Mr. Greenleaf is a 36 year old male who suffers from Bipolar Disorder, alcoholism and chronic back pain. He is well-known to the nurses at the facility as he has been arrested numerous times in the past year for public intoxication. He was last incarcerated approximately three weeks ago, and only stayed for two days at that time. Currently, his medications on intake included lithium 600 mg BID and Tylenol PRN. He reported that he drinks daily about one pint of vodka, and his last drink was earlier today. In the past, Mr. Greenleaf has had seizures during his detoxification from alcohol. He denies suicidality and any wish to harm others. The officer who brought Mr. Greenleaf in stated that the Breathalyzer malfunctioned and so he did not have an accurate reading of Mr. Greenleaf’s blood alcohol level (BAL). Mr. Greenleaf complained to the officer that he was having diarrhea and vomiting prior to his arrest, which the officer reported to the Intake nurse.
The Intake nurse completing the Receiving Screening obtained the following vital signs: blood pressure: 128/82; pulse 90 beats per minute; respirations: 16 breaths per minute; oxygen saturation level of 98% on room air; and a temperature of 98.6℉. She documented that Mr. Greenleaf was alert and oriented x 4 (person, place, time and situation) and in no acute distress. His heart, lung and abdominal assessments were unremarkable. His pupils were equal, round, reactive to light and accommodation (PERRLA); handgrasps were equal and strong, and his gait was steady. She did note that his hands were both slightly tremulous. The nurse verified Mr. Greenleaf’s prescription for Lithium by contacting the dispensing pharmacy, and placed him on CIWA monitoring for the next three days per the facility protocol. She completed the first one while he was in Intake and documented a 2 as the results. Per the procedure at this facility, Mr. Greenleaf was housed in the medical monitoring area to facilitate the completion of the CIWAs each shift per the protocol. The on-call provider was contacted and ordered the Lithium as verified, with a follow-up scheduled in two weeks for Chronic Care Clinic – mental health and chronic pain. The provider also ordered a Lithium level to be drawn in ten days. The nurse did not go over Mr. Greenleaf’s history or current complaints because the provider “knew” Mr. Greenleaf because he was a “frequent flyer.”
The next day, Mr. Greenleaf was assessed, and his CIWA had risen to a 9. His vital signs were as follows: blood pressure: 146/94; pulse: 110 beats per minute; respirations: 18 breaths per minute; oxygen saturation 97% on room air; temperature 98.6℉. The nurse completing the assessment contacted the provider on-call, who ordered Librium for Mr. Greenleaf on a six day tapering schedule: day one and two – 50 mg BID; day three and four – 50 mg QD; day five and six – 25 mg QD; and stop. Per the protocol, the CIWA monitoring was increased to twice per shift and extended for three days.
On days three and four, Mr. Greenleaf was visibly improving. His CIWA scores were decreasing (from the high of 9 on day 2) and were zeros on the two assessments on day four. His vital signs were all within normal parameters as well.
On day five, Mr. Greenleaf submitted a Health Services Request for his back pain, stating that it had worsened since he had to sleep on the boat on the floor. He was seen by the Sick Call nurse, who used the musculoskeletal nursing protocol for back pain. The evaluation was unremarkable, except for hand tremors like he exhibited on intake. Because Mr. Greenleaf said that 200 mg of ibuprofen was not enough (and this was all the nurse could legally order under the protocol), the nurse contacted the provider, who ordered 800 mg of ibuprofen PO BID for 10 days. His first dose was administered during the Nursing Sick Call encounter.
On day six, Mr. Greenleaf submitted a Health Services Request for diarrhea and vomiting, which began that morning. He was seen the following day (seven), and reported that the vomiting has been intermittent, but the diarrhea has been ongoing for more than 24 hours. In fact, Mr. Greenleaf told the nurse that he had had some diarrhea when he was out on the street as well. He also stated that he developed a headache last night and it was continuing today, even with the ibuprofen. The Sick Call nurse was not the person who saw Mr. Greenleaf for his previous Health Service Request. The nurse asked Mr. Greenleaf if there could be “any way” that he was detoxing from opiates. Mr. Greenleaf adamantly denied any opiate use. The nurse asked Mr. Greenleaf about his back pain, and Mr. Greenleaf reported that it was pretty much controlled on the 800 mg of ibuprofen that was ordered, although he did say that a few times he had to also take more ibuprofen that he purchased at the commissary. The Sick Call nurse obtained vital signs that included the following measures: blood pressure: 136/80; pulse: 90 beats per minute; respirations: 20 breaths per minute; oxygen saturation 97% on room air; temperature 98.8℉. He noted that Mr. Greenleaf’s hands and arms seemed to shake as he measured the vital signs and actually made three attempts before he was able to get a reading. When he was having trouble measuring the blood pressure, the nurse again asked Mr. Greenleaf if he used opiates out on the street, to which he again replied with a little agitation that he did not. Per the nursing protocol for diarrhea, the Sick Call nurse ordered Immodium 4mg x 1 and then once after every loose stool to a maximum of 16 mg per day for two days. When Mr. Greenleaf asked about the headache, the nurse told him to “drink more” because it was probably due to a little dehydration from the diarrhea. The Sick Call nurse scheduled Mr. Greenleaf for a follow-up with the nurse in 3 days. For the third time, the nurse asked Mr. Greenleaf if he was detoxing from opiates right before he left the encounter. The answer was the same, and caused Mr. Greenleaf to become quite agitated as he left the room. Also on day 6 Mr. Greenleaf was moved to general population because his Alcohol Detox was completed.
Two days later, the officer from Mr. Greenleaf’s housing unit called the medical unit to report that Mr. Greenleaf was “acting crazy.” He informed the nurse that the night shift had reported in pass-off that Mr. Greenleaf was agitated and not acting like himself, although he was new to the unit and so really they did not know what his usual behaviors were. As the day went on, Mr. Greenleaf’s behavior became more and more confused, until he was seen arguing with an invisible “girlfriend” who he was accusing of going out on a date with the officer. At that point, the officer called medical.
The nurse arriving to assess Mr. Greenleaf’s mental status changes noted that he was agitated and confused, tremulous and ataxic. He complained that his head hurt and he was dizzy. He did allow her to measure his vital signs, which were the following: blood pressure: 90/50; pulse: 130 beats per minute; respirations: 20 breaths per minute; oxygen saturation 98% on room air; temperature 98.9℉. Emergency Medical Services was activated, the provider was contacted, and Mr. Greenleaf was sent to the emergency department.
What Do You Think is Going on with Mr. Greenleaf?
In the emergency department, Mr. Greenleaf’s labs indicated that he was lithium toxic, with a level of 3.2 MMOL (usual parameters 0.6 – 1.2 MMOL). He was treated as an inpatient for four days, and then he returned to the facility with his lithium within therapeutic levels and his mental status returned to baseline.
How Did This Happen?
The provider ordered a Lithium level for Mr. Greenleaf when he was first admitted to the facility, but it was ordered for 10 days later. Although Mr. Greenleaf reported that he was taking all of his medications as ordered in the community, it is still important to get levels on medications such as Lithium as soon as the patient arrives. A history of alcoholism and current use of alcohol daily could mean that Mr. Greenleaf doesn’t always remember whether he took his medication or not; and he may take the dose too many times in a day or miss days. Also, Mr. Greenleaf had complaints of diarrhea in the community and presented with some hand tremors, both signs of early Lithium toxicity. Since these symptoms could also be explained by gastrointestinal disorder and the alcoholism itself, it was important for the nurse to include this information in any report to the provider and to follow-up with Mr. Greenleaf to see if the symptoms were improving.
How Did This Happen?
Mr. Greenleaf, a patient prescribed and taking Lithium twice a day, was also prescribed ibuprofen for his chronic back pain, a medication that potentiates Lithium in the blood. In addition, he was not just ordered the over the counter strength, but a provider authorized the administration of 800 mg twice a day, and then, he also took more on his own. The provider should have checked Mr. Greenleaf’s history, including his current medications, before prescribing the ibuprofen, but the nurses evaluating Mr. Greenleaf and those administering the medications to him each day should have noted that he was prescribed Lithium and ibuprofen, and should have known that these medications are contraindicated. Identifying this, the nurses should have held the ibuprofen and reported back to the provider to ensure that she was aware that Mr. Greenleaf was prescribed these medications. Even though the provider ordered the medications, the nurses administering them had an obligation to know the potential interaction of these medications. They also should be familiar with the signs of an increasing Lithium level, including hand tremors, diarrhea, vomiting, agitation, confusion, headache, vision changes, dizziness and ataxia.
How Did This Happen?
When the Sick Call nurse reviewed the chart before seeing Mr. Greenleaf for his complaint of diarrhea and intermittent vomiting, he should have noted that Mr. Greenleaf was prescribed Lithium and ibuprofen, and had had hand tremors when he was admitted to the facility, and that he had complained of diarrhea while out on the street. The nurse should have realized that it is abnormal to shake so much that blood pressure readings could not be obtained on the first attempt, and after fully assessing Mr. Greenleaf, should have contacted a provider. It seemed like the Sick Call nurse had already decided that Mr. Greenleaf’s diarrhea and vomiting was attributable to an undisclosed opiate addiction, and so was closed to other reasons that this might be occurring. This bias could have caused the nurse to ignore other possibilities and not seek the counsel of a provider as he should have. If the nurse had contacted the provider, and the provider had ordered the lithium level at that point, Mr. Greenleaf’s Lithium toxicity could have been identified earlier than it was, and he may have been able to be managed at the facility. Instead, he became life-threateningly toxic and required an inpatient stay, which could have resulted in consequences far worse for Mr. Greenleaf.
For more information about Bipolar Disorder, go to The Correctional Nurse Educator accredited class entitled, Common Mental Health Disorders for the Correctional Nurse.
Please share any experiences you have had in your practice with patients presenting with unusual signs and symptoms and prescribed Lithium below in the Comments section…did you think of Lithium toxicity?
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.