I recently had a situation where I noticed my patient was becoming increasingly agitated, word salad was present, and left sided weakness was present. The patient had a head CT without contrast completed approximately 3 hours prior that was negative for stroke.
Despite the recent negative head CT, I was concerned that my patient may be actively having a stroke. I made my charge nurse aware of the situation. She assessed the patient and also suspected stroke. At this point we sent a STAT page out to the hospitalist. 15 minutes passed by and there was no response (per my hospital policy, 15 minutes is the time frame a hospitalist is expected to return a STAT page).
My charge nurse called the house supervisor at this point and made them aware of the situation. The house supervisor made the decision to ask a provider from the emergency department to assess my patient for possible stroke. The emergency department doctor came, assessed the patient, felt that the patient was having a stroke, and ordered a head CT with contrast. This CT came back positive for stroke.
Around the time all of this was happening, the hospitalist (who I had tried to page at the start of all of this) arrived on the floor and stated that he did not feel the patient had a significant change in condition and that it was wrong to call a stroke alert and involve the ED doctor.
He stated that it made his night harder and that we should have just paged him a second time. Although the patient did come in with word salad and left sided weakness it was, in my opinion, worsening. The patient was also becoming agitated which was new. I feel that I was looking out for the best interest of my patient and I don’t know what I should have done differently. I’m a relatively new nurse so I just wanted an opinion from someone who has more experience than myself.
To answer your question, yes, this is the process for activating a stroke alert at my hospital.
Thanks for the reply.
I think the process sounds concerning for a couple of different reasons but that is getting way off track and out of your purview. You did what you were supposed to do and the patient ended up getting the care they needed. ??
Not sure where the patient came through to get to your care, but an ER would take the symptoms and timeframe into consideration, complete a CT to rule out a BLEED, and then consult neuro for possible TPA or surgery to treat a clot. Even if they were outside the treatment window, they would still at least have neuro following them, especially if there was no history of mental illness or dementia and this was a sudden change of mentation.
Seems like when you initiated the chain of events, the patient was finally able to get on the right treatment path.
Good job! At my hospital, even though I’m in critical care/ICU, we automatically call RRT with suspected CVAs. This allows us to get the orders we need right away from the RRT protocols without the physician. I think you handled this situation well!
I recently had a situation where I noticed my patient was becoming increasingly agitated, word salad was present, and left sided weakness was present. The patient had a head CT without contrast completed approximately 3 hours prior that was negative for stroke.
Despite the recent negative head CT, I was concerned that my patient may be actively having a stroke. I made my charge nurse aware of the situation. She assessed the patient and also suspected stroke. At this point we sent a STAT page out to the hospitalist. 15 minutes passed by and there was no response (per my hospital policy, 15 minutes is the time frame a hospitalist is expected to return a STAT page).
My charge nurse called the house supervisor at this point and made them aware of the situation. The house supervisor made the decision to ask a provider from the emergency department to assess my patient for possible stroke. The emergency department doctor came, assessed the patient, felt that the patient was having a stroke, and ordered a head CT with contrast. This CT came back positive for stroke.
Around the time all of this was happening, the hospitalist (who I had tried to page at the start of all of this) arrived on the floor and stated that he did not feel the patient had a significant change in condition and that it was wrong to call a stroke alert and involve the ED doctor.
He stated that it made his night harder and that we should have just paged him a second time. Although the patient did come in with word salad and left sided weakness it was, in my opinion, worsening. The patient was also becoming agitated which was new. I feel that I was looking out for the best interest of my patient and I don’t know what I should have done differently. I’m a relatively new nurse so I just wanted an opinion from someone who has more experience than myself.
I am a bit confused with your post. You said your patient came in with those symptoms (but worse ) and neg CT without contrast? So sound like the patient had a stroke when he came in. Just to make it clear you know but the purpose of CT without contrast at admission in patients who come in with stroke/TIA is to rule out hemorrhagic stroke...not ischemia stroke. So even tho his/her initial CT without contrast is negative...it does not mean that he did not have a stroke. CT without contrast does not show early stroke. You need CT with contrast to show a clot or MRI to confirm the stroke.
You said the second CT with contrast showed stroke...I assumed it showed clot. Is it a new clot or the clot the patient already had from admission.
Another theory I have (I scanned through your post so I may misunderstand) is the patient had a stroke at admission. His symptoms may worsen because of continuing edema...which peaked 72 hours after stroke particularly those with large MCA stroke. So technically you did not need to activate stroke alert or can just wait for the physician to return call again...but just a gentle inform the physician about neuro change. Most of time, there is not much to do. Neurosurgeon may choose to do a hemicrani but not until more significant neuro change or midline shift...hence why I said this matter can be dealed with in a urgent...not emergent manner.
My opinion: you did the right thing if he/she did not have a stroke at admission...but your post (the continuing stroke symptoms) told me he did...stroke alert is for new stroke. Stroke alert is not for neuro change.
Good job! At my hospital, even though I’m in critical care/ICU, we automatically call RRT with suspected CVAs. This allows us to get the orders we need right away from the RRT protocols without the physician. I think you handled this situation well!
The patient came in with those symptoms...he may already have a stroke...tho not 100% sure from the post so it may not be a suspected CVA. See my post above for explanation. I used to be Neuro ICU responding to stroke alert.
The patient came in with those symptoms...he may already have a stroke...tho not 100% sure from the post so it may not be a suspected CVA. See my post above for explanation. I used to be Neuro ICU responding to stroke alert.
To clarify, the patient came in with altered mental status. From the orders the physician was putting in (lactic acid, abx, etc.) it seemed like they were more concerned about possible sepsis than stroke. The patient was not a stroke alert in ED. I should also add that the 2nd CT was positive for a hemorrhagic stroke.
To clarify, the patient came in with altered mental status. From the orders the physician was putting in (lactic acid, abx, etc.) it seemed like they were more concerned about possible sepsis than stroke. The patient was not a stroke alert in ED. I should also add that the 2nd CT was positive for a hemorrhagic stroke.
Hmm this made no sense. Those S/S are not typical for sepsis unless he has a septic emboli, but if CT at admission did not show hemorrhagic stroke and the 2nd CT was positive for hemorrhagic stroke then you did the right thing by calling the stroke alert
You provided excellent care for your patient despite barriers and this is what being a nurse is all about. The hospitalist isn't in charge of your license, let that roll off of you. They don't have to like being wrong and they might even learn something.
.thumb.jpeg.99f2e6bf68e7749cbc77be28d62de6a1.jpeg){kind=small}
Stillcrazyafteralltheseyears
45 Posts
You did the right thing! Keep following your instincts. Hoorah!