An 18 year-old girl with no significant

An 18 year-old girl with no significant past medical history presented with confusion. Ten days prior to presentation, she developed left ear pain and a fever. She was seen in an outside emergency department and given a prescription for Augmentin, which she never filled. Eight days later, her friends noted that she was confused, so they brought her to your hospital. What tests, medications and other interventions are expected for her course of treatment? What are your priority nursing concerns & interventions? A urine pregnancy test and toxicology screen were negative. Her white blood cell count was elevated at 19,000 with a significant left shift. Non-contrast CT of the head and neck was normal. Lumbar puncture was significant for an opening pressure of 35 cm H2O, 3 nucleated cells, protein 112 mg/dl, and glucose 51 mg/dl. She was started on meningitic doses of cefotaxime, vancomycin, and acyclovir, as well as dexsamethasone. Her symptoms initially seemed to improve but, on hospital day #2, she developed aphasia. On your first exam on shift, she was afebrile, and her vital signs were stable. Her general medical examination was remarkable for a ruptured left tympanic membrane with pus in the ear canal. Her neck was supple. She was awake, alert, and attentive. She could not follow commands but could mimic the examiner. She was unable to name, repeat, read, or write and she tended to perseverate on words. Her pupils were equally reactive from 6 mm to 4 mm, and normal appearing. Her cranial nerves were otherwise intact. She had increased tone in her right leg, decreased strength in her right arm and leg, and a right pronator drift. She withdrew all four extremities to noxious stimuli. Her reflexes were 3+ at the right ankle and knee and 2+ elsewhere. Her right toe was equivocal but her left toe was clearly downgoing. What are your priority nursing concerns? Communicate an SBAR to the provider S: B: A: R: An MRI scan was obtained: The MRI scan showed acute subdural empyema. Subdural empyemas are collections of pus in the potential space between the dura mater and the arachnoid membrane. Patients typically present with fever, vomiting, meningismus, and focal neurological signs. The vast majority of cases result from direct extension of infection from adjacent structures (i.e. paranasal sinuses, middle ear). MRI is the imaging study of choice, as MRI has a higher sensitivity for detecting small subdural fluid collections and is better able to differentiate between subdural empyemas and other fluid collections, such as sterile effusions and chronic subdural hematomas. Lumber puncture is contraindicated given the risk of herniation. If CSF is obtained, it may be normal or may show a low-grade pleocytosis unless the subdural empyema is associated with meningitis. A select group of low-risk patients may be able to be treated with antibiotics and serial imaging; however, many patients require surgical evacuation of the pus through either a burr hole or a craniectomy. Although >90% of patients with subdural empyema survive, 15 to 44% of them have permanent neurologic deficits. The patient underwent a procedure to have the empyema evacuated. She came back to your unit in stable condition. Write a SOAP note at the end of your shift: S: O: A: P:

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