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.
He received 324mg of ASA in triage (CT ordered at that time). 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.
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%. I realized in retrospect I should have done a FSBS, but his symptoms had been present for more than a day, so it didn't cross my mind. Didn't have orders for either though, but could have "protocolled" either.
CT came back "unremarkable". 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. 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.
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
4) Pt positioning- i did what was comfortable for the patient. Should I have done something else?
5) other nursing interventions that i should have done?
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
Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH.
essentially you did fine, and even if he had a bleed that asa po wouldn't of killed himthat'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..
essentially i agree that the op did fine, but she is asking for advice regarding the current evidence based guidelines for acute stroke care.
the aspirin and the blanket isn't really a good comparison to use!
the guideline of not giving asa prior to a scan is there for a reason.
blood sugar should have been done a triage though, if not do that before much else next time.
yes blood sugar is important, but most important in a patient who has decreased conscious level where it is difficult to assess if there is a unilateral weakness.
here the op stated that the patient had a def' unilateral weakness, and no decrease in conscious level was reported.
1 assess the abcs. address any compromise in the patient's status as clinically indicated.
#oxygen administration- op stated that wasn't required.
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.
why a catheter ?
no controlled studies define optimum bp levels but only decrease it 15% over 2 hours.
in what clinical situation?
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.
i certainly wouldn't be lowering bp in a patient with raised icp as you could end up very quickly with an unresponsive patient with worsening neurological symptoms due to a fall in the cpp.
but how many stroke patients have icp monitoring in situ- only the sickest ones.
how are you going to enforce the no head turning in a patient who is conscious and maybe has a visual field disturbance, visual neglect or dysphasia, or indeed all 3?!
as far as i'm aware there are no guidelines that recommend this in stroke.
in many patients with dysphagia one of the techniques recommended by slps to help swallowing and prevent aspiration is to turn the head to one side.
provide analgesia and sedation as needed.
why would you sedate a stroke patient unless they required ventilation?
misswoosie
429 Posts
why would you sedate a stroke patient unless they required ventilation?