Collaborating with HCP: Initial Orders – Stroke Nursing Care in ER

00:01 Okay, now the physician has written initial orders for your patient.

00:05 Now, if you practice doing SBAR if it felt awkward for you, that's okay.

00:10 It does for all of us when we start.

00:12 I remember when I first started, we had a particularly cranky surgeon, that when we had to call him, we would practice with each other, I would practice with my preceptor before I called the physician and I almost had to have someone hold my hand because I would just break out in a sweat, because I was so concerned about talking to him.

00:30 Doesn't need to be that way.

00:32 When you use a tool like SBAR, when you have everything in order that you think that patient might need, then you've done your best to give him the most important role.

00:42 Now, if you're talking to a physician, and they ask you a question, and the doctor asking you say, you know, I apologize, I don't have that, but I will get it for you.

00:49 That's okay.

00:50 You just do your homework ahead of time, try to make sure you have your ducks in a row, S-B-A, and R.

00:57 So here's the orders.

00:59 Just like we thought, STAT noncontrast brain CT or MRI.

01:03 Finger stick blood glucose, Monitor continuous oxygen SAT and titrate oxygen to keep SAT greater than 94%, and a 12 lead EKG.

01:13 Well, out of these four orders based on what you already know about Mr. Johnson's case, what are our priorities? Okay, well, when we're looking at the orders, we know that time is tissue so that CAT scan is going to be a really good idea.

01:31 Fingerstick blood glucose, that's not a bad thing, either, right? Because we want to rule out if he's has low blood sugar.

01:38 Continuous sat.

01:40 Hey, we already got that covered, right? We got him in, we got him on oxygen.

01:43 We already have that in there. So that's essentially already done.

01:46 12 lead EKG.

01:47 Now, sometimes an ER, the nurses will do that or have a tech that does that.

01:51 But we have him on a heart monitor, so we already know that he's in atrial fib, and nothing looked at that weird to us.

01:58 So three and four are already done Between the CAT scan or the MRI, which do you think is most important? We're actually going to focus on all three of these.

02:07 But we're going to make sure we make arrangements to get that patient to a CAT scan or MRI, quickly.

02:13 Now, we probably have some time to do a quick finger stick blood glucose.

02:17 And if there's a tech in the unit, we wouldn't use them for this.

02:22 We would want a nurse to do this in NCLEX world, because this is an initial assessment and there's a lot going on with the patient.

02:28 So it would be better for the nurse to do that.

02:31 Now, that may or may not happen that way in real life, but from an NCLEX priority, that would be the role.

02:36 Okay, let's talk about possible lab work.

02:39 We identified what the priorities are.

02:42 But you can also have lab drawn quickly as you're getting all this done.

02:46 So some of the things that may be considered if the patient is a possible thrombolytic patient, which Mr. Johnson might be, we don't know yet, because we haven't seen the results of that CAT scan or MRI, you can expect that the physician would want a CBC, because we're looking at platelets and see what's going on there.

03:03 Other things that have to do with bleeding would include prothrombin time, INR, APTT, which is an activated partial thromboplastin time.

03:14 A direct factor Xa activity assay, if he's been taking a direct thrombin inhibitor.

03:19 We'd also want to look at troponin, see if maybe something was going on cardiac.

03:24 So that's a lot of the possible lab work that might be drawn for a patient because remember, we're trying to rule out other possibilities.

03:32 Now, he's going to need close monitoring of his blood pressure.

03:35 So since he's brand new, we're not sure what's going on, we're going to monitor his blood pressure every 15 minutes to keep it below about 180/105.

03:44 What? Yeah. See, here's the problem with strokes.

03:51 We need to keep stroke blood pressures, if he is in fact having a stroke.

03:54 And since that's in the title of the case study, I know that you know that, but that diastolic is pretty high, isn't it? Normally, we'd be concerned.

04:04 But we've learned that you want to keep a stroke patient's blood pressure high, so that brain is perfused.

04:11 So you work with the healthcare provider and he or she will help you know the parameters that they want to keep that blood pressure at but just be prepared.

04:20 Patients with an acute stroke, we often want that blood pressure higher than we normally would on a regular med-surg unit, because we want to make sure the brain gets perfused.