Your 'normal-looking' patient just might be having a TIA

Most strokes occur within 24 hours

If a patient tells you they felt a little funny a few hours ago but feel absolutely fine now, would you be inclined to discharge them home? Or would you assess them for a possible transient ischemic attack (TIA)?

Your TIA patient's symptoms might have been subtle to begin with and might have disappeared altogether by the time they reach the ED. But in fact, a patient with a possible TIA is a major opportunity for ED nurses.

"TIAs are medical emergencies. Recognizing, evaluating, and treating a TIA can reduce the risk of stroke," says Dana Stradling, RN, BSN, CCRN, manager of the Stroke and Cerebrovascular Center at University of California — Irvine. "In a sense, they are lottery ticket winners. They are coming to the ED before an actual stroke has occurred."

Research shows that almost half of strokes occurring after TIAs happen within 24 hours, which gives added urgency to the ED nursing assessment.1

Bernadette E. Cale, RN, BSN, CEN, supervisor of patient care emergency services at Scripps Memorial Hospital La Jolla (CA), says any of that these common TIA symptoms could be overlooked by a busy ED nurse: brief episodes of loss of one's thought, unable to express words, dizziness, weakness, and syncopal episodes. "Sometimes patients will present to the ED and feel fine after being forced to come in by a family member because they just were not feeling right," says Cale. "A patient may even present with nausea and vomiting. Their symptoms most likely have resolved."

At triage, Cale says to ask these questions: When did the patient's symptoms start? How often is the patient experiencing symptoms? Does the patient remember what happened? Is the patient oriented at the time of triage? Does the patient have a history of diabetes mellitus, hypertension, TIA, or other neurological or cardiac issues?

If you suspect TIA, Cale says these interventions should be done:

  • Perform a neurological assessment and continuous follow-up assessments.
  • Document any changes or recurring symptoms.
  • Check blood sugar, and continuously monitor vital signs.
  • Place the patient on a cardiac monitor.
  • Treat symptoms such as blood sugar, high blood pressure, nausea, and vomiting.

Jeanne Leighton, RN, CEN, department head of the ED at Eastern Maine Medical Center in Bangor, says TIA patients might present "just feeling episodically different," and might tell you they think it's due to a change in their medication regime. "They may have an intermittent change in gait or strength in their arms or legs," Leighton says. "Or while eating, food may have seemed to spill from the side of their mouth briefly." [The protocol used by ED nurses for patients with stroke symptoms is included. For assistance, contact customer service at (800) 688-2421 or customerservice@ahcmedia.com.]

Reference

  1. Chandratheva A, Mehta Z, Geraghty OC, et al. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009; 72:1,941-1,947.

Sources

For more information on improving care of patients with transient ischemic attack, contact:

  • Lauren Brandt, RN, MSN, CNS, Director, Neurosciences, Brain & Spine Center, Brackenridge Hospital, Austin, TX. Phone: (512) 324-7782. E-mail: LBrandt@seton.org.
  • Bernadette E. Cale, RN, BSN, CEN, Emergency Services, Scripps Memorial Hospital La Jolla (CA) E-mail: cale.bernadette@scrippshealth.org.
  • Julia Ferrari, MD. E-mail: julia.ferrari@bbwien.at.
  • Jeanne Leighton, RN, CEN, Emergency Department, Eastern Maine Medical Center, Bangor. Phone: (207) 973-9547. E-mail: jleighton@emh.org.
  • Dana Stradling, RN, BSN, CCRN, Stroke and Cerebrovascular Center, University of California -- Irvine, Phone: (714) 456-2343. E-mail: dstradli@uci.edu.

 

What baseline and follow-up exams tell you

Where is the right place for you to be when caring for a patient with a possible transient ischemic attack? Right at the bedside, doing follow-up neurological examinations as needed, says Bernadette E. Cale, RN, BSN, CEN, supervisor of patient care emergency services at Scripps Memorial Hospital La Jolla (CA).

Cale recently cared for a woman whose hand felt a little numb earlier in the day and had trouble speaking, but now felt fine. During the ED nursing initial assessment, she was alert and oriented to person, place, time, and circumstance, and had clear speech and strong, equal grasps. A neurological assessment was performed and findings were normal, but blood work and a head CT were ordered based on what had occurred previously.

"About an hour into her treatment phase, the husband came and grabbed the ED nurse because the patient was unable to express what she was thinking," says Cale. "She still had strong grasps, equal pupils, and was able to nod her head yes or no, but the patient could not get words out."

The ED physician immediately was called to witness her symptoms, but as he arrived to the bed they had resolved. However, in this case, the patient was able to verbalize what had just happened and was admitted to the hospital.

Continuous exams

"Due to the variability and different times the patient had symptoms, it was important to be at the bedside" to perform continuous neurological examinations and report these findings to the ED physician, says Cale. If the patient was by herself and the ED nurse failed to do follow exams continuously, the symptoms could have been missed or misinterpreted, says Cale.

First, establish the patient's normal baseline of function, such as walking with a limp. This step should be done by talking not just to the patient, but also a family member, caregiver, or friend. Jeanne Leighton, RN, CEN, department head of the ED at Eastern Maine Medical Center in Bangor, says, "They may well notice a difference in the patient's presentation or activity that the patient may think is a fleeting aberrancy."

You'll also need to do a baseline dysphagia screen, she says. "With the baseline status established, it will be much easier to pick up on subtle increase of the patient's symptoms," says Leighton. [The dysphagia screening tool used by ED nurses for patients with stroke symptoms is included. For assistance, contact customer service at (800) 688-2421 or customerservice@ahcmedia.com.]


Which TIA patients have highest stroke risk?

Of 8,291 patients presenting with a transient ischemic attack (TIA) or minor ischemic stroke, defined as a National Institutes of Health Stroke Scale score under four, 374 experienced early clinical worsening, says a new study.1 The researchers used data from the Austrian Stroke Unit Registry for the years 2003 through 2008.

Some patients were found to be at higher risk, including those with diabetes, hypertension, acute infection, and cardiac decompensation. "The implications and possible clinical changes for emergency nurses are to pay full attention to early detection of acute infections like a urinary tract infection, pneumonia, or other septic conditions, as well as cardiac decompensation, in these patients," says Julia Ferrari, MD, the study's lead author.

The study's findings emphasize the need for TIA patients to be closely monitored, says Lauren Brandt, RN, MSN, CNS, director of neurosciences at the Brain & Spine Center, Brackenridge Hospital in Austin, TX. "The use of a standardized protocol or checklist is necessary to identify the high risk patients," says Brandt. "Consistency in diagnostic and clinical evaluation is a must, to prevent sending someone out when their risk of completing a stroke is high."

Reference

  1. Ferrari J, Knoflach M, Kiechl S, et al. Early clinical worsening in patients with TIA or minor stroke. Neurology 2010; 74:136-141.