INTRODUCTION

A regular feature of this section will be the presentation of hypothetical cases. The purpose of these case presentations is to inspire discussion about some of the more difficult decisions in neuroscience nursing. Interspersed throughout each case will be set of questions about what the optimal management should be at that point. All of the readers will be invited to vote on those answers using a link to a survey https://www.surveymonkey.com/s/snicases. Please try to answer each question as you go through the case rather than finishing the case before answering the questions. The results of the survey will be presented in the subsequent issue. All readers are encouraged to send comments to the editor regarding the results of the survey and important discussion points arising highlighted in that or later issues. These cases can be used by any of the readers at their own institutions to spark discussions. Nothing in these case presentations is to be taken as a suggestion for patient management as the hypothetical cases may feature both medically appropriate and medically inappropriate decisions. The key is the discussion that follows.

CASE PRESENTATION

A 75-year-old female is admitted to the emergency room (ER) with a diagnosis of syncope. The ambulance drivers stated that the patient stood up after having lunch with a friend and fell to the floor and did not shake. When the ambulance team arrived she was conscious but tired and confused. Her blood pressure was 130/90, heart rate 100, and O₂sat 95%. On arrival, the patient says she does not know at all what happened and wonders why she was in the ER.

The ER physician evaluates the patient and finds that the patient is awake and alert and moving all extremities well. He orders a computed tomography (CT) of the head, an electrocardiogram (EKG), and routine blood work including Complete Blood Count (CBC), comprehensive metabolic panel and a toxicology screen; all of these are normal. The patient is connected to an EKG monitor in the ER. All tests were normal except for a white count of 12. The ER physician decides that the patient most likely had syncope and should be admitted to a medical telemetry floor.

Question 1

What diagnoses are you actively considering at this point? (Check all appropriate)

Syncope

Question 2

How confident at this point are you about a diagnosis of syncope?

Definite

Before the intern from the medicine service arrives in the ER to perform the admission history and physical, the patient's sister who was present during the event arrives but states she has to leave soon.

Question 3

The ER is always very busy and time is limited. Which of the following would be the highest priority for the nurse interacting with the sister?

Obtain an extensive history from the sister

Question 4

If you seek additional history at this point, what is the most important question to ask?

When you speak with the sister she noted that the patient had a moderate head injury 5 years ago from which she recuperated with only minimal problems with gait. She said on the day of the event, the patient was well but about 5 min after she stood up, she developed a funny look on her face and fell to the ground. There was a small amount of shaking. The patient was lying on the ground unconscious for about 5 min and just started to wake as the ambulance arrived.

Question 5

Does this additional information change your diagnosis?

Yes

Question 6

Based on this new information, what action do you take?

Document the additional history on your ER nursing documentation sheet

The ER nurse calls the medical intern and is told that they will be down in an hour or so to evaluate the patient

Question 7

What do you do at this time?

Wait for the intern to come down

The ER nurse taking care of the patient goes off duty and signs out the additional information to the nurse who will be taking care of the patient. The patient's sister goes home. By the time the intern comes down to the ER to admit the patient, the nurse now taking care of the patient has a few additional patients to take care of and does not get a chance to speak with intern. The patient is admitted to the medicine telemetry floor.

Question 8

Is there anything the nursing staff might do to prevent this from happening in the future?

The patient is admitted to the medicine floor. The only available bed is one at the end of the hall. Approximately 1.5 h after arriving on the floor, the nurse in the next room hears a scream. She runs into the patient's room and sees the patient on the floor. The patient is unresponsive. Blood pressure is 180/100, heart rate is 100 and regular, respiratory rate is 18 O₂sat is 98%. In a few minutes the patient is lethargic but moving both arms and the right leg but the patient does not move the left leg. Trying to move the left leg produces severe pain.

Question 9

What is the most likely diagnosis now?

Syncope

Question 10

What piece of information was most important in making this diagnosis at this point?

The nurse calls the intern covering to inform him about this event. The intern orders an X-ray to determine whether there is a fracture in the left leg. The intern reviews the telemetry recording during the event but does not note an arrhythmia. The X-ray shows a left hip fracture and the intern orders a stat orthopedics consult. The patient becomes alert and oriented. The intern makes the diagnosis of orthostatic hypotension and orders the nurse to keep the patient at bed rest.

Question 11

What should be done about neurological checks?

Institute neurological checks q4 h

Question 12

What other actions should the nurse take?

Call the intern to suggest another diagnosis

The nurse reviews the ER documentation and notes the history of head injury and suggests that the patient may have had a seizure. The intern replies that this is very unlikely. The intern stated that neurological checks every 8 h would be sufficient.

Question 13

What should the nurse do at this time?

Tell the intern that he is incorrect

The nurse calls the resident who initially is reluctant to discuss the case but with presentation of the clinical situation agrees that this may have been a seizure. He orders the patient to go to intensive care and have neurological checks q1 h. The resident orders keppra (levetiracetam) 1000 mg IV and then 500 mg IV q12 h.

Question 14

Which change would practically have most likely prevented the negative outcome of a hip fracture in the patient?

The intern could have arrived to the ER in a more timely manner

The next day the patient was taken to surgery to repair the hip fracture. The patient had significant pain after the repair and required regular narcotics for pain control. On POD #2, the patient became agitated with increased respirations and tachycardia. The nurse called the intern for additional pain med orders. The intern did not immediately return the call so the nurse then called the resident. The resident ordered medication for breakthrough pain. The resident did come to the floor to assess the patient. Thirty minutes after receiving medication for breakthrough pain the patient became tachypneic with an O₂sat of 82% on Room Air (RA). Oxygen @2L via Nasal Cannula (NC) was applied; however, the O₂sat dropped to 78%. Rapid Response Team (RRT) was called. The patient became unresponsive with no spontaneous breaths and no pulse. A code was called, however, the resuscitation attempt was unsuccessful and the patient expired.

Question 15

What was the most likely cause of death?

Allergic reaction to pain medication