Cardiovascular

Speeding to save a stroke victim

Albert Woodbury, age 73, is admitted to your cardiac evaluation unit after suffering a myocardial infarction. Over the next 3 days, his course is stable, and he’s scheduled for discharge today.
During discharge teaching, his speech becomes garbled and you notice a left facial droop. You quickly obtain his vital signs; they’re all normal.

Call for help
Suspecting Mr. Woodbury is having a stroke, you call the charge nurse and ask her to stay with him while you activate the rapid response team (RRT) and contact the house officer. Within minutes, Michelle Riley, the RRT nurse, arrives. You’re relieved to see her, knowing she’s certified by the National Institutes of Health in Stroke Scale training. (The scale evaluates 11 parameters to help determine the extent of neurologic impairment and monitor for improvements or deterioration from baseline.) Then the house officer arrives. He immediately pages the staff neurologist on call.

On the scene
Michelle asks about Mr. Woodbury’s symptoms; you tell her he was symptom-free 30 minutes earlier. While waiting for the neurologist to arrive, she surveys him for neurologic deficits that suggest an acute stroke. Besides garbled speech and a facial droop, she notes weakness in his left arm and leg.
When the neurologist gets there, he orders “crisis” blood work, including a complete blood count, prothrombin time, partial thromboplastin time, fibrinogen level, and basic metabolic profile. After checking the patient’s morning weight, you insert two I.V. lines, as ordered.
Michelle accompanies Mr. Woodbury to the radiology department for an urgent computed tomography scan, which is read immediately as an ischemic stroke. Meanwhile, his blood work shows normal chemistries and no coagulopathy. A quick but thorough review of the patient history finds no contraindications for thrombolytic therapy.
As ordered, Michelle administers tissue plasminogen activator (tPA), titrating the weight-based dose. She closely monitors Mr. Woodbury’s neurologic status and response to the drug, staying alert for signs of bleeding. You and Michelle prepare him for transfer to the stroke unit.

Outcome
Mr. Woodbury is observed for signs and symptoms of obvious or occult bleeding. Because of the bleeding risk, heparin is withheld and caregivers take such precautions as minimal venipunctures followed by compression, bruising precautions, occult blood urine and stool tests, and avoidance of automatic blood pressure measurement.
After 5 days in the stroke unit, Mr. Woodbury has only minor paresis in his left arm. He’s discharged to a rehabilitation facility for physical and occupational therapy.

Education and follow-up
Before discharge, the patient and his family receive extensive education about his prescribed medications, diet, and activity. The nurse emphasizes the need to comply with therapy to control his hypertension and coronary artery disease (risk factors for stroke).
Mr. Woodbury was fortunate to be hospitalized in a facility with an organized in-house stroke response. Also, timely tPA administration can increase functional outcome in stroke patients by up to 30% at 3 months. Michelle’s specialized stroke training and competence in administering tPA boosted the chance for a good result.
Mr. Woodbury’s case shows why all healthcare providers need to stay alert for possible stroke in every patient. For Mr. Woodbury, your keen observations helped minimize the potentially devastating cascade of neurologic impairment that could have occurred, and your colleagues’ swift actions provided the care he needed at a moment’s notice.

For a list of selected references, visit www.AmericanNurseToday.com.


Mary Lu Daly, MS, RN, CCRN, CCNS, and Jeanne Powers, MS, RN, CCRN-CMC, are Clinical Nurse Specialists in the Medical Intensive Care Unit at Rochester General Hospital in Rochester, N.Y. Ms. Daly is program coordinator of the hospital’s Rapid Response Team (RRT); Ms. Powers serves on the RRT committee.

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