Debbie was caring for a patient who was admitted through our ED after falling and hitting his head while walking his dog. He had sustained a subdural hematoma and had surgery to evacuate the hematoma. He had been in the ICU where his post op recovery period was remarkable in that he was anti-coagulated post op and then developed a post op bleed which left him with stroke like symptoms including decreased sensation and movement on the right side as well as slow and deliberate speech. He also had a seizure during this post op period and was started on Keppra. He had improved dramatically over the next few days and was transferred to a medical/surgical unit 6 days post op. Two days later, Debbie, a Float Pool nurse was assigned this patient for the first time.
The plan this day was for the patient to be transferred to Marionjoy Rehab. As this was her first day with this patient, Debbie had very little to compare his mentation with except for the report she received and previous documentation. Previous documentation indicated that he was slightly confused, conversational, eating on his own and had weakness of his right side which was minimal and his pupils were equal round, reactive to light. On her first assessment, she found this patient to be completely normal except neurologically he seemed very sleepy but actually more orientated than before with a slight weakness on the right side. He was able to follow commands easily and walked with PT with a walker. His girlfriend came to visit around 11 am and informed her that she thought he was very sleepy but otherwise seemed about the same. At noon she repeated her neuro assessment and found no change other than increased sleepiness to the point that he fell asleep while eating.
Debbie spoke to the Trauma physicians twice about this assessment, called neurology, and of course called the neurosurgeon. She wanted them all to be aware of the plan to discharge the patient that day and she wanted to be sure that they were all aware of the change in level of consciousness. Because the patient had been placed on Keppra post op, and that dose was increased 2 days later the neurologist thought this could be the cause of his increased sleepiness and so the dose was decreased. All of the physicians signed off the case.
Deb was still was not comfortable with the patient being so lethargic and pushed for the neurosurgeon to see the patient one last time. She pushed because first, she always listens to family because they know the patient better than she did as it was her first time caring for this patient. Secondly, Debbie had a gut feeling that something wasn't right and finally, she felt that everyone was too anxious to discharge this patient after he had had so many post op complications. Debbie was able to get the PA for Neurosurgery to physically come in and see this patient and she agreed with Debbie that this patient was definitively more lethargic then previously (she had interacted with him daily). She ordered a CT scan stat, and it revealed a large increase in the size of the existing subdural hematoma with a midline shift. The patient went emergently to the OR within 2 hours. Post op he did well with improvement in his neurological status. He recovered in the ICU, then on a medical/surgical unit. He was transferred to Marionjoy 5 days post surgery.
Without Debbie’s excellent assessment skills and advocacy for this patient, his clinical outcome may have been quite different.