Who Can Answer this Scenario?

[angieedoll]

A CT tech at a local hospital and an order comes through from the ER. The order is for a CT of the brain to R/O (rule out) CVA (cerebral vascular accident aka stroke). You go to the ER to bring the patient back to CT and the patient is asleep. You verify the patient identification all the meanwhile speaking to the patient and explaining what you are bringing them back for and a brief description of what you are going to do.

You bring the patient back to CT and you are getting ready to transfer the patient over to the table and the patient wakes up in a frantic hustle screaming "NO! NO! NO! NO! NO!" repeatedly along with some other words that don't make any sense. She has a glazed over look in her eyes. You ask the patient "do you want the scan on your brain still?" She continues with the "NO!" repeatedly. You repeat yourself in an effort to ensure that the patient understands what she is saying, "Ma'am, so are you refusing the exam for the CT of your brain???" She repeats with the "NO!"

You bring the patient back to the ER and tell the ER doctor on duty the situation. He goes over to the patient and tells her that we need to do the exam to see if she has a bleed in her head. He looks to you and says, "Go ahead and do the exam. I don't care if she keeps saying 'NO!'. Don't come back with her until you've done the exam"

What do you do and how do you feel about it?

Would/should the Tech continue with the Procedure?

[carolinapooh, BSN, RN]

I'm no ED RN, but that to me qualifies as a change in status, and I think the exam should go forward. She's not coherent, she's answering inappropriately, she's gone from calm to combative, her gaze has changed - I agree with the doc. If she is bleeding into her brain, they won't know without a CT. I would, just for my own CYA, find out if she has any family with her in the ED and make sure they're notified immediately. To me, this is shoot-now-ask-questions-later, and the doc is probably thinking if she's bleeding and I didn't find it, it's my behind. Chart the crap out of it. To me the benefit outweighs risk here.

My guess is the answer is you should refuse the exam, though, because this is nursing school and they're not going to think 'real world' all the time - but the patient is clearly not rational and not oriented.

[akulahawkRN, ADN, RN, EMT-P]

The patient isn't rational or oriented. There's no way this patient is able to either give informed consent or refuse care. The CT tech should do the scan under implied consent. The tech, by bringing the patient back to the ED, could very well have cost significant time and actually contributed to further harm through the delay of care.

If I was the tech, knowing what I know, I'd continue the procedure so that the extent of injury and whether or not a bleed is present can be known, and I'd be OK with doing the CT scan. I'd be more concerned about the patient moving her head during the scan and significantly degrading the image than I'd be about what the patient's verbalizing. Now if the patient started making sense, then I'd have to determine mental status so that I can find out if the patient can then refuse.

[Esme12, ASN, BSN, RN]

Given what you have learned in school so far...what do you think? I like students to give their thoughts, start the dialog and we will happily join in. I am sure your clinical instructors want you apply what you have learned in school and apply accordingly. Using your critical thinking skill with the knowledge you have so far and making the best decision.

Tell me what you think !! I'll jump in...:)

[NYCRN16]

Esme is right, think the situation over on both sides of the coin. Do you think the doctor was right or wrong to say the scan continues?

[BrooklynRN11201]

definitely change in mental status - the reaction could be BECAUSE OF the suspected CVA

I would agree with the Dr - implied consent, you need to act fast with CVAs

I would ask the Dr for a sedative or something first.

[rnmelody]

Change in mental status definitely signals cva or hypoxia the brain. In order for the doctor to treat the pt accordingly,he has establish a dianosis. Find the immediate family to get consent quick!

[KelRN215, BSN, RN]

The patient is in no condition to refuse the exam and I agree with the MD, it needs to be completed whether she's screaming "No" or not.

[NICU Guy, BSN, RN]

If she is screaming NO and then some other bizarre words, Is she answering your question "NO NO NO I don't want the CT test" or a bizarre question in her head like "NO NO NO I don't want pink bunnies in my soup" because of the brain trauma.

[nurseprnRN, BSN, RN]

Sometimes you get these questions and there isn't always a right or wrong answer. Your faculty wants to know how your thinking as nurse is coming along. The want to know if you will search out the basic ethics information (I hate to say it, but Wikipedia is actually not a bad place to start. START.) and other aspects, and come to a conclusion, and defend it. So, OP ... what do you think now?

[angieedoll]

Sometimes you get these questions and there isn't always a right or wrong answer. Your faculty wants to know how your thinking as nurse is coming along. The want to know if you will search out the basic ethics information (I hate to say it but Wikipedia is actually not a bad place to start. START.) and other aspects, and come to a conclusion, and defend it. So, OP ... what do you think now?[/quote']

It's actually a question from my husbands Rad Tech program. I guess his class had a HUGE debate on it. Some said yes, proceed due to the lack of time wasting, others said no, don't do it for the possible risk of battery and to verify any possible option of a power of an attorney.

It's very interesting.

[Esme12, ASN, BSN, RN]

A rad techs point of view and responsibility is completely different from the nurses point of view. The way thins question is answered by a nurse is different. It is difficult to answer questions appropriately without ALL the information up front.

It is up to the Emergency Department personnel to determine competency. If a patient is deemed unable to make an informed decision the test will go forward with either the famlies permission or on the absence of the family the patient can be deemed medically unstable and incompetent (in danger to self) and the test will be performed. POA isn't in play here. I have had many patients saying no while we performed necessary intervention/testing.

Yes the CT would be performed as this may be causing the patient agitation.confusion....which may be life threatening if undiagnosed.