A lot of people seemed to like my last real-life case study and I had another interesting one last night... so thought I'd post it.
Here goes...
40-year-old woman was at work when she experienced sudden and acute onset of numbness, tingling, and weakness in her R arm and the R side of her face.
She was rushed through triage to an open room but none of the pod nurses heard the call... I got involved when a call went out that "Dr. Bill needs nursing assistance in room 8." I walked in to see one nurse starting a line on her right arm, someone getting her onto the monitor, someone else getting the EKG set up...
What do you suppose was my first action? What transpired in the first few minutes? What other pieces of information do we need STAT as we talk this through?
Come play the game with me, even if you don't know the answers.
What I gather from the scenario above is that the patient is having a stroke, thus I would want to activate the stroke team, use the ABC method: check the O2 sat, and administer O2 if necessary, vital signs,neurocheck, check for facial symmetry, speech etc. place an IV in the unaffected arm, place the patient on monitor, obtain EKG, obtain order for CT scan, gather medical history...including family history, onset of symptoms, medication h/o …current and past meds including the use of blood thinners, recreational drugs, smoking, and diet; obtain order for blood work: CBC,CMP, PT/PTT/INR, Cholesterol panel,VDRL,FTA,Toxicology….serum or urine, Cardiac enzymes Troponin(CPK,CK)LDH , homocystine, and APL.
With the collaboration of the medical, and nursing teams all tests, and TX should be done within a three hours’ time frame.
"I do not have all the answers,but together we can find them."
Also, if her BP is high and we are worried about a second stroke, is there a drug protocol to try to bring the BP down asap? I'm asking as a SN (student nurse).
Same type of patient came into the ER where I worked. I got vitals, started IV's. drew labs, EKG, med and medication history taken.
Doctor delayed seeing the patient while playing on the computer ignoring my plea to see the patient. She started projectile vomiting after being in the ER for 45 minutes, became unconscious. Was rushed for a CT scan. Had a brain bleed. Died the next day at 52 years old. Vital signs and symptoms should help with progression of medical testing needed. I always prepare for the worst and hope for the best.
Not trying to take this thread in another direction, but how do you (universal RN "you") handle something like this? I would forever wonder in the back of my mind if the patient could/would have survived if seen sooner. I really wonder how I will react if in a situation like this, to be totally honest. Do you ever have a one-on-one with a doctor who does something like this? I know professional courtesy and all that, but dang, it would be really hard to not to confront the doctor for something like this (privately and as professionally as possible, of course).
How DO you handle something like this, both in the moment and also after the fact?
Measuring a patient's vital signs,and examining the patient will reveal to the medical,as well as the nursing teams how to proceed;thus if the BP is high a drug protocol would be in place, it will be ordered,and implemented ,or it would be activated to prevent another stroke,likewise Oxygen will be provided if the O2 sat is low. I also forget to mention that hypoglycemia can also be mistaken for a stroke,so finger stick blood glucose level should be measured,as well as serum Hemoglobin A1C. The labs are collected to rule out/confirm a stroke,or differential diagnosis.
"I do not have all the answers,but together we can find them."
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Not trying to take this thread in another direction, but how do you (universal RN "you") handle something like this? I would forever wonder in the back of my mind if the patient could/would have survived if seen sooner. I really wonder how I will react if in a situation like this, to be totally honest. Do you ever have a one-on-one with a doctor who does something like this? I know professional courtesy and all that, but dang, it would be really hard to not to confront the doctor for something like this (privately and as professionally as possible, of course).
How DO you handle something like this, both in the moment and also after the fact?
Totally off topic, but to answer your question. Yes there has been times I have gone toe toe with a MD over something when I KNEW I was right. Were there times that a more timely intervention could have changed an outcome? MAYBE...a BIG maybe.
With a head bleed that is so massive....while the 45 minds were frustrating for the nurse...the devastating results from the massive bleed probably would not have been able to be negated
She started projectile vomiting after being in the ER for 45 minutes, became unconscious. Was rushed for a CT scan. Had a brain bleed. Died the next day at 52 years old.
would have still ruptured in the CT 45 mins earlier become unconscious with a fatal outcome. However...I would be writing this up to risk management, the medical director, and the ethics committee...as well as submitting it for M&M (morbidity/mortality) rounds.
I have circumvented the MD in the ED and called the medical director. IN one facility we had in house pediatricians who would see critical children in the ED and get them transferred out...I had a kid wiht asthma that the ED MD, good doc, that wasn't impressed with this kid....and frankly was being a butt head that night...this kid was going to code. I called the in house pedi and told her to come down now because this kid was going to code.
He was NOT happy to say the least. I wrote it up to the medical director and he was spoken to in M&M rounds.
But before I stick my neck out I make sure I am right.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Answers!Answers!
Good insight.......
Measuring a patient's vital signs,and examining the patient will reveal to the medical,as well as the nursing teams how to proceed;thus if the BP is high a drug protocol would be in place, it will be ordered,and implemented ,or it would be activated to prevent another stroke,likewise Oxygen will be provided if the O2 sat is low. I also forget to mention that hypoglycemia can also be mistaken for a stroke,so finger stick blood glucose level should be measured,as well as serum Hemoglobin A1C.
"I do not have all the answers,but together we can find them."
(M Ecallawh)
A finger stick glucose is important and can be done stat....when in an emergency we are not so concerned with recent adherence for it ha little to do with the immediate situation. It is important for later for their non-adherance may have precipitated/complicated the event....but has little to do with the current emergent treatment of the patient.
When you become more experienced your brain will start to click off possibilities in your brain.
For me this presentation makes me think
Head bleed
Possible aortic arch aneurysm rupture/leak/dissection
Stroke
MI
DKA
Drugs like meth/cocaine
So....now what work up would you be thinking the patient will need. Start at the basics.
As stated before I think we'd want to get ready to get:
-CBC
-Chemistries
-Finger stick glucose
-Check urine for presence of ketones
-Cardiac Enzymes
-Clotting studies
-Tox screen
-MRI without contrast
If this IS caused by some either DKA (which I doubt given her age) or HHNS (more likely given her age), I believe that it may be related to the rapid diuresis and maybe extreme sodium loss which consequently is causing hyponatremia and cerebral edema. I think that's a far stretch. Also, I do not know how dehydration in HHNS or DKA affects the BP.
The CBC will also help tell us if there's an infection that could've caused the HHNS or DKA.
Tox screen will tell us if this is due to drug use.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
As stated before I think we'd want to get ready to get:
-CBC
-Chemistries
-Finger stick glucose
-Check urine for presence of ketones
-Cardiac Enzymes
-Clotting studies
-Tox screen
-MRI without contrast
If this IS caused by some either DKA (which I doubt given her age) or HHNS (more likely given her age), I believe that it may be related to the rapid diuresis and maybe extreme sodium loss which consequently is causing hyponatremia and cerebral edema. I think that's a far stretch. Also, I do not know how dehydration in HHNS or DKA affects the BP.
The CBC will also help tell us if there's an infection that could've caused the HHNS or DKA.
Tox screen will tell us if this is due to drug use.
I think I'm stretching a bit far. Lol.
Well done!!
But when someone comes into the emergency room you have no clue about their background or history....everything is on the table. Drugs can be a common issue and some patients like a 40 year old Mom would be the last thing you suspect...but you have no idea what skeletons they have in their closet.
Seldom is an emergent MRI is taken in the ED. IN some academic centers that might be a consideration but at most facilities they do not have the staff available on an emergent basis nor do the MD's want to wait for the procedure to be done on a "unstable patient" over an extended period of time.
Time is of the essence.
You would also look for a widening mediastinum for an aortic dissection with a CXR and EKG changes with a 12 lead EKG.
So let's review... pt is hypertensive... yes, has a history of same, yes is on meds, yes, is taking them... but none of that is really critical to where we are at the outset... as always in the ED, we're looking for the seconds-to-minutes emergencies... a BP of 175, even if symptomatic, doesn't rise to that level when compared to the obvious... CVA.
And yet, the BP is concerning in this case... not in and of itself but because of its impact on other treatment. What's up with that?
+++
So, within 10 minutes:
neurology was at the bedside beginning her exam
We had 2 lines started... why 2? And why was I planning to start a 3rd ASAP?
No, they don't need to be large-bore lines... 20's are perfectly fine... probably even preferred in this situation.
[*]Fingerstick... sugar is 125... no smoking gun there
[*]EKG is done... NSR...
[*]Labs are drawn... CBC/BMP/Coags/Trop... All that's needed at this point... all sent first priority (which means we inform the lab that they're there and that they get bumped to the front of the line, even ahead of STAT... our lab has 4 levels... first priority, STAT, ED-routine, routine)
Lipids and that stuff require the patient be NPO for 8 hours and really don't tell us anything useful in the first hour
[*]Pt is taken STAT to CT... who are called ahead of time and will pull someone off the table if need be... Stroke alerts get buzzed ahead of anybody... because time-is-brain.
[*]Neurologist follows along, continues her exam until the pt is in the scanner, and then watches the CT in progress.
....
So:
Why the STAT CT? What are we looking for, even before the radiologist sees it?
If I could only get one tube of blood, run only one test, which would it be?
Why multiple lines? Why is large-bore (a) unnecessary and (b) even possibly even counterproductive?
Why the EKG and fingerstick? (Esme already hit this)
And what about the blood pressure? Is it an issue at this moment? Why or why not? If so, what do we do?
What one small, and often incidental, piece of information do we need about this patient? (that nobody has yet touched on)
Urine... we could put it in the 'nice-to-have' arena but we're not going to delay anything else to get it and, regardless, given the presentation of this patient, it's not going to tell us anything that's likely to change our course of treatment.
Stick with me, this gets a bit more interesting...
As stated before I think we'd want to get ready to get:
-MRI without contrast
MRI is generally indicated but not immediately... remember, time-is-brain... got bigger fish to fry before we take the time to put the patient in the tube.
And when it's done, it generally includes angiography.
Wow! Ummm, I am just getting into nursing school so I am not quite skilled at this yet!! But I need to ask if starting an IV in the affected side is right? Also, vitals should be taken, sounds like a stroke maybe?
Isis Phoenix
39 Posts
What I gather from the scenario above is that the patient is having a stroke, thus I would want to activate the stroke team, use the ABC method: check the O2 sat, and administer O2 if necessary, vital signs,neurocheck, check for facial symmetry, speech etc. place an IV in the unaffected arm, place the patient on monitor, obtain EKG, obtain order for CT scan, gather medical history...including family history, onset of symptoms, medication h/o …current and past meds including the use of blood thinners, recreational drugs, smoking, and diet; obtain order for blood work: CBC,CMP, PT/PTT/INR, Cholesterol panel,VDRL,FTA,Toxicology….serum or urine, Cardiac enzymes Troponin(CPK,CK)LDH , homocystine, and APL.
With the collaboration of the medical, and nursing teams all tests, and TX should be done within a three hours’ time frame.
"I do not have all the answers,but together we can find them."
(M Ecallawh)