Last week, I had a really great learning experience. This week, my assigned patient (Yes, we were supposed to have 2 this week. Unfortunately, census was down so we only had 1.) Anyhow, my assigned patient was admitted over the weekend with a change in mental status. Try writing that up for clinical prep – shoot there are so dang many things that contribute to a change in mental status. It is difficult to know which direction to effectively write up without knowing any further history. But I got it done. Arrive at the clinical hospital 0630, ready to go. Get report on my patient, learn some things important, like there was a right subclavian portacath. (immediately knew that she was most likely a cancer patient, since they tend to have these for chemo medications). She was s/p breast ca and a left radical mastectomy. She became seriously confused, was admitted, and had a raging UTI.
It’s no secret that a UTI will cause a confused presentation in the elderly. Much documentation has been done on that subject alone. Heck, Pope John Paul the III died from a UTI that progressed to sepsis. But this woman was only 50. Hmm.. ok, I thought. Also learn that she has a positive history for diabetes and hypertension. Pretty common these days, especially together. But I was not prepared for her. Not by any means. You see, I walk in to greet her, and find out she was the size of the hospital bed itself. Literally. They had ordered the special bed for her, but it had yet to come in. So in the meantime, she is packed into the regular bed on an air mattress. She couldn’t turn or move because there was no room. None. She is 530 lbs. And full of fluid.
She has widespread anasarca, which is now weeping and causing skin breakdown. Everywhere. Straie were puffy and full of fluid, looking like they would bust at any moment. Left lower leg is dusky and her toes are almost black. Her skin is literally sloughing off from the fluid overload. But that wasn’t even her main problem. Nope.
Although that in itself is pretty horrible to see, it must be even more horrible to experience.
Her main problem, however, was pancytopenia from the chemo. Her WBC count… normally 5-10, were 0.9. Hgb was 7.9 after a unit of prbc’s and procrit. Most seriously though… her platelets were 6, when normally 150-450. There was petechiae everywhere and purpura over her left leg as well. DIC was a formidable risk, and ever present in the mind. Sure she had open sores where her skin was tearing to let the excess fluid out. DIC, on the other hand, could be a potentially fatal complication. Yes, she had received some irradiated platelets, but still her numbers only went up to 12. She was on vitamin k. Her bleeding times were well out of whack.. as to be expected.
She was really a nice woman struck by cancer and now all of these complications. She was concerned that she was dying, and chose to ask me instead of her primary physician about her prognosis. (of course, I told her what I knew, that her blood counts were really low and her circulation was disrupted from her edema, but it was not my place for talking about a prognosis). Luckily, the second day, she had received her special bed and we were able to move her around in the bed to the best of our ability. Most of all, I felt sad for her situation. There was nothing as a nurse that I could do to really help her other than continue to try to keep her as comfortable as possible and monitor for any acute bleeding and pain. Couldn’t even dress the wounds properly as her skin was just too moist to have anything adhere to it. She was a completely different patient than I had last week, but still, extremely sick nonetheless. I guess that next week I will get my walkie-talkie :)
