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 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 ). 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).
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.
I've also, to add to my previous posts, had patients ON A VENT, on PROPOFOL maxed out, with both morphine and dilaudid at the max, requesting to sign out (via a written note) AMA. Since I had administered mind-altering drugs, and since pulling the tube would have killed the pt., I refused to let them sign now. Plenty of pts are alert enough in ICU to c/o headache and refuse meds. But if they're neuro, you've got to question their soundness of mind.
I've also had pts. who were hypoxic and refusing intubation. If they're hypoxic, even though they're talking, the laws in my state say they're not of sound mind. I've had the same patients recover, come back, and thank me for recognizing they could not make their own decisions. "Sound enough to refuse" is not a justification, if the pt. was potentially neurologically impaired. If that were the case, we could make an argument that if a person wants to kill themselves, and they are alert and sound enough to state why they would be better dead than alive, we should let them do the deed. After all, if they're sound enough to refuse treatment, we're good to let them go without treatment of their disorder.
I'm concerned that a stroke unit doesn't have labetalol. It's on our stroke order sets and it's a tele unit, not ICU. Labetalol is the blood pressure lowering drug of choice for neuro patients.
No neuro changes but N/V & H/A...those are changes, consistent with increasing ICP (as you know, you stated he needed ICP monitoring). But in any event, that guy SHOULD have been in the unit to begin with. Never should have been a tele admit.
It sounds like you don't have the support you need. Or the drugs (like labetalol).
I'm concerned that a stroke unit doesn't have labetalol. It's on our stroke order sets and it's a tele unit, not ICU. Labetalol is the blood pressure lowering drug of choice for neuro patients.
No neuro changes but N/V & H/A...those are changes, consistent with increasing ICP (as you know, you stated he needed ICP monitoring). But in any event, that guy SHOULD have been in the unit to begin with. Never should have been a tele admit.
It sounds like you don't have the support you need. Or the drugs (like labetalol).
I am new to the hospital, but we don't keep stock medications, except if they are in the Accudose (or Pyxis, whatever you want to call it). Our Accudose doesn't have Labetalol in it -- it always comes up from Pharmacy. Accudose normally only carries PRNs (e.g. Tylenol), controls, narcs, I've seen a few suppositories in it, too.
We dont have extra meds like that stashed away in a seperate medication cart or anything like that... Do other hospitals have meds stocked like this?
Meds are usually stocked according to the unit and its acuity. A lot of meds we have readily available in the ICU would not be available on a med/surg or a stroke unit. Or thats how i've seen it done.
Specializes in onc, M/S, hospice, nursing informatics.
It seems as if you did a good job and I wouldn't worry about how you handled the situation. The only thing that I don't see mentioned already is the fact that the CT had not been ordered. You don't say when the neurosurgeon called to ask why it wasn't done. Did you see the order for the CT when you checked your chart at the beginning of the shift (please tell me that you do this!)? You should have noticed that it wasn't done or even ordered (or gotten report that it had not) and ordered it immediately. For this, the doc has a right to be upset. The remainder I think you did fine.
Med-surg units don't have labetalol in their pyxis but the Stroke Unit does. Our stroke unit is only a little over a year old and I was instrumental in its development. I wrote the stroke order sets, etc. Up until recently, I was the Team Leader (i.e., asst. manager) of that unit. (Now manager of a surgical progressive tele unit.) We most commonly saw the ischemic stroke patients but we took a few bleeds. If it were a big bleed, though, or unstable, it was in the unit.
I've also, to add to my previous posts, had patients ON A VENT, on PROPOFOL maxed out, with both morphine and dilaudid at the max, requesting to sign out (via a written note) AMA. Since I had administered mind-altering drugs, and since pulling the tube would have killed the pt., I refused to let them sign now. Plenty of pts are alert enough in ICU to c/o headache and refuse meds. But if they're neuro, you've got to question their soundness of mind.
I've also had pts. who were hypoxic and refusing intubation. If they're hypoxic, even though they're talking, the laws in my state say they're not of sound mind. I've had the same patients recover, come back, and thank me for recognizing they could not make their own decisions. "Sound enough to refuse" is not a justification, if the pt. was potentially neurologically impaired. If that were the case, we could make an argument that if a person wants to kill themselves, and they are alert and sound enough to state why they would be better dead than alive, we should let them do the deed. After all, if they're sound enough to refuse treatment, we're good to let them go without treatment of their disorder.
Excellent points. You do have to consider the whole picture. Certain things render a patient incapacitated.
The nurse further clarified that the patient was A&O x 4, and at this point if they refuse a Tylenol, which isn't a life-threatening measure, I still support the op's actions. Also, if a patient is refusing Tylenol, why would I call for something stronger?
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.
You're thinking like an ICU nurse, not a floor nurse with an A&O x 4 patient and five other patients to tend to. In our assessments we consider GU for sure, and if a patient is currently A&O x 4 and continent a foley isn't something I would think about. Again, when the doctor said he needed critical care monitoring for potential complications, my focus would have been getting him to ICU ASAP and dealing with the more pressing issue of his BP, if the GU was already covered with his continence, I would have let you in ICU worry about his potential for decompensating into incontence.
Good discussion. I think great minds ICU/med-surg do think alike, but the actions/apporach and priorities are different. :chuckle
Specializes in Cardiothoracic Transplant Telemetry.
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.
Everyone has the potential to become incontinent- heck if I laugh too hard I can become incontinent, but that does not mean that I need a foley now.... If the patient is continent now, then there is no indication for him to need a foley. As a matter of fact compliance with bedrest and risk for falls is higher in the patient with a foley in. If and when the patient becomes incontinent is the time to make the decision for the foley.
You also have to remember that the foley may be covered under your critical care standing orders, but on the floors you generally need a specific order for a cath- we can't just pop one in because we feel like it. Our stroke orders allow for a foley- but only if the patient IS incontinent- not if they might be later
Specializes in Cardiothoracic Transplant Telemetry.
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As for tylenol, if the pt. refused, and they had a hemorrhagic stroke, were they of sound mind to make a refusal?
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.
Just my
Do the patients that enter your unit lose their ability to make any decisions about their care? Just because someone is has a stroke does not mean that they necessarily lose the capacity to make decisions for themselves. If the patient is able to answer questions appropriately- they are able to decide what I put where. I know that on the floor if I were to administer a Tylenol suppository to a patient that was currently alert and refusing that I would be facing prison time, the loss of my license and a big law suit.
I agree with Nightcrawler, you are seeing this from the ICU perspective. I work on the floor and I can't put a foley in someone because they "might" decompensate. If they are incontinent, our first move is to put an Attends on them anyway, not stick a foley in them and put them at risk for an infection. If we feel skin breakdown is a potentially serious issue or the patient cannot void, we can get an order for a foley. But it is not standing orders. Even on our stroke set, we have to call for an order for a foley and explain why we are asking. I'm not saying the ICU nurse didn't have the right to ask those questions, but what you consider "basic" care on the ICU is not "basic" care for floor nurses. Foleys on our unit are taken pretty seriously. There must be a real need for it before we're going to place one.
And yeah, if I try and stick a Tylenol suppository up a guy's bum who is A&O x 4, I'm more likely to get socked or arrested for assault. :)
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)
). 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!"
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leslie :-D
11,191 Posts
agree, that foley isn't up there in list of priorities.
leslie