hemorrhagic cva

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Specializes in Acute Care.

I work on a "stroke" unit but, to be honest, about 99% of the time, we never see a hemorrhagic CVA. I had a pt yesterday with a 2.6cmx3.4cm, I believe, cerebellar hemmorrhage :no: and to make it worse, he was a prisoner so any test he had to go to, we had issues trying to get security to come (the pt has a prison guard at bedside 24/7 but any transport also needs our security personell). I had issues trying to get his BP down 180s/90s-- gave him his standard PO bp meds, he threw them up (Why is he not in ICU for ICP monitoring!?!?!?) . Gave him Zofran and IV Vasotec. Vomiting subsided, BP didnt come down. Got an order for Labetalol IV - faxed order to pharmacy. Labetalol is not something we normally give on our unit -- I had given it once before. (BTW, his neuro checks were OK, just c/o N/V and HA)

Waiting for it to come from pharmacy and neurosurgeon calls and chews me out b/c pt hasnt had his CT yet (pt was a new admit on night shift, neurosurgeon had handwritten orders - nightshift had put in every order EXCEPT the CT :banghead:). I wasnt even told about a CT scan in report. I put CT in for STAT - Shortly after the pt came back from CT- gave pt the labetaloo that had FINALLY come up - BP came down to 160s/80sand neurosurgeon came up and said "I wanna know why the ER doctor didn't put this man in the unit like I told him to!"

I also called report to ICU - she was more concerned about why he didnt have a foley and why we havent given him anything for his HA 5/10 (pt refused Tylenol PO and supp.). I tried explaining to ICU nurse that the MDs NEVER EVER EVER EVER give us anything that would interfere with a neuro check -- no narcs, no Ativan/Xanax, nothing. She didnt get it. Are ICU nurses used to getting these things or do you think maybe she was new? I'd have docs order restraints or 1:1 for pts than Ativan for disoriented pts on neuro checks, or just say to me "Sorry, all you get is Tylenol" for pts who c/o pain.

Is there something I shouldve done differently? Something I should've picked up on earlier? Should I have called the MD as soon as I got out of report and asked for a unit bed? (Luckily, my charge nurse who is way more experienced than my lowly 5 months in acute care, had called and had an ICU bed on hold).

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Specializes in ICU/Critical Care.

You're not suppose to give benzos or narcs to a CVA patient because it could interfere with neuro checks. Tylenol is ok. I don't know what that ICU nurse was talking about. Don't worry about that nurse. There are some ICU nurses who think that they are better than floor nurses. I don't know why that is but it's stupid.

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Specializes in Med-Surg.

I think you did the best you could in a bad situation.

I agree, when I worked nuerosciences we never gave meds that might alter a neurocheck, expect when the patient had other injuries. Invariably trauma doc would order lots of good meds and neuro doc would come in and d/c them all because he couldn't assess his patient.

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Specializes in Acute Care.
You're not suppose to give benzos or narcs to a CVA patient because it could interfere with neuro checks. Tylenol is ok. I don't know what that ICU nurse was talking about. Don't worry about that nurse. There are some ICU nurses who think that they are better than floor nurses. I don't know why that is but it's stupid.

I'm not really worried about that nurse b/c everything I said, she acted like she didnt understand. How she works in ICU, I have no idea. I mentioned to her that the pt had just come back from CT and the neurosurgeon put in for a transfer to ICU. She said "Oh, is the hemorrhage getting larger?". I told her I hadnt personally spoken to neurosurgeon about it and the report wasnt transcribed into the computer yet, either. She got really confused about that.

I also feel bad b/c it took FOREVER!!! to transfer this pt to the unit, like close to 2 hrs long. We just moved to a brand new unit, and they have yet to give us a portable tele monitor for transferring pts - plus, I had to call ICU to give report, go to ICU to borrow their portable tele monitor, come back to my unit, call security and transport and wait for them to come up. Plus, the ICU and our new unit is like a 10-15 minute walk to/from...

And yesterday was just ridiculous... all this for one pt and I had 5 others to care for... My charge nurse and I even had to beg my nurse manager to come out to the floor to help pass meds. Oh, and I had a nurse extern following me that day. She probably thinks I'm a dingbat!

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Specializes in ICU/Critical Care.

Crap happens. You did your very best. I wouldn't feel bad about it taking so long. Last time I worked at my step down job, I had a patient who was having focal seizures, took him to CT, found out he was bleeding. Gave him FFP, gave report to ICU. It took a little over an hour to finally get him to ICU but they never complained about it.

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I'm not really worried about that nurse b/c everything I said, she acted like she didnt understand. How she works in ICU, I have no idea.

You know, ICU nurses have to learn just like you did when you started working in acute care. Nurses have to learn to be nurses where ever they decide to work. They can be newbies fresh out of school like anyone else. So that's how she worked in an ICU. Now whether or not new grads should be able to work iin an ICU or not is a whole different discussion.

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Specializes in Critical Care.

>I also called report to ICU - she was more concerned about why he didnt have a foley and why we havent given him anything for his HA 5/10 (pt refused Tylenol PO and supp.).>

As an ICU RN, I'll bite. There were opportunities, in the ED and your floor (placing a foley takes appx. 5-10 minutes with a bit of help), to place a foley. You had bigger fish to fry-- I get that. You were occupied with BP/ neuro issues. But certainly there could have been a few minutes somewhere in the chain where a foley could be placed? Esp. in ED? When pts. come to ICU, there are normally a zillion labs/ scans/ meds that are added that a floor cannot administer . . . so we are running our behinds off on our new admit, with another critical patient to care for (who can get ignored due to the admission). A Foley in place would be a priority for a patient who you thought was crashing/ needing ICU admission. . . . and should have, if dx'ed with a hemorrhagic CVA in ED, been placed at that time.

As for tylenol, if the pt. refused, and they had a hemorrhagic stroke, were they of sound mind to make a refusal?

Those were perhaps the concerns the ICU nurse might have had.

> I tried explaining to ICU nurse that the MDs NEVER EVER EVER EVER give us anything that would interfere with a neuro check -- no narcs, no Ativan/Xanax, nothing. She didnt get it. Are ICU nurses used to getting these things or do you think maybe she was new? I'd have docs order restraints or 1:1 for pts than Ativan for disoriented pts on neuro checks, or just say to me "Sorry, all you get is Tylenol" for pts who c/o pain.

Yeah-- you don't want to give neuro-altering drugs to a neuro pt. But you state that "all you get is Tylenol", but you didn't give tylenol. So once again, this might be where the ICU RN is questioning your actions-- once again, wondering if the pt. was actually competent, as an ICU upgrade, to refuse tylenol. These two things (foley and tylenol) would also be what I'd be questioning-- sadly, regardless of your other patients/ demands. When I get report, I want to know what was done to MY patient, and why basics (foley, tylenol) were skipped over. I don't think less of you if they're not done; but I have to question it-- it's my job because as soon as I get report, that pt. is my responsibility.

That said, if you didn't have support, and the ED didn't have the patient set up, and you got them passed off from a previous RN who also didn't get stuff set up, you did the best you could. Just wanted to clarify why the ICU RN would have questioned you (because we also get a lot of confusion from the floors on transfer as to why we're concerned about the "little stuff"). If I'm getting report on a crashing patient, I question EVERYTHING. It's the only way I can fully prepare me for taking the best possible care of a critical patient. ICU is all micromanagement (we look at all systems, all labs, all scans, and incorporate them into a total picture). Floor nursing is macromanagement (issue-focused assessment). Both are hard, and having been a new hire into ICU and knowing nothing else, I don't know if I could do a floor RN's job. 5-7 pts, no chance to do a complete assessment, stuck with crashing pts with no supplies/ treatment protocol not requiring MD consults, demanding families? Ack! Both are specialties. But both also have different focuses.

Just my :twocents:

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Specializes in Med-Surg.
Ack! Both are specialties. But both also have different focuses.

Just my :twocents:

How very true.

Remember a foley isn't necessary "basic" on a floor patient, especially with continent people, it might be for the ICU patient. It's not something we automatically do with everyone. When a patient is upgraded to ICU our main focus is getting the patient off the floor, we don't stop to think..."o.k. now the patient is critical and it's basic care for a critical patient to have a foley", especially if they are voiding and are alert.

Probably if a patient was alert and sound enough to complain of a headache, then yes they were sound enough to refuse. So the nurse attempted to deal with the "basics" of pain control and shouldn't be criticized for not addressing the issue or asking the doc for stronger medications by that nurse.

However, the ICU nurse should not be criticized either for asking appropriate questions from head to toe. This infomration is vital to the care of the patient.

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Specializes in ICU/Critical Care.

NurseyPoo, if it was me accepting your patient, I really wouldn't have care whether or not you had placed a foley. I don't have a problem doing it myself. The patient would have gotten one anyway and to be honest, its not at the top of my priority list right away. BP and pain control would be my top priorities and I wouldn't have expected you to have inserted a foley.

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Specializes in Critical Care.
How very true.

Remember a foley isn't necessary "basic" on a floor patient, especially with continent people, it might be for the ICU patient. It's not something we automatically do with everyone. When a patient is upgraded to ICU our main focus is getting the patient off the floor.

I agree. And placing foleys too frequently has been shown to lead to hospital-acquired UTI's. But if a person is having a hemorrhagic stroke, should not a nurse(ICU, ER or FLOOR) possibly thing about the fact that, if they decompensate, they may need a foley due to loss of continence (or in the case of a stroke, depending on area, noncompliance)? And although I know the pt was made ICU status, and the goal should be to move them to ICU ASAP (our facility has a 30 min move goal), I just wanted to explain why a nurse in ICU would question why a foley wasn't placed prior to that decision point.

Even though a pt may be continent at admission, it's a nurse's responsibility to assess incontinence/ potential for incontinence as the patient's care needs progress.

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Specializes in Acute Care.

The pt was A&O x 4, no neuro deficits at this point. Just the N/V and HA. He was offered Tylenol PO and refused. Also told him we had orders for a rectal supp. if he didnt think he could tolerate the PO and he laughed and said "no way" (He was in his 40s, so I am guessing he wasnt as open to rolling over and having a young woman stick a supp in his rectum, unlike our older patients who are not as shy about supp. and enemas :)).

But, like Tweety said, when we have 6-7 pts on the floor and a person is A&O and continent we normally don't shove a foley in them unless there's a specific order for one.

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Specializes in ICU/Critical Care.
I agree. And placing foleys too frequently has been shown to lead to hospital-acquired UTI's. But if a person is having a hemorrhagic stroke, should not a nurse(ICU, ER or FLOOR) possibly thing about the fact that, if they decompensate, they may need a foley due to loss of continence (or in the case of a stroke, depending on area, noncompliance)? And although I know the pt was made ICU status, and the goal should be to move them to ICU ASAP (our facility has a 30 min move goal), I just wanted to explain why a nurse in ICU would question why a foley wasn't placed prior to that decision point.

Even though a pt may be continent at admission, it's a nurse's responsibility to assess incontinence/ potential for incontinence as the patient's care needs progress.

Either way, incontinence would not be the bigger priority. I agree it probably should have been addressed in either the ER or on the floor. How do we know it wasn't? The patient could have refused anyways. If the patient decompensates, the first thing I'm going to worry about is ABC not F. I can worry about that after.

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