Alteplase: Nursing Priorities and Dosage Calculation – Stroke Nursing Care in ER

by Rhonda Lawes

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    00:01 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.

    00:28 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.

    00:40 Make sure that his weight is accurate. You need to weigh the patient.

    00:45 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.

    00:57 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.

    01:09 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.

    01:29 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.

    01:42 So when you're taking an exam, you just think about the things that we did with him.

    01:47 So, without looking at your notes, see if you can answer these questions.

    01:51 And if I were you, pause after each one so you have time to really think it through.

    01:56 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.

    02:13 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.

    02:28 Anything that puts him at risk to be a bleeder, that's what is going to be your contra-indication for receiving it.

    02:34 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.

    02:53 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.

    03:00 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.

    03:07 The total dose of alteplase is 0.9 mg/kg of body weight IV.

    03:16 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.

    03:27 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.

    03:47 Okay. So, let's say, Mr. Johnson weighs 170 pounds.

    03:52 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.

    04:01 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.

    04:26 Okay. The total dose is 0.9 mg/kg.

    04:31 So we've got 0.9 times 77.11 kg.

    04:36 That gives us 69.39 mg.

    04:41 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.

    04:59 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.

    05:16 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.

    05:32 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.

    05:49 You pause the video and do that math yourself.

    05:55 Okay. We have verified the dosage. We know exactly what we're going to do.

    06:00 Now, we've given the medication, we've watched him through the entire process, so all the alteplase is in.

    06:07 Now your job is just about done, but you have one more critically important piece.

    06:13 Because of what's going on with Mr. Johnson, we don't just discharge him home.

    06:16 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.

    06:43 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.

    07:15 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.

    07:34 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.

    07:45 Now, don't get frustrated with this or down on yourself.

    07:48 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 o give a clear, succinct, concise, and objective report to your colleague.

    About the Lecture

    The lecture Alteplase: Nursing Priorities and Dosage Calculation – Stroke Nursing Care in ER by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient.

    Included Quiz Questions

    1. Mr. Johnson will bleed a lot after the tPA, so starting the IVs beforehand will cause less trauma to the area.
    2. Mr. Johnson will probably need blood after the tPA, so two access points will make this intervention faster.
    3. Mr. Johnson will likely need vasopressors after the tPA, so starting a second IV will help speed the process along.
    4. Mr. Johnson will need fluids after the therapy, so a second large-bore IV helps get fluid in at a faster rate.
    1. 0.9 mg/kg with 10% as a bolus and 90% as an hour infusion
    2. 0.9 mcg/kg with 10% as a bolus and 90% as an hour infusion
    3. 0.9 g/kg with 10% as a bolus and 90% as an hour infusion
    4. 1.0 mg/kg with 10% as a bolus and 90% as an hour infusion
    1. 62.451
    2. 69.5 mg
    3. 70 mg
    4. 6.939 mg
    1. Situation, background, assessment, and recommendations
    2. Scenario, background, alteplase dosing, and recommendations
    3. Situation, background, assessment, and resources used
    4. Situation, body weight, alteplase dosing, and recommendations

    Author of lecture Alteplase: Nursing Priorities and Dosage Calculation – Stroke Nursing Care in ER

     Rhonda Lawes

    Rhonda Lawes

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