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Case Study

Case Study. Lindsay Trantum ACNP-BC VUMC Neurological ICU. Case Study.

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Case Study

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  1. Case Study Lindsay Trantum ACNP-BC VUMC Neurological ICU

  2. Case Study • Mr. Cam is a 73 y/o male with hx of HTN, COPD, smoking and hyperlipidemia admitted for acute right MCA CVA. His hospital course has been complicated by cerebral edema requiring decompressive craniectomy, UTI, non-convulsive status epilepticus requiring ativan prn and persistent electrolyte abnormalities.

  3. Case Study • On hospital day 4, the bedside RN comes to you and says that Mr. Cam is complaining that spiders are crawling all over him and he’s screaming that we are all trying to kill him.

  4. What is the most likely diagnosis? A. Paranoid schizophrenia B. ICU delirium C. Altered mental status D. Sepsis

  5. What tests would you order? A. UA and culture B. Comprehensive metabolic panel C. Ammonia D. Non-contrasted head CR E. All of the above

  6. Case Study • 2 hours later, Mr. Cam’s nurse comes to you and says that he is biting and spitting at the staff and becoming increasingly more agitated

  7. What is the most appropriate pharmacologic intervention? • Lorazepam 2mg IV q2h prn • Seroquel 25mg BID increase by 25mg q12h until desired effect • Haldol 2.5mg q2h prn • Both a and c • Both b and c

  8. Case Study • On hospital day 8, Mr. Cam becomes hypoxemic and lethargic. You decide he needs to be intubated.

  9. Which sedative would you choose? a. dexmedetomidine b. Propofol c. Fentanyl d. Versed e. Either a, b or c

  10. What interventions will assist you in decreasing Mr. Cam’s delirium? • SBT and assess for extubation daily • Keeping him sedated with fentanyl and versed until ready to extubate • Early mobility • Use of eye glasses and hearing aides • Maintaining a day/night cycle • A, C, D, E • A, B, D, E

  11. Identify Mr. Cam’s delirium risk factors • UTI • Intubation/Respiratory failure • Stroke • Electrolyte Abnormalities • Lorazepam administration • All of the above

  12. Case Study • On hospital day 11, Mr. Cam is extubated. That evening, he starts picking at his IV sites and pulling on his foley.

  13. What is your next course of action? • Versed 2mg IV prn • Re-intubate for his safety • Continue Seroquel and prnhaldol • Add dexmedetomidine • Both c and d • None of the above

  14. Case Study • On hospital day 16, Mr. Cam’s ICU delirium clears. He is transferred to the floor and eventually to in-patient rehab. Unfortunately, he still suffers from mild long-term cognitive impairment.

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