New acute approach alters triage, assessment
New acute approach alters triage, assessment
Sharpen skills to keep abreast of changing era
The next stroke patient who arrives at your emergency department (ED) has a better chance of complete recovery than his or her parent or even older sibling, thanks to new time-sensitive interventions. The treatment of stroke patients has undergone a complete turnaround in recent months, and cardiovascular nurses are now administering acute time-dependent interventions. It may be time to reevaluate these skills:
• Triage.
The triage nurse needs to ask in-depth questions to determine the onset time of symptoms. "When someone comes in complaining of a focal deficit, we need to find out if it’s acute or if it’s been going on for a day or so," explains Patti Bratina, RN, BSN, clinical research coordinator for the stroke treatment team at the University of Texas in Houston. "Instead of asking when the symptoms started, a better question to ask is, When was the last time you felt totally normal?’"
Some patients will respond that the last time they felt normal was before going to sleep. "Most of the time, those patients won’t be eligible for treatment, but that isn’t always the case," notes Bratina. It’s not uncommon for patients to take naps in the middle of the day, wake up with stroke symptoms, and still be within the time limit for treatment, she says.
• Continual assessment of blood pressure.
A patient may be ineligible for treatment if his or her blood pressure is too high. Blood pressure must be assessed repeatedly. It’s critical for good decision making, says Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of neurology at University Hospital, University of Cincinnati Medical Center.
• Awake neurological exams.
Previously, most acute-driven care was done for patients who weren’t awake. "Nurses need to beef up their awake neurologic assessment skills," stresses Spilker.
Using the Glasgow Coma Scale is not an effective way to assess a stroke patient, emphasizes Laura R. Sauerbeck, RN, BSN, CEN, clinical research coordinator for the Greater Cincinnati/Northern Kentucky Stroke Team in Cincinnati. "That is basically a trauma or coma scale and doesn’t measure deficits in an awake neurologic patient," she says. "For most stroke patients, unless speech is affected, we’ll get a score of 15, which nowhere near demonstrates the severity of their deficit."
The 11-item Stroke Scale, developed by the National Institutes of Health for awake neurologic assessment of stroke patients, is more accurate and gives you a snapshot of what the patient is doing at that time. The concise user-friendly version can be done in five minutes. "It’s great to have it pre- and post-thrombolytics," says Sauerbeck, "because sometimes 10 minutes into the infusion, [patients] who were totally flaccid on one side are moving their arms and talking clearly, and you can document that change."
(Editor’s note: You can print out this scale from the Internet at http://nshade.uah.ualberta.ca/synapse/ 00090000.html or at http://www.vh.org/Providers/ ClinGuide/Stroke/Question.html.)
• Recognition of symptoms.
Because the window for treatment is just three hours, you must determine rapidly if a patient has symptoms of stroke, as opposed to those of a hypoglycemic attack, heart attack, or Todd’s paralysis, recommends Karen Rapp, RN, BSN, CCRN, clinical coordinator of the University of California-San Diego Stroke Center.
• Pre-ordering of tests.
Tests should be ordered in advance of the patient’s arrival at the ED to speed the process. Having a pathway in place legitimizes this practice, says Sauerbeck. "If the medical staff has a standardized protocol in place for treating stroke patients, then nurses can pre-order before the doctor gets into the room," she explains. "The sooner the nurse gets CT notified, the better the patient’s chance to be eligible to receive thrombolytic therapy."
• Patient education.
A telephone survey of patients conducted at the University of Cincinnati Medical Center revealed that considerable education is needed to increase the public’s awareness of stroke symptoms.1 Of 1,880 respondents, more than 25% couldn’t name a single warning sign of a stoke. Elderly people, who are at highest risk for stroke, were most likely to be unable to name a single warning sign.
Patients should be told to come to the ED immediately if they perceive any symptoms of a stroke.
Reference
1. Pancioli A, Broderick J, Kothari R, et al. Public perception of stroke warning signs and potential risk factors. Stroke 1997; 28:1,236.
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