Our job just, like we talked about,
I need to be sure as a nurse
before I give this medication that he
doesn't have any contraindications
for this medication. Now, the
most efficient way to
do that is for the healthcare
provider and you
to be in the room at the same time
when you ask the family and the
patient all of these questions. You want
to make sure that we're within the
time window to give that treatment.
You want to start 2 large bores,
that's the gauge of the IV, 2 big IVs.
Now, the reason you want to start
those first is because he's
going to really be a bleeder
after getting the alteplase
for the tPA. So you want to make sure
that you don't have to stick him
after he's gotten the tPA.
Make sure that his weight is accurate.
You need to weigh the patient.
Don't just go with what they say,
"Yeah, I weigh about this," because
usually certain genders don't know their
weight, and other genders don't
tell the truth about their weight.
So weigh the patient if you can.
So complete the weight-based dosage
calculations for alteplase. Now,
you'll do this and you'll double check,
triple check your work with
pharmacy and with a peer to make
sure that you have that accurate.
So, if the NG or Foley are required,
you can put those in before
because you don't want to do anything
that could risk bleeding. So,
we don't routinely put in an NG
or a Foley for a stroke
because it risks infection, but if you
know you're going to need it,
you do that before you do the alteplase,
if you can get it in quickly enough.
So let's think through some more
questions. I know we've
paused and looked at some things, but I want
you to be very clear on this. See, this is
the fun way to study. Now, you have a
picture of Mr. Johnson in your head.
So when you're taking an exam, you just
think about the things that we did with him.
So, without looking at your notes, see
if you can answer these questions.
And if I were you, pause after each one so
you have time to really think it through.
Okay. So, what are some examples of risk
factors that would have ruled out Mr. Johnson
to receive alteplase therapy?
Okay. Welcome back. Hopefully, you
were able to recall several risk factors.
Also, think about it in 1 big category.
The risks for receiving alteplase or
being a risk to bleed, and then you
can pretty much fill in the
blanks from there, right? So
don't memorize a list,
memorize the main problem, the
concept. Alteplase, a thrombolytic.
Anything that puts him at risk
to be a bleeder,
that's what is going to be your
contra-indication for receiving it.
So, what is the worst-case scenario for
Mr. Johnson after receiving alteplase?
kay, right. The worst-case scenario
for Mr. Johnson after
alteplase, since it's a thrombolytic,
is excessive hemorrhaging.
I'm really going to be worried about if
it happens in his head, but it's not
going to be that fun if it happens
anywhere else in his body, too.
Okay. So, let's walk through how you do
dosage calculation. Here's the healthcare
provider's order, and this is
how TPA is usually given.
The total dose of alteplase is
0.9 mg/kg of body weight IV.
Now, they want you to give 10% of the
dose as a bolus, and the remainder of the 0.9
mg/kg per body weight dose over 1 hour.
Okay. When it's your first time to give this,
you'll absolutely want someone to walk
you through it. But I don't care if it's
the 900th time that you've given it,
you always, always double check
and triple check a very specific
medication like this with a peer, and I
would do it with a Pharm.D, just to be sure.
Okay. So, let's say, Mr. Johnson
weighs 170 pounds.
We know that because we weighed him.
We didn't take any patient report
for this drug. It's critical. We weighed him
so we know that it's an accurate weight.
Well, the order says 0.9 mg/kg
of body weight. That's the total dose.
So in order to get kilograms, 170
divided by 2.2 is 77.1. Now, before we go on,
pause, and I want you to figure
out what the total dose is.
Okay. The total dose is 0.9 mg/kg.
So we've got 0.9 times 77.11 kg.
That gives us 69.39 mg.
That is our total dose. So be really careful
because we know the next order
says, give 10% of the dose
as a bolus. So, now, pause the video, and figure
out what 10% of the total dose would be.
Right. That's just moving a decimal
point, but 10% equals
0.10 times 69.39,
that gives us 6.939 mg as a bolus.
Now, bolus just means,
boom. You give it. Okay, we don't
have to give that slowly.
So we're going to give that bolus to get
that first bang, then there should be 90%
of the dose left. So, 69.39 minus the 10%
gives us 62.451, and I want to
give that over an hour.
All right. So, probably give that on
an IV piggyback and watch that
very, very closely. But just to be sure,
I'm going to go back and add 62.451
plus 6.939 and make sure that that
adds up to the total dose.
You pause the video and
do that math yourself.
Okay. We have verified the dosage.
We know exactly what we're going to do.
Now, we've given the medication, we've
watched him through the entire
process, so all the alteplase is in.
Now your job is just about done, but you
have one more critically important piece.
Because of what's going on with Mr. Johnson,
we don't just discharge him home.
All the patients who get alteplase for an
ischemic stroke should be admitted to an
intensive care unit because they need
really close neurological and
cardiac monitoring. So your job
now is to pass on care
to an ICU nurse. So you're going to start
to prepare a new SBAR for giving report
to the ICU nurse about Mr. Johnson. Okay,
you already know how to do SBAR
because you already did one to
speak to the health care provider.
Now what I want you to do is to pause
the video and think through
everything that's gone on from the
time Mr. Johnson came into ER,
the report you got then before ER, till
now. What are you going to tell that
ICU nurse: the situation, the
background, the assessment,
and if you have a recommendation for
the nurse that you're transferring care
to might be what you think specifically
they need to keep a close eye on.
Okay. Welcome back. I know that can
feel a little bit awkward or sometimes
people are hesitant to do that.
I hate role play,
but it actually is a very effective way
to learn. So if you haven't tried
to write out your assessment yet, please
pause the video now and go back and do it.
If you have already completed it, I
will supply you right here with
just some ideas of specific information
from Mr. Johnson's case that should
be included when you give report.
Now, don't get frustrated with this
or down on yourself.
I just want you to have some examples of
how you can take the information of a whole
ER visit, put it in a succinct
report that will give your
colleague in ICU the information that they
need. So compare the suggested example
to what you created, and then you can look
for ways that you can improve your ability
to give a clear, succinct, concise, and
objective report to your colleague.