I am blessed by the fact that about 90% of the drs I work around in my hospital are very open to a nurse's ideas and assessments. However, sometimes it just doesn't happen. So here's one for all you neuro nurses to cringe over...
I work on a med/surg/tele/onc floor. Very busy of course. One of my pts was a recent hemorrhagic stroke victim on day #2 in the hospital. In her early 80's and purportedly one of those who still chopped-her-own-wood type ladies until this happened. Upon first assessment, she was alert and oriented x1. She could hold her own cup and swallow her liquids and pills just fine. She could speak clearly and had no sensory or motor deficits. She couldn't properly identify objects, though. When asked what a pen was, she said a dishwasher. Cute. Pupils were definitely off. The right one was dilated and did not react. The left was dilated and reacted sluggishly. Anyway, so I was thinking this little lady was pretty lucky comparatively. This was 0700...
At 1300, the family called me to the room b/c the pt was red-faced and sweating. She had a mild fever at 99, and she was only hot around her face and chest/neck area. So I gave her a cool rag wipe down, turned down her room temp some, and gave the rag to the daughter who said she'd keep changing it up. Checked VS. Stable, but BP was elevated. It had been 145/84 in the am, and was now 185/92. Gave her a small dose of PRN clonidine. Instructed daughter to watch her closely, and I would try to be in every 15 minutes ( on med/surg no less!) One hr went by. The sweating stopped, her face stayed red and hot, the temp resolved, the BP was still high, but not as bad, but... I just had a premonition something bad was about to go down. Next check finds Glascow of 12, and pupillary reactions slightly changed. The right still remained dilated and nonreactive, but the left, which was still dilated, would start to constrict and then dilate again, whereas before it had just sluggishly constricted. I was calling and asking for advice from the neuro floor when the neurosurgeon arrived on scene to do his rounds finally. This is 1500.
*Sigh* He's one of the 10%. Actually, he falls into a different category b/c not only does he not listen to you, but he tries to demean you and be as rude as possible. Yay. Anyway, I don't care. I can be a ***** with the best of them when it comes to my pts. So I inform him of the goings on and he politely seems to listen. Then, when he makes no response, I take a hint and go check my other pts. He isn't big on discussing plans with us "underlings." So when I return, I look at his order. "Place 10 MD order sheets and 10 Progress Note sheets in chart immediately. Now." Whatta idiot.
So I keep watching my lady... At 1600, I have a Glascow of 9 and pupils are fixed and dilated. I call the neuro people up again and they give me advice on not moving the pt if possible and to keep her HOB up and all those ICP things that I vaguely remember from nursing school.
By 1700, I'm worried. The pt's daughter is worried. Glascow of 3. No responses from pt to auditory, tactile, or painful stimuli. Pupils are pinpoint and nonreactive. No corneal reflex. No nothing except she's still breathing on her own. I call Mr Talkative and inform him of the changes. He says "That's all I need to know." *Click* Wonderful. I'm ******. The daughter can sense how ****** I am even though I try to be calm and reserved. I understand that surgical intervention isn't exactly the best option for an 80 y/o lady, but you know what? It's not up to him! This lady was very active prior to this. It's not like she was just a couch potato waiting to die. She had quality of life. Something to live for. Her husband was at the bedside for a while and kept asking me what's wrong, why's she sleep so much, when can she come home?...
At 1800, the dr calls back and says, "Well, I guess we could do another CT scan on her." Yay! So I sent her off to the CT scanner while I tried to catch up on everything I'd missed during the day while worrying over her. I was there late as a matter of fact. I didn't leave until 2030. So I saw the results. They weren't what I expected. The scan showed no significant changes to the bleed. BUT I KNOW WHAT I SAW!!! I watched this lady go from almost normal to almost nothing over the course of a few hours. I knew I was right. CT scans aren't perfect, but they're all we've got sometimes. However, everyone's heard of "Don't watch the monitor, watch the pt." This was one of those times, I knew.
I was off the next day, but my coworker called and told me that she had gotten the pt for the day. The pt had recovered some function overnight (Glascow of 8) but had gotten rapidly worse over the morning. The dr hadn't wanted to send her to the ICU, but he did eventually. She went back down to a Glascow 3 on the floor and then went to the ICU. Then, the dr spoke to the family and convinced them to make her a DNR. She died 2 hrs later at 1400... Poor little lady.
Whew. Thanks for letting me vent guys. I needed that. I've been carrying it around for a few days now.
Specializes in Acute Care Cardiac, Education, Prof Practice.
First off *hugs*. I am so sorry you had to go through a day like that.
Second, I would write the flibberty-gibbet up. I would write down all the vitals, the conversations, the Glasgow changes and slam it down on everyone's desk I could figure matters. I had a stroke patient lose a small amount of use of her left hand when we got her pressure down 20 pts. She went to the unit fifteen minutes later.
We bust our humps on Med/Surg as I am sure you know, and when patients change that dramatically and quickly they need someone who isn't trying to manage five to six very ill patients. Med/Surg isn't what it used to be. I know our floor is basically ICU step-down now.
So when I return, I look at his order. "Place 10 MD order sheets and 10 Progress Note sheets in chart immediately. Now." Whatta idiot.
Wow. What an a-hole. I would have to call him on that one... that's not a medical order and I do not complete secretarial functions for physicians... because I don't work for them. Pig.
Specializes in multispecialty ICU, SICU including CV.
Here are some resources for you about the standard of care. Sorry if this is repetitive or you know this already. They are from the AHA site -- obviously a very reliable source on coronary disease and stroke.
Blood Pressure Management
The optimal level of a patient's blood pressure should be based on individual factors such as chronic hypertension, elevated intracranial pressure (ICP), age, presumed cause of hemorrhage, and interval since onset. In general, recommendations for treatment of elevated blood pressure in patients with ICH are more aggressive than those for patients with ischemic stroke.36 The theoretical rationale for lowering blood pressure is to decrease the risk of ongoing bleeding from ruptured small arteries and arterioles. A prospective observational study of growth in the volume of ICH did not demonstrate a relation between baseline blood pressure and subsequent growth of ICH, but frequent early use of hypertensive agents in this study may have obscured any relationship.29 Conversely, overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury, particularly in the setting of increased intracranial pressure.
To balance these 2 theoretical rationales, the writing group recommends that blood pressure levels be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension37 .
Wow. Very informative. Thanks for all the info. And to someone who was wondering if the bleed was due to blood thinning, it wasn't. However, we were giving her Vit K anyway. I believe next time I am just going to grab the house nursing supervisor and tell her we're transferring my pt up to ICU. Then the dr will either have to deal with giving some new orders, or at least my pt will be able to be more properly observed. Luckily, none of my other pts were as bad off as this little lady, but I'm sure they wondered what happened to me when I started doing Q15min checks on her. Our unit may as well be an ICU step-down nowadays b/c I find that I almost always have 2 pts that require Q30min checks (not a realistic expectation on my floor.) And then 1 or 2 more that require Q1hr checks by the nurse not the aide. The others are usually okay to wait 2 hrs in between (with the aide rounding on them in between of course.) I'm planning on trying to transfer over to the SICU so at least I will have 2 pts and more resources for this kind of stuff.
You did a good job. Kudos to you. Sounds like in this ladies case, there probably wasn't a lot that could have been done for her; the bleed may not have been fixable in any way. However, the doctor could have been more... I don't know, sometimes I wish that not only would doctors be more sensitive, but I wish that they would be nice enough to explain things, and in a nice way too, not in a "You should know this, idiot" kind of way. No, I SHOULDN'T know certain things, *idiot*, I didn't go to medical school!
that was my question: what could have been done for this pt?
i also recognize the delicate balance of maintaining the optimal bp, so the pt's brain gets adequate perfusion.
so short of aggressively (?) addressing her htn (although, not outrageously high), what else could have been medically done?
that said, even if the dr. was (silently) acknowledging any perceived futility of tx, he definitely should have approached the
family and elicited input.
i would definitely write this up as an incident report and distribute to appropriate personnel.
Specializes in Acute Care Cardiac, Education, Prof Practice.
Until someone stamps the patient DNR they need to be in the unit for those kinds of changes. If he thought there was no chance, like Leslie said, he needed to inform the family.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
The physician should've addressed her code status when he made his initial rounds. Making her comfortable should've been a priority, instead of letting it go so long.
Death is an inevitable thing in this situation; wish the family got more support instead of all of the added stress from what was a poor prognosis.
He was playing "control freak" and unfortunately YOU and the family paid a high emotional price.
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Tait, MSN, RN
2,142 Posts
First off *hugs*. I am so sorry you had to go through a day like that.
Second, I would write the flibberty-gibbet up. I would write down all the vitals, the conversations, the Glasgow changes and slam it down on everyone's desk I could figure matters. I had a stroke patient lose a small amount of use of her left hand when we got her pressure down 20 pts. She went to the unit fifteen minutes later.
We bust our humps on Med/Surg as I am sure you know, and when patients change that dramatically and quickly they need someone who isn't trying to manage five to six very ill patients. Med/Surg isn't what it used to be. I know our floor is basically ICU step-down now.
Thank you for sharing.
Take care,
Tait