Incorrect medication prep

MunoRN, RN · Apr 10, 2015

If the patient has been able to take pills since their stroke then you did nothing wrong, a "history of a stroke" by itself in no way means the patient can't have pills. Even if they were being admitted with a stroke (vs chest pain), there are initial stroke swallow screens that are validated for use by bedside RN's which could have still allowed the patient to take pills.

Suggesting that nobody with a history of stroke should ever take pills is a bit beyond "reasonable" ignorance on the part of a nurse responsible for orienting new nurses, if it were me I'd consider the need for a new preceptor.

ARN1992 · Apr 10, 2015

She was a stroke nurse, so because A "stroke" wasn't completely ruled out (with an MRI) that's why she told me that. The doctor spoke with me earlier in the night and she didn't seem concerned, and I wasn't too concerned either considering the patient was presenting fairly normal. I went in to check on him about a half hour after I gave the med and he was fine. I KNOW that if he was placed under a stroke protocol from the beginning we wouldn't give him PO Meds. But he is being sent to the stoke unit so that's what makes me worried. I didn't harm the patient, at least not in that time frame, but I'm still nervous

MunoRN, RN · Apr 10, 2015

You would need some sort of basis for treating the patient as though they had a stroke, we don't assume all new admits have had a stroke until it's been ruled out by imaging even if there are no S/S of a new stroke.

ARN1992 · Apr 10, 2015

So if he tolerated the PO med. The stroke nurses would just be annoyed and I won't get in trouble?

MunoRN, RN · Apr 10, 2015

If there is no reason to believe he's had a new stroke, and hasn't had pre-existing dysphagia that prohibits him from being able to take pills after his previous stroke, then there is no reason why a reasonable nurse would think you should be in "trouble". Keep in mind that not all nurses are "reasonable" so I can't guarantee another nurse won't disagree with giving the patient PO meds despite the lack of any reason not to, your preceptor for example. Being a new nurse, there are immense opportunities to learn, including examples of poor critical thinking to avoid as well as good critical thinking to emulate. So in your mind, using your own critical thinking, how would you determine if a patient can take PO meds?

ARN1992 · Apr 10, 2015

If his only "stroke-like" symptom is a headache, but he isn't in any sort of acute distress and is speaking normally and is moving his arms and legs normally then I'd think he's okay. If CT showed no signs, an MRI is the absolute yes/no. But if he presents with no signs of a stroke, and he takes the po med and is fine, then it's not an issue, and I checked up on him right before I left and he was fine. The issue isn't the med itself, it's the route. I think she was just trying to scare me and make me more aware of the precautions you need to take for stroke patients.

MunoRN, RN · Apr 10, 2015

There's not really any reason to just routinely make all patients with a headache NPO out of concern they dont' have a safe swallow. You would need more specific information to be concerned enough to make the patient NPO due to swallow issues.

Whether it's appropriate and safe for a patient to take PO is certainly something you should consider for every patient you come across, as well as the plan of care for the patient and how ativan might fit into that plan of care. Is the patient going to the stroke floor simply because they have residuals from previous stroke and so the Physician thought it made sense to put them there? Are they going to the stroke floor because the Physician wants frequent neuro monitoring to assess for a developing new stroke? How might ativan affect that monitoring?

ARN1992 · Apr 10, 2015

I think to assess for a possible developing stroke. His diagnosis before transfer to floor was a CVA, but CT showed no signs of bleeding. Idk why they made that call, maybe because of the history and headache and they wanted to just watch that it doesn't develop any further. The Ativan was given for anxiety, which the doctor told me to my face she wanted to give the patient that. The hospital it's determined he'd go to the stroke unit. But he swallowed the pill fine was was fine afterwards.

If he was having neurological changes then I wouldn't have given it to him. If anything he was BeTTER than what he was when he initially came in.

**NICU Guy, BSN, RN** · Apr 10, 2015

If he had no outward signs of a stroke, A&O X3 and no difficulty swallowing, I would ask him to swallow a small sip of water and see if he coughs before giving the pill if a stroke is suspected. Just because he has a history of stroke, it doesn't mean that every time he comes to the ER, he is having a stroke. You used good clinical judgement. Stroke nurses see potential stroke patients in every patient that has a headache as much as cardiac nurses see MI in everyone that has shoulder pain or heartburn.

CamillusRN, BSN · Apr 10, 2015

As long as he had an intact gag reflex (tolerated small amounts of water) and was alert enough to protect his airway, I see no problem with what you did.

flipflopsNsweetTea · Apr 10, 2015

I KNOW that if he was placed under a stroke protocol from the beginning we wouldn't give him PO Meds.

Hmm...

We get almost all the stroke patients that are admitted to the hospital on my unit (unless they go to the ICU) and when the stroke protocol is ordered, pts are automatically NPO until they pass the dysphagia screening to be done by the bedside nurse, usually done in the ER before they are admitted. If they don't pass that screening, the orders will be changed to NPO until seen by speech. If they do pass the initial dysphagia screening, they have usually already been given some meds in the ECC, like ASA.

So, in my experience, you acted appropriately.