Case Study #2

2) Initial vitals... BP=175/105, HR=94, SpO2=100% RA, T=36.6, R=18, HA pain 6/10...

Anything of concern there?

BP is of concern, if I recall correctly >150/100 increase risk of second stroke. HA pain as well...worst headache ever?? Sudden? What type of pain? HR I would watch as well since it's on the high end of normal (whenever I see changes in HR I think of compensation for maintaining CO, so that's why I'd keep an eye on it, even though it's in normal range)

Did we assess for any recent head trauma/fall?

2) Initial vitals... BP=175/105, HR=94, SpO2=100% RA, T=36.6, R=18, HA pain 6/10...

Anything of concern there?

The BP combined with the heart rate and headache make me think increased ICP, possibly first stage of Cushing's triad. But why is the ICP elevated? Get any labs or tests back yet?

Editing to add that I've been sitting here on my tablet reading through the responses and talking out loud to my husband. He's alternating between watching the Blue jays/Yanks game and being entertained by me talking through this scenario.

What is her past medical history? Oriented? Definitely a scan needed. That BP and HA are concerning.

Viral studies needed? Or is that reaching?

Why are we doing the labs ya'll suggested?

I want others to explain. I'm that annoying nurse who asks students for rationale.

Yes HTN and sudden HA are of concern and are suggestive of SAH. We could also evaluate hx of TIA, hx of trauma however minimal, is she diabetic, hx of arrythmias or valvular disease?

Should we also be concerned of seizures?

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.

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)