As nurses, when we see an acute change in condition, part of what we should be doing in our assessment is determining if there are reversible or treatable elements that are causing the change. In RN school, Dr. Dagen instructed the students about using the D.O.G. mnemonic to help us remember that if a patient has an acute change of condition, to check whether there were new medications the patient is taking, their O2 saturation level and their glucose level.

I would further add that as a hospice nurse dealing with mainly geriatric patients, if there is an altered level of consciousness (LOC)/personality change, also consider the patient may have an infection. For any of you dealing with geriatric patients, add “I” for infection, hence “D.O.G.I.” While this mnemonic is typically used for acute changes in the level of consciousness, the thought process behind it can also be used for other acute changes in patient conditions.

Before we go into a real-life case study, let’s go over what is meant by an “acute change of condition.” We should know that chronic is often something the patient has been going through for a long time, often greater than six months. Know that “acute” can be instantaneously or from the last time a healthcare professional saw the patient. The latter is often the case in hospice and home health because the patient may not be seen daily.

Also, know that while most of the time the “D” (for drugs/medications) often means the medication was “recently” started by the patient, not all side effects, including adverse effects, show up quickly. Now for the case study.

The patient in this case study is a male in their 70s with a primary diagnosis of lung cancer. Those who have been nurses for a while and senior nursing school students may recall that there’s a triad — an extremely close relationship between the heart, the lungs, and the kidneys. If there’s heart disease, lung and kidney issues are often involved, and so goes the chain.

Between the last visit on Thursday, 1/2/2020, and Monday, 1/6/2020, the patient developed new-onset +2 BLE edema in the lower calves to the dorsum and lower right base crackles on 6L O2. The option of starting Lasix was discussed with the family. Still, the patient is not interested in yet another medication to take along with frequent urination related to already having issues due to an enlarged prostate as part of BPH, given the patient is in their 70s.

The last medication (D) changes took place on 12/26:

• MS Contin increased from 75 mg BID to 90 mg TID based on using 270 mg morphine daily for pain control.
• Mucinex increased from 1,200 mg daily to BID r/t the cancer-causing increased mucus production, making it more difficult for the patient to breathe, resulting in increased anxiety and pain from breathing.
• Senna increased from 8.6 mg x 2 tablets daily to BID r/t increased constipation from increasing doses of opioids.

While it can be uncommon for MS Contin to cause urinary retention, the patient was reporting that while it was difficult to start a stream, once he started, he would urinate adequately. None of the other medications are known to cause fluid retention.

The patient typically states between 92% and 94% and denies shortness of breath. The patient has no history of diabetes and is not having any episodes of hypoglycemia or hyperglycemia.

Earlier, I wrote that some medications could take time for side effects to become apparent. Steroids are one of those classifications of medications where side effects can be relatively immediate (with just taking a few doses) to a few months. The patient has cancer with Mets to the bone where Dexamethasone is typically the steroid of choice to help with work of breathing (lung cancer patient on continuous O2 is a suitable candidate) and inflammatory pain from the bone cancer and tumor growth. Here the patient was started on 4 mg Dexamethasone daily in November 2019 and was doing so well on it, was increased to 4 mg Dexamethasone BID in early December 2019.

One of the side effects of steroids is fluid retention. A conversation with the doctor confirmed the right thing to do would be to “trial” the patient by going back daily to see if the dose reduction reduced the edema.

On the most recent RN visit, after going from 4 mg Dexamethasone BID to daily, the patient’s face was less puffy, the lungs no longer had crackles, and BLE edema was still present at +2. The current plan of care action is to re-assess the edema and puffy areas on the next RN visit and, if present, talk about completely stopping Dexamethasone with the medical director.

Fellow nurses and students on their journey to becoming nurses, I encourage you to be diligent about learning the reversible and treatable causes of acute changes of condition.