Suspect stroke if patient has altered mental status
Suspect stroke if patient has altered mental status
While being assessed for a possible stroke by the ED physician, a woman clearly and promptly told him the month, year, and where she was. However, her daughter confided to ED nurses that her mother couldn't remember having lunch together the day before.
"The next minute she would remember it. It was coming and going," says Julie Telban, RN, BSN, CEN, an ED nurse at University of Pittsburgh Medical Center Presbyterian.
Assess family member's insight into more subtle memory loss or confusion, she says. "If the patient is having brief episodes of minor neurological changes with losses of memory or slight confusion, it might be very mild, something that only their family can pick up on," she says. "They might tell you the patient has bridge every Tuesday and they forgot today."
When researchers from the University of Michigan Health System in Ann Arbor compared the symptoms of 461 male and female stroke patients, they found that women were 42% more likely to have an atypical symptom.1 More than half of women had one or more atypical symptoms, most often a sudden change in mental status, such as disorientation or confusion.
Previously, stroke was considered only if patients presented with "traditional" symptoms such as unilateral numbness or weakness, but Telban says "now you would be at fault for missing even subtle signs like vision loss or confusion. If a patient has any altered mental state, or even just says they 'aren't themselves,' they go right back."
Transient episodes of subtle neurological changes such as memory loss or periods of confusion, dizzy episodes, can be warning signs of impending vessel occlusion, says Telban. "Further diagnostic studies such as MRI [magnetic resonance imaging] and carotid Doppler may prevent a stroke or complete occlusion of a vessel," she says.
Atypical presentations also are seen in posterior strokes, notes Telban. She gives the example of a young woman transferred as a toxicology consult and possible drug overdose. "She presented as very sleepy and had difficulty opening her eyes. At first, it appeared she was being uncooperative, but she was diagnosed by MRI with a posterior stroke," says Telban.
Reference
- Lisabeth LD, Brown DL, Hughes R. Acute stroke symptoms: Comparing women and men. Stroke 2009; 40:2,031-2,036.
Source
For more information on assessment of stroke patients, contact:
- Julie Telban, RN, BSN, CEN, Emergency Department, University of Pittsburgh Medical Center Presbyterian. Phone: (724) 647-3334. E-mail: [email protected].
ED nurses may be wrongly blamed for time delays Emergency nursing input is needed When University of Pittsburgh Medical Center Presbyterian was becoming certified by The Joint Commission as a Primary Stroke Center, ED nurses were "less than thrilled about the sudden influx of 'drop everything and take care of this patient,' with patients being flown in for very time-sensitive and rigorous treatment," says Julie Telban, RN, an ED nurse at the facility. The problem was that ED nurses bore most of the pressure for meeting the required time frames for interventions. "Blame would often be cast on the nurse when critical labs weren't back in time or the CT wasn't quick enough. These were elements that may have been out of that nurse's hands," says Telban. "This developed some negativity." Telban played a role in changing this, by serving as the nursing representative for the ED at monthly meetings organized by the hospital's stroke team. "First, acknowledgment of the ED nurses important role in this patient population's successful outcome was recognized," says Telban. "It needed to be a priority for all to make this work — physicians, CT techs, MRI and lab staff, not just the ED nurses. " One item that Telban brought up was simply who was notified of a stroke patient's presence in the ED, and how this was done. "Could the triage nurse make the call or should an ED physician evaluate the patient first? Should we page the neurologist on call or should the neurology attending also be aware?" Telban says "it was trial and error for a while. If we let the triage nurse or medics call it with limited information, we got a lot of false alarms. This began to overwhelm a very busy neurology service, which had a negative effect." Now, the triage nurse makes the initial alert to the ED attending of a possible stroke patient, and the attending confirms this and begins the ordering process. "Prior to the computerized charting that we use now, we developed an order set for stroke patients. This established expected guidelines for treatment such as page to stroke team, AccuCheck blood sugar, labs, type/screen, EKG, and stat CT of the head," says Telban. "We do not use these anymore, but they were helpful." Telban says "a proactive ED bedside nurse can call the CT tech to inform them a stroke patient is coming, giving instant priority to that patient. Simultaneously, while the medic crew is in the hall, if the patient is stable, the physician can order the CT verbally and it is done immediately." |
Flag stroke patient labs to get top priority A man taking warfarin for atrial fibrillation presented to the ED with right-sided flaccidity. "A CT scan from another facility was negative for a bleed or completed stroke, and we had no coagulation results," says Julie Telban, RN, an ED nurse at University of Pittsburgh Medical Center Presbyterian. This patient could receive tissue plasminogen activator (tPA), if his international normalized ratio (INR) was less than 1.7. ED nurses were standing at his bedside, tPA in hand, minutes away from the treatment window of three hours, waiting for the lab results from a blood draw. "We were frantically calling the lab time and time again, and told they could not hurry the process along," says Telban. "It ended up that the patient did get the tPA, but this was a common point of frustration. We were waiting for 20 minutes or more for an INR to come back." All ED labs already were flagged with "ED" labels which gave them priority over all other hospital labs. Nurses now flag stroke labs with "stroke" labels, attached to the order set sheets by the bedside nurse. "This alerts the order entry tech of the priority of these labs over the other multiple specimens in front of them," says Telban. "Otherwise, an overwhelmed order entry tech might finally send the labs after they sat on their desk for 20 minutes because they were just placing orders in the order they were given. Now the stroke labs get priority over all ED patients, and we get the results back more quickly." |
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