Summary: Download! What to do if your patient has a seizure, vomits blood or self-extubates, etc. In this crazy job called nursing, everything that can go wrong WILL go wrong at some point in your career. I am dedicating this post to some worst case scenarios. WORST CASE SCENARIOS: HEAD AND NECK 1. Your patient begins to have seizure activity. Ativan IV, pad the siderails, patient may need to be intubated, consult Neurology and start prophylactic meds like Dilatin or Keppra. Neuro may want to do an EEG or head CT or both. An OGT or NGT might be a good idea after seizure has resolved to help prevent aspiration. 2. Your patient has a decreased in LOC, AMS, new onset confusion. Assess your patient for any other neurological deficits or vital sign changes. If the patient is at high risk for falls, take appropriate precautions like bed alarm and possible restraints or mittens until you can determine the cause. Notify the physician. Depending on the patient’s history- the physician may order a variety of interventions e.g. Stat Head CT, pan cultures to screen for an infectious process, lab work to check for electrolyte imbalances (sodium levels, ammonia levels, etc.) or a stat ABG to determine oxygenation status. If you have a Neuro patient with a sudden decline in LOC or a change in their Neuro exam (for example, the patient was following commands and now is not)- you will likely do a stat Head CT and those results will determine the plan of care. 3. Your Neuro patient has high ICP values. Depending on the cause of the problem, Neurosurgery may place an EVD or take the patient to IR to do a coiling or clipping or craniotomy in the OR. If the patient has an EVD, the drain may be lowered to allow for more CSF drainage. The patient may need hypertonic solutions (3% NS) or an osmotic diuretic (Mannitol). If ICP’s are related to patient activity, sedation may need to be increased. In severe cases, patient may need to be placed into a barbiturate coma. 4. Feeding tube problems are endless. Patients do not like to have feeding tubes (FT) inserted. You may need a one time dose of Ativan, Fentanyl or Morphine, etc. to calm your patient down long enough to place the tube. *Do not use the FT until it is confirmed that it is in the correct place and not in the lungs. Our hospital requires x-ray verification. Once the tube is in and taped firmly onto the nose- there are some things that can go wrong... If the FT is dislodged or gets pulled out, STOP THE FEEDINGS! If the tube has been slightly dislodged- re-secure and shoot a repeat x-ray. If the tube is hanging all the way out, d/c the FT and insert a new one. *Our hospital just started using "bridles" which secure the feeding tubes to the patient’s nasal septum so if the patient pulls on the tube- it causes pain and they stop. Instead of restraining patients who attempt to manipulate the FT, try mittens! **If the FT becomes clogged, try flushing it. You can try warm water and anything with carbonation (soda pop, ginger ale) to try to break up the clog. If nothing works, you may have to d/c and reinsert. If the FT is kinked or coiled on the x-ray, you will likely not be able to get any feedings down the tube so you will have to d/c the FT and insert a new one. Check residuals by pulling back on the FT with the syringe. If residuals are large, do not reinsert the residual and decrease or stop the rate of TF (notify physician). If residuals are moderate, decrease the rate of TF. If the residuals are small, the rate of TF is probably ok. Check residuals every 4 hours at least or more frequently as needed. Also check residuals if you stop hearing bowel sounds, bowel sounds are hypoactive and/or patient complains of pain or nausea. 5. Your patient is vomiting. IV Zofran, place NGT or OGT to low continuous suction or low intermittent suction to suction out the stomach contents.
