrong. When your patient becomes very unstable, you find it very hard to leave the room.

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Ros, N L502

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72 year old female, Russian speaking only History of AF, CHF, and BPH P/w GLF with head trauma to the right side of the head, found to have a L frontal ischemic stroke and a R IPH. Neuro: AOx2-3, fluctuates, Left extremities are weak but able to move, Right side flaccid. Cardiac: on tele, AF in 80s, BP 135/92 Pulmonary: on RA, minimal wheezing and diminished lung sounds GI: Incontinent, Last BM yesterday, on a soft and bite sized diet, thin liquids GU: Foley placed 15 days ago for retention Skin: dry, fragile skin, bruising on R elbow and hip, coccyx is red but blanchable Vascular: PICC x2 lumen on left upper arm, last dressing change done 4 days ago

Kro, A L514

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P/w T2-8 Fusion and T5 decompression/laminectomy, with a history of mitral valve replacement requiring a pause in her anticoagulants. Today is POD #1, JPx1, Foley is still in. She also has an epidural nerve block with lidocaine in the back close to her incision. It is running a basal rate of lidocaine and the lidocaine lab was just checked at 0600 (normal). She has not gotten out of bed yet, but will need Aspen CTO Brace when OOB. She is still on a PCA Dilaudid drip, 0.2mg Q10min schedule. She did not receive any PO oxy overnight and was sleeping when you came in to do handoff.

Boo, T L506

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P/w a history of moyamoya, s/p R ECIC, POD #1. Pt has a wound on the right side of his head, with pain under control with oxy 5mg prn. He is AOx4, BMAT 4 with FWW. He wants to know about what his plan of care will be and whether he will be able to discharge home today.

McM, T L512

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P/w R thalamic stroke, h/o DM2, HTN, s/p PFO closure yesterday. Pain is under control at the procedure site with Toradol and oxy. She is AOx4, BMAT 4, NIH 0. When you come in during handoff, she asks you to order her food as she wants to eat. She states she hasn't eaten since yesterday at 1500.

L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC

Moyamoya, ECIC POD #1, AOx4, BMAT 4

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

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Morning Assessments

As you go to your first patient to do your VS and morning assessments, you receive a call from Lab. ROS, N L502: Critical Lab Hemoglobin 6.7 What are your next steps?

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Morning Assessments

You can't find any consent in the patient's chart and the patient only speaks Russian. What do you do next?

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC - Critical Lab Hb 6.7, Awaiting consent to be done by MD

Moyamoya, ECIC POD #1, AOx4, BMAT 4

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 Calling for a BG check, states she is feeling shaky

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Calling for pain meds, says 10/10 pain., OT also calling to see if pt can be seen by OT now.

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L512

BG is 54, pt is becoming more diaphoretic. What now?

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L512

After giving her glucose tabs, BG comes back up to 125. However, right after that BG check, you notice the patient is having a R facial droop and some slurring of words. What are your next steps?

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L512

After you bring her back from CT, patient now wants to eat her breakfast that she has been waiting for. Would you give it to her?

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC - Critical Lab Hb 6.7, Consent is done per MD, Awaiting type and screen with blood type verification

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Still awaiting her morning meds, VS, assessments

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT shows not a LVO, need MRI

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 given by Float RN, still awaiting morning meds, VS, assessments

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L506

As you bring in your morning meds for 6, you hear a crash in the room! You find your patient sitting on the bathroom floor. She states that she was going to the bathroom but she lost her balance.

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L512

You perform the MRI screening form, called the MRI, and was told they will take her in 30 min.

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC - Critical Lab Hb 6.7, Awaiting consent to be done by MD

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable. CT neg

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, not LVO Awaiting MRI

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 Family calling for RN urgently

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L514

Patient’s wife is very angry that you are not treating her husband well. She was told that he would go home today and she drove three hours to pick him up and he is not ready. Patient’s wife is yelling and threating to sue you and the hospital. “You are all incompetent and even the food here is bad it’s making his mouth feel numb and everything tastes like rust.” I am taking home now and started to pack up his belongings and getting the patient dressed. When you try to stop her, she says if you come near her, she’ll punch you in the face.

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC - Critical Lab Hb 6.7, Consent is done per MD, Type and Screen resulted

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, Awaiting CT results Calling for bathroom

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Still needs his overdue Miralax and Senna

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L502

Please prime the blood tubing.

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC - Critical Lab Hb 6.7, 1 unit pRBC running now

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, not LVO Awaiting MRI

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Critical lab: Lidocaine level 6.2

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L514

Critical Lab: Lidocaine 6.2 What are your next steps?

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC - Critical Lab Hb 6.7, 1 unit pRBC running now

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable Maintenance fluids beeping

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, not LVO MRI done

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Critical lab: Lidocaine level 6.2 Lidocaine stopped, continuing PCA Still need 1300 Gabapentin

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L514

While about to give the 1300 gabapentin to 14, you see that you already pulled his gabapentin and find out that you had mistakenly given the dose to L502. L502 happens to be calling noting that she is feeling itchy.

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC Critical Lab Hb 6.7, 1 unit pRBC running now Feeling itchy, possible allergic rxn from gabapentin

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable CT neg for any changes in head NA calls to ask for your help for pt back to bed

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, not LVO MRI done

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Critical lab: Lidocaine level 6.2 Lidocaine stopped, continuing PCA 1300 Gabapentin given

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L506

PT had gotten her up into a chair about 30 min ago. You go in and notice she is quite sleepy in the chair. Vitals are taken and show low BP: 82/54, HR 114, RR 19, Temp 99.9F. What do you do next? What device would you use?

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L506

Back in bed, his BP comes back up to 100/66, HR 90, RR 20. He perks up a little more with his legs up. What are your next steps?

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC Critical Lab Hb 6.7, 1 unit pRBC running now Feeling itchy, posisble allergic rxn from gabapentin Family calling for you to check on patient, seems "out of it"

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable CT neg for any changes in head Possibly orthostatic in chair, back in bed now

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, not LVO MRI done

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Critical lab: Lidocaine level 6.2 Lidocaine stopped, continuing PCA 1300 Gabapentin given

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L502

You come into the room to see patient is asleep. Family says she is more sleepy than before. New vitals: BP 79/52, HR 118, RR 13, Temp 101.2f. Patient arousable to sternal rubs, but having a hard time staying awake. What do you do?

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L502

Critical lab comes back Lactate is 5.2 What do you do?

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L502

All labs are drawn, bolus and antibiotics are started. Vital signs begin to stabilize. Patient becomes more alert and back to baseline. While talking with the patient, you notice they begin looking and staring to the right. What do you do?

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L502

The neuro team replies saying they are on the way. While you are waiting, the patient begins having rhythmic arm jerking, heart rate elevates to 150s and he begins to desat to 80%. What do you do?

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC Critical Lab Hb 6.7, 1 unit pRBC running now Feeling itchy, posisble allergic rxn from gabapentin VS change, Critical lab Lactate 5.2 Sepsis workup done, seizure stabilized placed on EEG

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable CT neg for any changes in head Possibly orthostatic in chair, back in bed now

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, not LVO MRI done, confirmed new stroke in R BG

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Critical lab: Lidocaine level 6.2 Lidocaine stopped, continuing PCA 1300 Gabapentin given Tele alarm is ringing for desatting.

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L514

Tele alarm for 14 is alarming now, pt is desatting in bed. Pt is asleep, but even after awaking, his O2 sats are at 80%. Pt feels SOB, RR 28, HR 110, requiring 5L NC to maintain above 90% What do you do?

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L506: Boo, T

L502: Ros, N

L Frontal ischemic CVA, R IPH, GLF, AO2-3, BMAT 1, Foley, PICC Critical Lab Hb 6.7, 1 unit pRBC running now Feeling itchy, posisble allergic rxn from gabapentin VS change, Critical lab Lactate 5.2 Sepsis workup done, seizure stabilized placed on EEG

Moyamoya, ECIC POD #1, AOx4, BMAT 4 Had a fall in bathroom, VS otherwise stable CT neg for any changes in head Possibly orthostatic in chair, back in bed now

L512: McM, T

L514: Kro, A

R Thalamic CVA s/p PFO Closure yesterday, AOx4, BMAT 4 BG 54, stabilized Stroke Code, CT done, Awaiting MRI

T2-8 Fusion, T5 decompression, JPx1, Epidural Nerve Block Lidocaine, Foley, PCA 0.2mg Q10 min, AOx4, BMAT 4

Oxy 10mg given at 0800 DART called on family, Wife escorted out due to physical aggression, Pt willing to stay, Lidocaine and BMP labs sent Critical lab: Lidocaine level 6.2 Lidocaine stopped, continuing PCA 1300 Gabapentin given CT PE done, positive for PE

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