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#WorkUpWednesday | Altered Mental Status - Ep.1
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Pt comes to the ED via EMS after family called because patient is “just not acting right.” Vitals are currently stable, they arouse to tactile stimulation but are only oriented to self. After receiving report and gathering some background information you find out patient has a hx of liver failure but also fell two days ago fell and hit there head pretty hard.
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There are 2 main concerns here. Does the patient have a intracranial hemorrhage as a result from the fall two days ago. What is the patients ammonia level? Elevated ammonia levels are a complication of the liver not working properly and can help as a confirmatory test for hepatic (portal systemic) encephalopathy. Other than a full assessment and being placed on continuous monitor. What am I going to do?
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IV, LABS & FLUID. Establish an IV, preferably large bore and draw blood for labs and run POC labs if you have this capability. Ensure to draw an extra lavender on ice for your ammonia. Fluids. Unless they have a contraindication, they could use them. Just start them slow because if they are a bleed you don’t want to raise their blood pressure and increase the bleeding. LABS to focus on first: Hgb/Hct | Coags | Ammonia | Liver Profile | Lytes.
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CT HEAD. No waiting for the ammonia level to rule out hyperammonemia. Your doc will most likely want that CT ASAP!
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LACTULOSE. In the case of hyperammonemia this medication decreases ammonia levels by drawing ammonia from the blood into the large intestine, as well as more fluid, working like a laxative. So have fun cleaning it up! Luckily they’ll most likely be getting admitted so send a fair warning to the floor nurses. This could be a “ show”.
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NEUROLOGIST/NEUROSURGERY. If the pt has a confirmed bleed this is where we involve neurology. The patient could be anything as minimal as an admit to Neuro and watch with frequent Neuro checks or require surgical intervention.
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Other possible tests. BC’s (because everyone’s possible sepsis these days ). UA/DUA. EKG. MRI.
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Affiliation Over Accreditation.
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If there is one thing I’ve learned going through hiring processes and looking at what it takes to get into different hospitals. Honestly it doesn’t matter what school you went to as far as their accreditation goes. We all get the same degree.
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So here’s some advice related to that in which I gave to a patient and his wife after they asked me what school their daughter should attend for nursing. You have a hospital you want to work for? Pick the school that’s associated with that hospital system. That truly is your foot in the door. Clinical & class are your interview. Treat it as such.
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Share this with future nursing students you know. Could make the difference in them getting their dream job.
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What are some tips you have for people searching for their ideal nursing school?
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#Nurse #StudentNurse #NursingSchool #NursingSchoolProblems #NurseStrong #NursingTips
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