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What to do? A real life scenario – Updates Complete!

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All right nurses, here is a scenario for you. You walk into the room. The patient seems a bit “off” but he’s sick, (DM, HTN, etc.) and a bit older at 74 y/o.  The second time you head into the room, his wife and adult daughter are there.  They tell you he’s NEVER like this.  What’s the first thing you do?


Thanks for the responses!  Melzie said to check vitals, blood glucose, and neuro status.  I love that she included to do a neuro check. You don’t want to spend a long-time doing this. I’d stick to orientation questions only (who are you, where are you, what date it is). Maybe ask them the name of the family in the room with him.  You want to be sure to do this neuro check because you want objective data.  How confused is he?  How will we know when he’s better?  It’s important to listen to the family’s feeling about the patient, but it’s just as important to convert that information from a statement of opinion to objective medical data we can do something with.

Sheila also said to consider the possibility that the patient has a UTI.  This is a great point, especially since the patient is 74. The older the patient, the more confusion a UTI could cause, even without a fever present.  Of course, a root cause like this is a secondary concern for now.

So, I’d get the vitals and blood glucose and neuro check as quickly as possible.   The patient is oriented only to self.  He has no clue where he is, the date, or who is President.  His vital signs are within normal limits except for his blood pressure which is 74/50.  A quick glance at his charge reveals he is on blood pressure medicine and his BP is usually closer to 140/80, even when on meds.

You page the doc.

What do you do while you wait?


Wow.  See TaraRRT’s comment below.  I’m guessing she’s a Rapid Response nurse (based on her username) and did an amazing job of saying what she’d do next!  Here’s what I did:

I put the patient in trendelenberg and started running saline at 150 ml/hr.  The docs called me back immediately and arrived immediately so I did not, in this instance, call the rapid response team.  However, a call to the Rapid Response Team was definitely warranted given the situation.

The patient’s vitals recovered quickly.  The family was really grateful for my help–they felt very listened to and cared for.  This situation was actually a really good one for me as it was really early in my career and I felt like I made some good, quick decisions.

6 responses »

  1. bare with me as I am a new nurse. I would check him physically to be sure nothing is causing him discomfort, then I would check his BS if he has DM, next would be vitals and last a call to the doctor to r/o UTI (esp if he has a urinary cath). Of course, I would have asked him if anything is bothering him while doing all of these 🙂

    • Thanks for your response, Sheila! A great answer, especially for a new nurse. See updated post above. What would you do while you wait for the doctor?

  2. V/s, blood sugar and neuro check

    • Thanks for posting! Absolutely! So, you get the info and page the doctor. What do you do while you wait? VS are in updated post above.

      • At our facility (and most JCAHO-approved hospitals), we would call our rapid response team. If any of the neuro assessment stuff came up positive for stroke, we’d call our in-house stroke team.

        And while I waited… Follow any protocols in place for symptomatic hypotension. Ready a dose of neo, if possible. Know the location of the code cart and emergency med box. Assure patient’s safety, make sure he’s protecting his airway. Place him in modified Trendelenberg; reassess. Anticipate orders and prepare for IV fluids and labs, including UA and blood cultures. Get or prepare to get access for those things. Put him on a couple liters of oxygen, or increase what he’s already using if there are no contraindications. Keep him NPO; hold any tube feeds he’s getting. Assess him for signs of dehydration and infection. Assess his kidney status: has he been making urine at his usual rate? Care for my own kidneys: Empty my bladder. It might be a long shift.

      • Awesome! You thought of all sorts of things I hadn’t. You’re definitely a better nurse than I am! =)

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