stroke in LTC - page 2
what would your course of action be if you suspect a resident is having or had a stroke? Assume the resident is age 90.... Read More
May 21, '07I would do neuro assessment as those above describe. As for sending to ER, it will all depend on their code status and what family/Dr. wants me to do. Sometimes they want 'em sent and sometimes they don't. If they are full code - they are going out ASAP.
May 22, '07You should also be familiar with your agencies policies but I would hesitate before I would recommend calling 911 right off the bat. That is why I said it is hard because these questions are so vague however you also have to be careful because if you give too much information it can identify you or the patient.
You do have to be very efficient because there is a time window of usually 2 hours after the stroke starts that you can give the clot busters. So if you have a person who comes in for a short stay after a knee replacement (which would probably exclude them from a clot buster) you will be sending them out however if you have a person who has had multiple strokes and is a DNR then you may just provide comfort measures after talking with the doctor and the family. Always document this.
DNR definitely does not mean Do not treat, and I have bumped heads with many ERs and paramedics over this. The AMA has a great position statement on this as well. However you also need to look at what the patient's wishes are. In my state we have the POST forms that pts could check that said something to the effect of "Hospitalization only if comfort measures fail." Again they can rescind these at any point too.
May 22, '07Check for deficits, have them smile, check hand grasps, ect. Always notify family et PCP. Check to see what their Code status is. If they are Full Code, get them out of there. If they are comfort care only, provide just that. Do what the family et doctor's wishes are ultimately.
May 22, '071. Set of vitals and neuro assessment. (And you know, everyone forgets this one, but get a fingerstick blood glucose, because the symptoms can mimic stroke.) Probably most important thing is the time that the symptoms started. If the symptoms were not witnessed, you cannot assume. If the onset of symptoms were witnessed, you have a good chance of reversing the stroke completely by getting the patient to the ER.
2. Regardless of Code status, I would call 911, and then inform the doc and the family. First, because we have a 3-hour window in which to give clot-busters. Second, because DNR does not mean "do not treat." This is an acute event and needs to be treated. If you call everyone else first and then the patient/family decides not to treat, fine. At least you didn't miss the opportunity for the option to treat.
May 22, '07Quote from Angie O'Plasty, RNI agree 100% that DNR does NOT equal do not treat.. but in LTC we often know our residents and families pretty well and it would truely depend on the circumstances of each individual on how I would respond. As in someone else's example of a short term stay w/ knee replacement - they are going out ASAP. But a 90 year old severely comprimised resident and a knowledge that family is well aware that they are nearing end of life, I would definately contact the family first (if I can get ahold of them at onset) and let them decide on course of treatment, ie: hospital vs comfort. Then I would call Dr. and let him know what family wants done.2. Regardless of Code status, I would call 911, and then inform the doc and the family. First, because we have a 3-hour window in which to give clot-busters. Second, because DNR does not mean "do not treat." This is an acute event and needs to be treated. If you call everyone else first and then the patient/family decides not to treat, fine. At least you didn't miss the opportunity for the option to treat.
May 22, '07Saw one firsthand - came on duty at 0645 to find res. slumped over in his wheelchair. I got a set of vital signs, checked his grips (unequal, weak (L) side), hunted down the night nurse who believed resident to be faking it all. Stayed with him for fifteen minutes until day shift nurse came on, who bit the bullet and sent him out. Massive stroke.
May 23, '07Check obs, reassure, contact GP and family. If any symptoms occur that are distressing and cannot be dealt with within the home, ask GP for advice regarding hospital transfer.
Oct 17, '08I know this is an old thread but
1.In someone who is 90 then the DNR status and family and patients wishes are vital.
2.Need to exclude other things (Stroke mimics) that could cause decreased conscious level,lethargy,change in mental status,limb weakness eg infection, fit, recent drug therapy changes.recent trauma to the head (may be sud dural), medical history ie stroke in the past.
3. Only sure way to detect haemorrhage is by brain imaging (CT MRI)
4. Most patients on comadin/warfarin for AF that have strokes are infarcts and there INR is likely to be sub therapeutic
3.There is a very limited amount of data available on thrombolysis for stroke in patients over the age of 80, as they were excluded from most of the clinical trials,but
the risk of haemorrhage goes up with age
in UK rTpa is not licensed for use in over 80s (not sure in US)
most patients with a significant loss of independence (ie not living in their own home)
would not be considered for thrombolysis, or surgical intervention if a bleed, or if dopplers showed sig carotid artery stenosis.
Fitting at onset of a stroke is a contra-indication for thrombolysis.
4.It may be appropriate to optimise drug management of hypertension, hypercholesterolaemia , and swallowing problems
It should be about what is best for that patient and the best place to provide the care that is best for that patient.
Aug 2, '12I have a question about this as well -- with a possible stroke would you see handgrips weak bilaterally or usually one side weaker than the other? Or possibly both? (all the more reason to know pt's baseline.)