Care of the patient with stroke sxs >5 hrs PTA

PAERRN20 · Feb 6, 2010

Well I wouldn't have given the ASA in triage. What if the guy would have ended up an acute bleed? Regarding O2- I have never heard your nurse educator's theory. Free radicals? We have bigger issues here to worry about than free radicals. I would have checked the blood glucose immediately upon arrival to the bed. Monitor, EKG, IV, BGM...that is my order. Get those done and off to CT the patient goes. Stroke scale can wait til after the CT if needed. I have no idea why the MD didn't order pain meds. Could be the neuro issues, could be other reasons. Also the BP may have been elevated due to pain.

I think what you do was fine...don't beat yourself up! It will come with time :)

WonderRN · Feb 6, 2010

i forgot to mention that he did get an EKG right away....

Came back to the room, hooked up to the monitor and vitals by tech and EKG by tech, I started IV and got labs, quick assessment, MD at bedside, then XR came for portable CXR, and then CT called saying they were ready for the patient, pt transported. CT lets us know when they are ready, unless we are still in the 4.5 hr window for TPA.

cokristinug · Feb 6, 2010

I was taught not to give any narcotics, anxiolytics etc to a possible neuro patient because it could compromise the complete neuro assessment that will be done up on the floor when the neuro nurse and neurologist see the patient. If he was found to have a bleed, then i would assume narcotics and anxiolytics would be ordered to reduce anxiety and pain which could thus increase ICP. I disagree with the aspirin before the CT in triage. Maybe because 80% of strokes are ischemic he was just hoping that it was ischemic, but I don't see why he would take the chance. And definitely disagree with the oxygen issue. That's just weird. But it sounds like you really did your best! I would maybe review your hospitals stroke policy/procedure and ask your charge nurse or another preceptor. :)

sd1984 · Feb 6, 2010

In regards to positioning for ischemic stroke, HOB 0-15 degrees except when eating. Promoting blood flow I believe.

Editorial Team / Moderator · Feb 7, 2010

We giving nothing PO to anyone with stroke-like symptoms until we've done the dysphagia screen (the swallow test). If they fail, they get ASA PR, and that's only when we've made sure it's not a hemorrhagic stroke. The CT is the primary thing -- we've often rolled EMS stretchers directly from the ambulance to CT!

WonderRN · Feb 7, 2010

We giving nothing PO to anyone with stroke-like symptoms until we've done the dysphagia screen (the swallow test). If they fail, they get ASA PR, and that's only when we've made sure it's not a hemorrhagic stroke. The CT is the primary thing -- we've often rolled EMS stretchers directly from the ambulance to CT!

Lunah-

What about medication for pain after their CT is negative for hemorrhagic stroke (and ischemic stroke is assumed?) My patient kept complaining of a severe headache...

Editorial Team / Moderator · Feb 7, 2010

Nothing in our stroke protocol forbids pain meds, as far as I can recall.

misswoosie · Oct 26, 2010

i'm a new grad in the ed, and i need some help in understanding what to expect in the nursing care of those individuals with stroke like symptoms who are assumed to have ischemic stroke and who are not candidates for tpa,
the other night i had a patient who was in his 40s, had history of malignant hypertension, 3 tia's, and high cholesterol who presented with left sided weakness (weak hand grip, left sided pronator drift, left sided facial drooping only noticeable when he smiled). he also c/o of a headache (generalized) 10/10 and some blurred vision since approx 28hrs pta. (he was a&o x3, no slurred speech, intact gag reflex).
he also was complaining of some left sided chest pain and nausea.
first things first
is stroke the most likely diagnosis
did the left sided weakness come on suddenly?
does he have a history of migraine? (stroke mimic)
has there been any evidence of a seizure?
history
how long prior to admission was the onset of the left sided weakness?
was the story for the previous tias a good one ie sudden onset, lasting less than 30 mins, not associated with a headache.
has he had a ct/mri before and what were findings?
if he's had 3 tias then he should definitely have had carotid ultrasonography performed in the past. what were results?
what's his usual bp?
any recreational drug use?
atrial fibrillation?
thoughts
he's young
he does have def' risk factors of hypertension and hypercholesteraemia, plus or minus tia s (could poss' have been migraine?)
alternative diagnoses would be migraine imo- ie temporary weakness due to the migraine.
chest pain was probably due to the hypertension as coronary arteries perfuse during diastole, and if bp is too high then they don't perfuse, blood just kind of whizzes past the end of them in the aorta!
i calculate his nihss was 2?
1 for pronator drift and 1 for mild facial weakness, so he probably wouldn't have been a candidate for thrombolysis anyway, unless he deteriorated and was still within the time window..
he received 324mg of asa in triage (ct ordered at that time).
should not have been given prior to ct scan, nursing swallow assessment and definitive diagnosis of stroke
he came back to me, i placed him on the monitor, got vitals, started an iv and got labs and a quick assessment before the doctor came in. pt's bp was approx 230's/120's, notified md. i ran cardiac enzymes and gave labetalol 20mg as ordered before pt was transported to ct.
no evidence for reducing bp acutely in stroke, unless patient is a likely candidate for thrombolysis ie to reduce bleeding risk and even then evidence is debatable and risk of worsening neurological signs by dropping bp may outweigh reducing the risk of bleeding.
wanted to add that if this wasn't a stroke , but a migraine then in someone with a hx of tias and hypertension, dropping the bp suddenly could actually cause a stroke!
i did not place the patient on oxygen because per my educator, 02 can actually
worsen the effects of stroke d/t release of free radicals in the brain. pt's 02 sat at 100%.
never heard this one. i wouldn't have given him oxygen as sats were 100%
jury is still out on giving routine oxygen to stroke patients, however it's accepted that if sats are below 95% o2 would be given, especially if more severe stroke
i realized in retrospect i should have done a fsbs,
what's this please?:) but his symptoms had been present for more than a day,so sorry, you meant the weakness and the headache came on 28hrs pta? so it didn't cross my mind. didn't have orders for either though, but could have "protocolled" either.
ct came back "unremarkable".is that the same as normal! what a useless piece of info for a radiologist to report !
did a stroke physician read the scan as well?
bp decreased to something around 205/115, and physician said we are only to manage it if it is over 220 systolic. pt still c/o of pain 10/10, requested orders for pain med for pt while awaiting bed placement, but the physician would not give me anything for him.
that's paramount to malpractice imo. to have someone sitting there with a bp that high and give beta blockers before pain meds (i don't mean you, i mean the md).doesn't he know pain can cause hypertension? codeine could have been given.
not sure what he thought the diagnosis was after negative ct scan, although a lacunar stroke may not show up well on ct depending on if a neuro radiologist /stroke physician is reading it
doc placed bed order, dispositioned pt, and it was the end of his shift.....pt had an order for vicodin for the floor, talked to my charge nurse and current attending doctor and was able to give it to the pt (after pt passed 30cc swallow test). (not trying to go over the first doc's head, just occurred to me at that time that he might have input pain med orders for the floor)
a few questions....
1) would the 324mg of asa had been contraindicated in hemorrhagic stroke? should we have waited to administer until the ct was neg?
2) i understand hypertension during acute ischemic stroke is desirable to maintain perfusion to the brain (aha/asa 2007 guideline to hold antihypertensives unless systolic > 220 and diastolic >120) but i don't quite understand the patho of that.
if it's an ischaemic stroke it's thought to maybe help to prevent stroke progression , and also thought that hypertension is a natural response to brain ischaemia.
there have been several studies loooking at treating bp in acute stroke including whether reg antihypertensive drugs should be continued or stopped for a period of time, and at what stage/level high bp should be treated acutely. we still don't have definitive guidelines
3) is there a reason why the doc would not want to give me pain med orders in the ed? perhaps b/c it could cloud the patient's neuro consult? the patient was very uncomfortable and the vicodin didn't help. i assume we don't want to give narcotics to those with hemorrhagic stroke d/t the vasodilation it causes, but we already knew the ct results
no! i don't see that there's ever a reason not to give analgesia to a pt with a score of 10!
4) pt positioning- i did what was comfortable for the patient. should i have done something else?
no, i would have done exactly the same
5) other nursing interventions that i should have done?
i would have assessed his neuro status every 10-15 mins for an hour after the labetalol was given to check for neuro deterioration, then maybe every 30 mins for another 2 hours, then hourly
thanks in advance for all your help. i am overwhelmed at times by what i don't know, but am trying so hard to learn, learn, learn.:bowingpur

do you know what the patients outcome was?

if it was a migraine then the symptoms should have resolved, although sometimes if a migraine goes on for a very long time it can cause a stroke

does your hospital take part in get with the guidelines for stroke or the paul coverdell stroke registry?

seems like there wasn't really a plan or for this guy after the scan was negative.

remember, history (of presenting complaint and past) and exam should always form the basis of a diagnosis, not results of investigations which should be used to confirm or rule out the initial diagnosis.

here's some resources

http://www.heart.org/heartorg/healthcareprofessional/getwiththeguidelineshfstroke/getwiththeguidelinesstrokehomepage/get-with-the-guidelines-stroke-toolbox_ucm_308030_article.jsp

http://www.newcastle-hospitals.org.uk/downloads/clinical-guidelines/care%20of%20the%20elderly/rosierv15.pdf

Editorial Team / Moderator · Oct 26, 2010

FSBS: fingerstick blood sugar.

We never give ASA to a suspected CVA until we rule out a bleed, and nothing by mouth until we've done a dysphagia screen. If they fail the dyphagia screen and aren't having a bleed, they get their ASA PR.

Just as an aside, I had a rather young patient with an migraine that looked totally like a CVA! Scary.

misswoosie · Oct 26, 2010

FSBS: fingerstick blood sugar.
We never give ASA to a suspected CVA until we rule out a bleed, and nothing by mouth until we've done a dysphagia screen. If they fail the dyphagia screen and aren't having a bleed, they get their ASA PR.
Just as an aside, I had a rather young patient with an migraine that looked totally like a CVA! Scary.

He's a difficult one.

Even though he's young for a stroke, he has risk factors.

Have my suspicions that prev' "TIAs" may have been migraines and that this may have been too.

Would have liked more history.

If migraine then even more reason to treat the pain etc and see if symptoms improve!

mmutk, BSN, RN, EMT-I · Oct 26, 2010

Essentially you did fine, and even if he had a bleed that ASA PO wouldn't of killed him. That's kind of like putting a blanket on someone with a fever, It's never been shown that a blanket as killed anyone with a fever. Blood sugar should have been done a triage though, IF NOT do that before much else next time.

#1 Assess the ABCs. Address any compromise in the patient's status as clinically indicated.

Oxygen administration

Establish intravenous (IV) access.

Obtain bedside glucose determination.

Institute cardiac monitoring and obtain an EKG.

Seizures Precautions

Head CT

Careful blood pressure (BP) monitoring is important.

Consult neurology.

2nd IV and Foley if a possible TPA candidate.

No controlled studies define optimum BP levels But only decrease it 15% over 2 hours.

Elevate the head of the bed to 30 degrees. This improves jugular venous outflow and lowers ICP. The head should be midline and not turned to the side.

Provide analgesia and sedation as needed.