This is Mr. G. and he has a lot of problems!
Back story: Mr. G. was in an alley outside a downtown casino and was noted to be having a generalized (tonic-clonic, or grand-mal) seizure. He was transported to the ER. Though he is well known to the ER staff, the nurse begins a careful assessment of the patient.
Vital signs: T 100.6, P 110, R 28, BP 108/62, %sat 80 on 4 L/min O2.
Observations: Mr. G. is arousable, but barely oriented x 1. He moves all extremities equally (defensively) but does not follow commands. The nurse cuts Mr. G. out of his very dirty t-shirt and notices that there is (probably) recent (wet) coffee-ground looking emesis down the front. Mr. G. is noted to be thin and malnourished in appearance. He is edentulous and icturic (yellow sclera.). Mr. G. has a wet cough that is not productive. In addition, Mr. G. is using his abdominal muscles to breathe out, and he has a "barrel-chest" (increased A-P diameter). Bowel sounds are pretty normal. Mr. G. also has yellow stained fingernails on his right hand. He has no jugular vein distension (JVD) with HOB at 45 degrees but he does have 2+ pitting edema in his lower legs bilaterally and he has been incontinent of urine.
Examination: The nurse auscultates Mr. G's chest and abdomen and notices the following... Expiration is much longer than inspiration. There are wheezes throughout. The breath sounds in both bases are broncho-vesicular to vesicular with coarse crackles that do not clear with cough. Heart sounds are fairly normal (S1 and S2) and the monitor shows sinus tachycardia. Mr. G's abdomen is slightly distended with normal bowel sounds but he grimaces upon deep palpation. While routine blood samples are being drawn, Mr. G. has another generalized seizure lasting 2 minutes. He is treated with IV lorazepam.
Labs:
Complete Metabolic Panel has the following findings: Na+ 149, K+ 5.2, Cl- 122, HCO3- 48, BUN 33, Creatinine 1.8, Glucose 120, ALT 45, AST 120, AlkPhos 75, Bilirubin 2.8, Albumin 2.3,
CBC: WBC 18.5 with 80% neutrophils 15% bands, Hct 21.5 Hgb 7.0, Platelets 108,000.
Coagulation studies were relatively normal.
Arterial blood gases: PaO2 80 mmHg, PaCO2 50, pH 7.3, %sat 90 on 40% mask
Dilantin levels: zero
BAL: zero
Diagnostics: Mr. G's CXR was interpreted to suggest that he has hyperinflated lungs and depressed diaphragms with consolidation consistent with pneumonia in both bases.
Clinical Reasoning about Mr. G... wow! Where to start?
Face facts! There isn't a lot that is NOT wrong with Mr. G. He has multiple chronic and acute conditions that compound one another. Where ought you to start? Even if you could determine all the "NANDA's" that fit Mr. G., which one is the highest priority? Let's do some "pre-NANDA" reasoning about this patient. To do this refer to the Systematic Outline of Basic Human Needs. Take each need in order of priority, from most to least in urgency.
Oxygenation: Does Mr. G. have a problem with oxygenation? Boy howdy! You better believe he does... and on at least 3 different levels. More about this below. Let's run through his other basic physiological needs.
Fluid and Electrolytes: About all we can say at this time, based upon Mr. G's labs is that he is likely dehydrated. This makes sense... he probably doesn't drink a lot of water. His serum Na+, BUN and Creatinine are all elevated. Also consider that with his low serum albumin, Mr. G will have fluid leaving his vasculature and going into his extracellular spaces.
Nutrition: Mr. G. looks malnourished and this is common in the homeless population that will spend available cash on drugs, cigarettes and alcohol. Add to that he is severely anemic (is it blood-loss anemia, or nutritional deficiency anemia? Answer is YES!) and has a very low serum albumin. Even if Mr. G had a lot of money, his diet would be limited by his absence of teeth. Another fact to remember with chronic alcoholic patients is that they are almost always folate, thiamine and B12 deficient.
Elimination: (does the patient empty his bowels and bladder normally). Mr. G. was incontinent of urine, but this is not uncommon during a generalized seizure. We know nothing about his bowels. He may be in the clear with this basic human need. We just don't have enough assessment data at this time to know.
Rest and restoration: (i.e., is the patient in acute or chronic pain and is his sleep pattern normal?) We really have insufficient evidence to assess this issue. The patient did grimace to deep abdominal palpation and we know nothing about his sleep patterns, though we could intuit that they are not very healthy.
Mobility: We really haven't assessed this yet either because we have not wanted to try to ambulate him. We know that he seems to have normal motor function in all 4 extremities. Mobility is also affected by balance and on this score, the nurse is justified to believe Mr. G. is a very high risk for falls.
Physiological safety mechanisms: This category includes all the protective mechanisms that keep people alive and functional. One of the foremost organs we have for our physiological safety is a functioning cerebral cortex. Mr. G. is in trouble neurologically because he is seizing and we can guess that he drinks himself into stupor when he has sufficient alcohol to do it (though this is only an assumption right now... and his blood alcohol level was zero.) The nurses on the clinical units must be alert for the possibility that Mr. G. will go into delirium tremens. Another physiological safety mechanism we have is the gag/cough reflexes that keep us from aspirating. These could have been impaired and failed Mr. G when he was immediately post-ictal or when/if he has a habit of drinking to stupor. And another important protective function is our immune system. Mr. G. has an elevated white count with a left shift and a fever. These findings strongly suggest he has an infection somewhere. The interpretation of his CXR suggests that this infection could be in his lungs.
Oxygenation: Does Mr. G. have a problem with oxygenation? Boy howdy! You better believe he does... and on at least 3 different levels. More about this below. Let's run through his other basic physiological needs.
Fluid and Electrolytes: About all we can say at this time, based upon Mr. G's labs is that he is likely dehydrated. This makes sense... he probably doesn't drink a lot of water. His serum Na+, BUN and Creatinine are all elevated. Also consider that with his low serum albumin, Mr. G will have fluid leaving his vasculature and going into his extracellular spaces.
Nutrition: Mr. G. looks malnourished and this is common in the homeless population that will spend available cash on drugs, cigarettes and alcohol. Add to that he is severely anemic (is it blood-loss anemia, or nutritional deficiency anemia? Answer is YES!) and has a very low serum albumin. Even if Mr. G had a lot of money, his diet would be limited by his absence of teeth. Another fact to remember with chronic alcoholic patients is that they are almost always folate, thiamine and B12 deficient.
Elimination: (does the patient empty his bowels and bladder normally). Mr. G. was incontinent of urine, but this is not uncommon during a generalized seizure. We know nothing about his bowels. He may be in the clear with this basic human need. We just don't have enough assessment data at this time to know.
Rest and restoration: (i.e., is the patient in acute or chronic pain and is his sleep pattern normal?) We really have insufficient evidence to assess this issue. The patient did grimace to deep abdominal palpation and we know nothing about his sleep patterns, though we could intuit that they are not very healthy.
Mobility: We really haven't assessed this yet either because we have not wanted to try to ambulate him. We know that he seems to have normal motor function in all 4 extremities. Mobility is also affected by balance and on this score, the nurse is justified to believe Mr. G. is a very high risk for falls.
Physiological safety mechanisms: This category includes all the protective mechanisms that keep people alive and functional. One of the foremost organs we have for our physiological safety is a functioning cerebral cortex. Mr. G. is in trouble neurologically because he is seizing and we can guess that he drinks himself into stupor when he has sufficient alcohol to do it (though this is only an assumption right now... and his blood alcohol level was zero.) The nurses on the clinical units must be alert for the possibility that Mr. G. will go into delirium tremens. Another physiological safety mechanism we have is the gag/cough reflexes that keep us from aspirating. These could have been impaired and failed Mr. G when he was immediately post-ictal or when/if he has a habit of drinking to stupor. And another important protective function is our immune system. Mr. G. has an elevated white count with a left shift and a fever. These findings strongly suggest he has an infection somewhere. The interpretation of his CXR suggests that this infection could be in his lungs.