Med Surg Case Study #37: Sharita Tarmus

Sharee Thomas | 32 years old

Chief Complaint: Sharita Tarmus presents to the emergency department with complaints of progressive weakness in her legs, which she has noticed over the past 3 days. She also reports tingling in her hands and feet.

Medical History:

Sharita has a recent history of an upper respiratory infection approximately two weeks ago, treated symptomatically at home. She has no significant past medical history, no known allergies, and is not currently on any medications.

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Nurse's Note:

• Patient is admitted to the emergency department with complaints of weakness in her lower extremities, which she reports has been worsening over the past 72 hours. She now finds it difficult to walk and is concerned as the weakness appears to be spreading upward. She denies any difficulty breathing at this time but reports a “pins and needles” sensation in her hands and feet. She is anxious and tearful, concerned about what might be happening.

Vital Signs:

• Blood pressure: 138/82 mmHg

• Heart rate: 92 bpm

• Respiratory rate: 18 breaths/min

• Temperature: 98.6°F (37°C)

• SpO2: 98% on room air

Provider's Orders:

• Admit to ICU for close monitoring.

• Perform a lumbar puncture and send CSF for analysis.

• Start IV fluids: Normal Saline at 75 mL/hr.

• Continuous ECG monitoring.

• Neurology consult.
  

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Patient is admitted to the ICU

Nurse's Note:

The patient’s weakness has progressed since admission, with notable decreased strength in both upper and lower extremities. Sharita now reports difficulty lifting her arms and states that the tingling in her hands has worsened. She remains alert and oriented, but her anxiety has increased, and she is visibly distressed about the loss of mobility. The lumbar puncture was performed, and CSF was sent to the lab. The neurology team is evaluating the patient.

Vital Signs

• Blood pressure: 144/88 mmHg

• Heart rate: 110 bpm

• Respiratory rate: 22 breaths/min

• Temperature: 98.4°F (36.9°C)

• SpO2: 97% on room air

Provider's Orders:

• Start IV Immunoglobulin (IVIG) therapy: 0.4 g/kg/day for 5 days.

• Obtain baseline pulmonary function tests (PFTs) and monitor vital capacity.

• Initiate VTE prophylaxis with enoxaparin 40 mg subcutaneously daily.

• Begin physical therapy consultation for passive range-of-motion exercises.

• Monitor for signs of respiratory compromise; prepare for possible intubation.

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The neurology team suspects Guillain–Barré Syndrome (GBS) based on clinical presentation and the results of the lumbar puncture, which showed elevated protein levels in the CSF.

The patient’s family has been notified of her condition, and discussions about the potential need for mechanical ventilation have begun.

Nurses Note: Sharita’s condition has continued to decline, with worsening weakness now affecting her ability to swallow. She reports feeling short of breath and is struggling to speak clearly. Her respiratory rate has increased, and she appears fatigued.

Vital Signs:

• Blood pressure: 140/85 mmHg

• Heart rate: 100 bpm

• Respiratory rate: 18 breaths/min

• Temperature: 99.2°F (37.3°C)

• SpO2: 97% on room air

Provider's Orders:

• Prepare for elective intubation due to worsening respiratory function.

• Continue IVIG therapy as prescribed.

• Increase O2 to 4L via nasal cannula; consider non-invasive ventilation if O2 saturation falls below 90%.

• Reassess vital capacity every 2 hours.

• Continue monitoring ECG and initiate atropine 0.5 mg IV PRN for bradycardia.

Follow Up Questions:

Question 1: What is the primary reason Sharita is being admitted to the ICU?

Question 2: Why was IVIG therapy initiated for Sharita?

Question 3: What are the indications that Sharita might require mechanical ventilation?

Question 4: What would be the nurse's priority intervention if Sharita’s oxygen saturation continues to decline despite supplemental oxygen?

Answers to Questions Below

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Answers

Question 1: What is the primary reason Sharita is being admitted to the ICU?

Sharita is being admitted to the ICU for close monitoring due to the rapid progression of her weakness and the potential for neuromuscular respiratory failure. Guillain–Barré Syndrome can progress quickly and lead to respiratory failure due to the involvement of the diaphragm and intercostal muscles, necessitating intensive monitoring and possible mechanical ventilation.

The ICU provides the necessary resources and expertise to manage patients with critical care needs, such as respiratory support and hemodynamic monitoring. Given the potential for rapid deterioration in GBS patients, ICU admission is crucial to prevent respiratory failure.

Question 2: Why was IVIG therapy initiated for Sharita?

IVIG therapy was initiated to decrease circulating antibodies that are attacking the peripheral nerve myelin. IVIG is a standard treatment for Guillain–Barré Syndrome as it can help reduce the severity and duration of symptoms by modulating the immune system's response. By starting IVIG early in the disease course, it is hoped to shorten the duration of the illness and prevent complications.

Question 3: What are the indications that Sharita might require mechanical ventilation?

Indications that Sharita might require mechanical ventilation include:

• Decreasing oxygen saturation despite increasing oxygen supplementation

• Increasing respiratory rate

• Use of accessory muscles to breathe

• Changes in mental status (e.g., confusion, agitation)

• Inability to protect the airway (e.g., decreased cough strength)

These signs and symptoms suggest that Sharita's respiratory muscles are weakening to the point where she can no longer adequately oxygenate her blood. Mechanical ventilation is necessary to support respiratory function and prevent respiratory failure.

Question 4: What would be the nurse's priority intervention if Sharita’s oxygen saturation continues to decline despite supplemental oxygen?

The nurse’s priority would be to prepare for elective intubation and mechanical ventilation.  If oxygen saturation continues to drop, it indicates that Sharita’s respiratory muscles are failing, and immediate intervention is needed to maintain adequate oxygenation and prevent respiratory arrest.

Med Surg Case Study #37: Sharita Tarmus