Cut delays by taking these actions for stroke

Even with the possibility of a 4½-hour window for treatment of stroke patients, you should always act with a sense of urgency, stresses Stacey Claus, RN, BSN, CNRN, clinical instructor for the Department of Nursing at Cleveland Clinic.

"Time is brain, and efforts to treat stroke quickly should continue to be our standard of care," Claus says. To cut delays, take these actions:

• Before the patient arrives, prepare the room and stretcher.

A travel monitor, intravenous (IV) equipment, blood tubes, lab slips, and paperwork should await the patient, says Joyce McIntyre, RN, MSN, clinical nurse specialist for the ED at Massachusetts General Hospital in Boston.

"An oxygen tank and large-volume pump can be placed on the stretcher just in case oxygen is needed or tPA [tissue plasminogen activator] is to be administered," she adds.

• If oxygen is needed, hook the nasal cannula directly to the portable tank and not to the gasses on the head wall.

"Oxygen is needed if a patient's room air oxygen saturation level is less than 92%," says McIntyre.

• Place alteplase in the room, and bring it to the CT scanner.

"This reduces valuable time once the decision has been made to administer tPA," says McIntyre. "Every second counts. With every second, brain cells become damaged and die."

• Expedite transport to the CT scanner.

Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain & Spine Center at Brackenridge Hospital in Austin, TX, says, "Acting as a patient advocate and getting them to the CT scanner timely is very important. Without that vital piece of information, treatment can be delayed."

• Place an 18-gauge IV in the patient's right antecubital vein, regardless of which side the patient has symptoms.

McIntyre says, "Placing an IV in the right arm promotes IV dye to travel to the brain; whereas, if the IV is placed in the left arm, the heart takes up the dye first. Thus, less dye gets to the brain."

• While one nurse is placing an IV in the right arm, have a second nurse on the patient's left side obtaining a finger stick to check the patient's glucose level.

"Hypoglycemia can mimic a stroke, while hyperglycemia may be a contraindication for administering tPA," says McIntyre. Labs should be sent immediately, she says. "A known creatinine value is helpful in determining whether or not to go ahead with a CT angiography," McIntyre says.

• Do not give patients with stroke symptoms anything by mouth until a swallowing screen is performed and passed.

All medications should be given IV or rectally; ask physicians to rewrite any order that is to be given orally, says McIntyre.

• If possible, give the electrocardiogram (ECG) after the patient has had the CT scan and tPA has been administered.

"It is not absolutely necessary to get an ECG prior to the CT unless a patient is having acute coronary syndrome symptoms that should be immediately assessed," says McIntyre. "If a patient is complaining of chest pain, jaw pain, left arm pain, or shortness of breath, the ECG should be done before the patient goes to CT. If the patient does not have cardiac symptoms, CT should not be delayed to obtain an ECG."

• If a patient arrives with symptoms of a stroke and has a fever, administer an antipyretic.

"Each degree of Celsius elevation doubles the risk of poor outcome," says McIntyre.1

Reference

  1. Badjatia N. Therapeutic temperature modulation in neurocritical care. Curr Neurology Neuroscience Rep 2006; 6:509-517.