4A Step Down at Ralph H. Johnson VA Medical Center

4A Step Down at Ralph H. Johnson VA Medical Center

Ralph H. Johnson VA Medical Center
Charleston, South Carolina
United States
Manny Concepcion, RN; Pamela Beemer, RN; Bonnie Burns, RN; Maria Teresa Alaisa, RN

A Veteran was admitted to 4A Step Down for alcohol detox, as well as 1:1 observation for suicidal ideation in June 2018. The day following his admission the patient's alcohol withdrawal symptoms quickly worsened, and he was becoming agitated, confused, delirious and hallucinating. When the patient would have moments of clarity he was wanting to leave the VA. The Primary Nurse, Teresa, who was caring for this Veteran, keenly noted the changes in his CIWA score and his behavior and kept the medical team informed. She ensured he received the appropriate medications and care in a timely manner to prevent worsening of his symptoms. Manny and Bonnie also recognized that the room the Veteran was in was not ideal, as it was far from the nurses’ station and also close to the exit of the unit. The patient had also complained of the loud noises coming from the door/exit, and this appeared to be further agitating him. The observation unit staff worked together to move the patient and all of his belongings to the room directly across from the nurses’ station and ensured that it was a safe room for 1:1 observation of a suicidal patient.

The Veteran's nurse, Teresa, also noticed that as the patient's condition was worsening, it was time to transition from oral Ativan to IV Ativan. She notified the MD team of the need to give IV Ativan and quickly administered the medication based on the patient's CIWA score and the doctor’s orders. Using her excellent clinical knowledge, upon re-evaluating the patient, she noted that the IV Ativan was not having the desired effects, and the Veteran was becoming more confused and agitated and a risk to his own safety as he was unstable on his feet and continued to try to get out of the bed. She again contacted the intern and the resident, and upon this contact, the on-call resident MD immediately came to the bedside to re-evaluate the patient. The MD asked for another now dose of Ativan to try to help with patient and his severe withdrawal symptoms, and then again returned in 15 minutes to reassess the patient. Meanwhile, Bonnie, Manny, and Teresa were all working together to ensure that the safety of the patient and the unit was maintained. Using creativity and utmost compassion with the patient became aggressive and adamant about leaving to go find Doritos, Manny quickly and gladly gave his own dinner which included Doritos to the Veteran. This calmed the Veteran for a substantial amount of time while Teresa was working steadily with the MD team to find alternative ways to keep the patient and the staff safe through his detox. Bonnie and Manny would rotate sitting at the bedside talking with the patient, to try to keep him calm and safe and also continued to assist in safely reorienting him without causing further agitation.

As Teresa continued to re-evaluate the patient and notify the MD team of her findings, it was evident that the patient was not having any improvement and his withdrawal symptoms were continuing to escalate.

At one point they were concerned that restraints may be needed as the patient was becoming aggressive and did not want the staff to touch him to keep him safe from falling when he would get out of bed. The nurse supervisor on, Pamela, was notified of what was taking place and immediately came to the unit to bring the staff a posey vest if needed and assess the situation. She utilized her knowledge and expertise in psychiatric nursing and recommended that this patient receive another agent, as multiple doses of IV Ativan had been given without improvement in patient condition. She encouraged the staff to reach out to the on-call hospitalist if further assistance was needed. Teresa contacted the on-call MD regarding these recommendations and he was agreeable to try an alternative medication to assist in improving the patient’s condition. Throughout this time, the on-call MD continued to return to the bedside every 15-30 min to assess the patient and assist the nursing staff in his care and was very supportive and present throughout the night, working together with the nurses as everyone shared their knowledge and expertise to find the best methods of care this patient to get him safely through the night.

With everyone’s teamwork and keeping a close eye on this Veteran, the Veteran was able to have improvement of his symptoms and rest throughout the night, without being restrained. When he awoke in the morning, the patient was alert, oriented and calm. The patient was able to be transitioned off the IV Ativan and onto oral medication taper and continued to have improving status as the hours passed. The next evening the patient was in great spirits, was no longer suicidal, and was making great headway to a safe recovery.