Case Study
Lindsay Trantum ACNP-BC
VUMC Neurological ICU
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.
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.
What is the most likely diagnosis?
A. Paranoid
schizophrenia
B. ICU delirium
C. Altered mental
status
D. Sepsis
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
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
What is the most appropriate pharmacologic
intervention?
a. Lorazepam 2mg IV q2h
prn
b. Seroquel 25mg BID
increase by 25mg q12h
until desired effect
c. Haldol 2.5mg q2h prn
d. Both a and c
e. Both b and c
Case Study
• On hospital day 8, Mr. Cam becomes
hypoxemic and lethargic. You decide he needs
to be intubated.
Which sedative would you choose?
a. dexmedetomidine
b. Propofol
c. Fentanyl
d. Versed
e. Either a, b or c
What interventions will assist you in decreasing Mr.
a.
b.
c.
d.
e.
f.
g.
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
Identify Mr. Cam’s delirium risk factors
a. UTI
b.Intubation/Respirator
y failure
c. Stroke
d.Electrolyte
Abnormalities
e.Lorazepam
administration
f. All of the above
Case Study
• On hospital day 11, Mr. Cam is extubated. That
evening, he starts picking at his IV sites and
pulling on his foley.
What is your next course of action?
a. Versed 2mg IV prn
b. Re-intubate for his
safety
c. Continue Seroquel and
prn haldol
d. Add dexmedetomidine
e. Both c and d
f. None of the above
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.