Friday, June 26, 2009

To ICU or Not?

I had a 47 year old patient several months ago that was admitted from an outside hospital because he had a ruptured appendix that ended up causing a MAJOR infection. He had been in our hospital for about 4 weeks and had just been transferred from ICU that morning.

He was extubated the day before, had been in a vest restraint as well as soft wrist restraints in ICU because he has pulled out a total of:

* 3 IVs
* 1 PICC Line
* 2 Small bowel feeding tubes
* 1 Foley catheter
* 1 Rectal tube
* 2 Chest tube
*Rectal Tube - the large blue end in the bottom left
of the picture is what is inserted into the rectum.
It is then inflated like the picture above to secure placement.
The other end of the long tubing is connected to a collection bag.

*Small Bowel Feeding Tube - Inserted into the nose down the back of the throat through the esophagus and stomach to the small bowel. Can be used to give liquid feedings and medications for patients that can't swallow well and are at risk for choking.
This was all included in my shift report at the beginning of my shift. The day shift nurse also told me he had been "pretty good" that day. He was no longer in restraints. He did however have a sitter, and his mother stayed in the room with him. But he wasn't pulling at anything. Well, HELLO??? Was there anything left to pull out??? He did have PICC Line but that was all that was left. He was only really oriented to his name. He had no idea where he was or why he was there. He could not tell me the year or who the president was. He was very confused and most of what he said didn't make sense. His mother was off the chain!!! You could tell she was so worried about him and she just wanted to do whatever she could to make him better, but really she couldn't do anything but sit there and listen to him talk crazy and drop the "F" bomb about every 45 seconds.
On first assessment he complained he couldn't breath. He thought his lung was collapsing again. His assessment was negative, however I did call the doctor just to inform her of how he was feeling, even though his lungs sounded great. He was pretty anxious so I ended up giving him oxygen just to make him feel better. I actually worked. It gave him something to play with. He didn't keep it on however. But since his O2 sats were 98% on room air, I wasn't really concerned too much.

As the night progressed, he became more and more confused. He was increasingly agitated and began hallucinating. He was seeing birds in the room, he thought there was a fire in the room. He also told the doctor how beautiful her ears were, they looked just like those of a baby deer. He was so sweet when he said it, he was sure he was giving her the grandest compliment.

I had been giving him, per her orders, Fentanyl 50-100 Mcg IV for pain. He could have it every 3 hours. Normally it would have made other patients sleep for a while. He was not sleeping. He was crawling out of bed, yelling, and requiring me to be in his room ALOT. I had 3 other patients so this was not that easy. She had me begin using Ativan to see if that would calm him. Two mg would calm him, but only for a short time. She decided to put a request in for a med psych bed and we were going to transfer him once there was a bed available. Well in the middle of the night this is not a quick task.
He kept complaining about his breathing and I kept talking to the doctor about it. Finally we got a chest x-ray, ABG's and some other labs. His x-ray didn't come back too bad but his ABG's were all jacked up. The doctor stated to me that if he was in ICU she would be intubating him right now. Then she said she was calling the ICU resident and they would probably intubate him and take him to ICU. She wanted to intubate him on the floor, without having the rapid response team or code team there.
While she was on her way to the room I called my house supervisor who also came because she was not going to allow anyone to be intubated on the floor without the team there. Well, short version, the ICU doctor wouldn't take him in ICU. They had 9 admits already that night and he and the other doctor that I was dealing with collaborated back and forth on what to do.

Ultimately he ended up with a 50% venti mask and alot more drugs. She said pretty much he was hyperventilating. He wouldn't slow down to breath well enough to get good air exchange. So she wanted him as sedated as I could get him without sending him to the ICU so he would breath slower and more calmly.

He ended up with the Fentanyl every 3 hours; 2 mg of Ativan every hour, and 5 mg of Haldol every 3 hours. I calling her before I gave any of it because he really wasn't going to sleep. He was calming down some but it was really hard to keept he mask on him. He kept taking it off. I was so afraid all the meds were going to catch up with him and eventually knock him on his butt! The doctor was calling me about every hour (when I wasn't calling her) checking on him. There was so much charting to do just to keep up with what we were doing with him. And then there were my three other patients.
He ended up sleeping about 45 minutes out of my 12 hours shift. Med Psych never had a bed, the meds never caught up with him.
I reported off to the day shift and apologized because he was going to be so much to handle. I recommended her getting him off the floor as soon as she could because he was really a 1 on 1 patient and this floor doesn't staff that way.
I went back to that floor 3 days later. . . . .
He was being discharged to home as I was coming on to my shift. He was a new man!!! Evidentally that day shift after I left him last, he was quiet. He didn't cause them any trouble at all. And by that next evening shift he was off all oxygen and totally alert and oriented and no longer hallucinating.

Now you tell me what causes someone to change mental status so quickly!!! I worried about him and the day shift nurse the whole time I was off that day. And within less than 24 hours he is totally a different man!!!
AMAZING, what a body goes through!! How much it can handle and how quickly it will recover sometimes. I was glad to see him going home. Not because I didn't want to take care of him again (although, it did make for a really rough night!!!), but because he was becoming more himself. He had a young daughter to go home to. He had a life. He was not an ill person before all of this. He was hallucinating and acting crazy before the doctor had me giving him all the meds, so it wasn't the meds causing him to be acting crazy. But whatever it was, it was better. He was going to be ok. He would be back to work in a few weeks after his surgical incision healed and hopefully he would have little memory of his bizzare behavior in the hospital.
Thank God for selective memory!!
Today, I wish him well as he should be fully recovered and living a full and happy life with his family, what mattered most to him!!!


  1. (ICU) psychosis is a strange and difficult thing we all deal with. Everyone from the patient, their family, and the entire health care team become frustrated and down right exhausted.
    It's an amazingly difficult wall we constantly beat our heads against, and every patient reacts and progresses through it differently unfortunately.
    Glad to hear the patient was improving and doing well.
    A job well done.

  2. Sean - thanks for stoping by and commenting! Since I don't work ICU, I rarely see this psychosis. It was an interesting learning experience that is for sure!!! And it was great to see him progress.

  3. What an amazing blog you have here. The documentation is fascinating.

  4. Maggie - Thanks for stoping by and leaving a comment. How did you find me? I love it when I get new visitors!!!

  5. Wow, don't know how you survived 12 hours of that especially with 3 other patients!!!

  6. Southern Drawl - honestly I am not sure how I did either. Only by the grace of God! I am not a very good psych nurse, and I know that. My patience run short. And I knew he totally was not normally like this and was really not well. I am just thankful I had a good team of nurses working with me that night that really pitched in and helped!!!