Do this to prepare if your patient might get tPA
If your patient is a possible candidate for tissue plasminogen activator (tPA), past medical/surgical history, allergies, and medications need to be reviewed, says Joyce McIntyre, RN, MSN, clinical nurse specialist for the ED at Massachusetts General Hospital in Boston.
"Nurses should document the time of the last dose of warfarin or aspirin and communicate that information to the physician," says McIntyre.
Document the patient's weight; mental status; neurological exam; interventions as they are provided; communications with the medical team, patient, family, and witnesses; time of symptom onset; and the time tPA is initiated, says Stacey Claus, RN, BSN, CNRN, clinical instructor for the Department of Nursing at Cleveland Clinic. "If the patient does not receive tPA and PO orders are written, then the nurse would need to perform and document a swallowing screen prior to giving anything PO," she says.
Your documentation should include frequent vital signs and neurological checks, as well as interventions such as decreased tactile stimulation, head of bed elevation, and seizure precautions, says Tia Moore, RN, CEN, clinical nurse educator for the ED at University of California — San Diego Medical Center.
Learn onset time
Most often, patients are not treated because the time of symptom onset is unknown, says Dawn K. Beland, RN, MSN, CCRN, CS, CNRN, stroke center coordinator at The Stroke Center at Hartford Hospital (CT).
"The patient may have woken with symptoms or been found with changes without a known time they were last seen well," she says.
Statements such as "the symptoms started about an hour ago" are less helpful than "the symptoms started at 10 a.m.," says Beland.
"Eliciting this information from EMS or the family can be difficult for the triage nurse, and the story can change as new people are contacted," says Beland. "Once the timeline is clear, we know whether or not the patient will be eligible for treatment."
If the timeline is solid, and the patient is presenting within three hours, the most frequent reason patients are not treated usually is related to hypertension, says Beland. "Uncontrolled hypertension puts the patient at risk for intracerebral hemorrhage or hemorrhagic transformation after tPA is given," says Beland.
If the patient's blood pressure cannot be controlled with labetalol or intravenous nicardipine hydrochloride, the patient should not be given IV tPA, warns Beland. "We use a very concise checklist that covers all of the inclusion/exclusion criteria, including the CT exclusions, that the nurse can pull and start checking off, even before the CT scan is done," says Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain & Spine Center at Brackenridge Hospital in Austin, TX. (See the ED's checklist with standing orders for thrombolytics.)
Take these steps before giving tPA, says McIntyre:
- Repeat vital signs to be sure the systolic blood pressure is less than 185 and the diastolic blood pressure is less than 110.
- Check lab values for these contraindications: Platelets less than 100,000, partial thromboplastin time greater than 40 seconds after heparin use, prothrombin time greater than 15, or international normalized ratio greater than 1.7.
- Assess the patency of the IV, and closely monitor the IV site while tPA is infusing.
- Do not perform any invasive procedure for 24 hours once tPA is given.
- Do not place urinary catheters, nasogastric tubes, or IVs unless absolutely necessary.
"If there is any lag time at all, such as waiting for a CT scanner to open or waiting for CT results, a second IV or Foley catheter could be placed after checking with the physician," says McIntyre.