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

by Rhonda Lawes

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    00:01 Hi. Welcome to our video series on neurological disorders.

    00:05 Now, we're going to continue following Mr. Johnson.

    00:08 We're looking at the nursing care of a stroke patient, but now we're going to be in the Med-Surg unit. So, in this series, you've had the opportunity to be an ER nurse, an ICU nurse, and now you'll see the role of a Medical-Surgical nurse.

    00:21 We're going to transfer Mr. Johnson to the next level of care.

    00:24 We're going to make it a Med-Surge/telemetry unit.

    00:28 Now, I want you to practice using the SBAR method for organizing your information to give report about Mr. Johnson. If you've already been the ICU nurse, you should have that ready to go. If not, we'll give you the opportunity to practice SBAR later on in the video series.

    00:43 Remember, SBAR is situation, background, assessment, and recommendation. Now, I also want you to practice receiving an abbreviated report from the ICU nurse, writing down the information that you feel is most important.

    00:57 I'll help guide you to identify that after you're done.

    01:01 So, write your notes about report in your downloadable notes as you listen to report on Mr. Johnson.

    01:08 Okay. Let's look at the health care provider's initial orders.

    01:12 Usually, you'll receive these often before you receive the patient or they may come with the patient. Most hospitals are using electronic orders.

    01:21 Now, orders are written in a little bit different language. They're not always complete sentences, but they'll have specific information to help you know what the physician wants done, or the healthcare provider wants done for this patient. Well, first of all, you're going to see an admission order, so it will say something like you see on the screen: "Admit patient to telemetry Med-Surg unit for telemetry monitoring." So we know that's why Mr. Johnson is coming here because it's the monitoring that's important. "Oxygen at 2 liters per nasal cannula." So we know that he'll have a nasal cannula on. That's the tubing that you see with a little prongs that go in the patient's nose, go around their ears, and we'll have it at a rate of 2 liters.

    02:02 Now, the patient will come with transportable oxygen, they'll come with it on a tank, and then when we get them in the room, we'll need to take it off the portable tank, turn off the tank, and connect it to the oxygen that's likely located in the wall.

    02:14 Now we're going to keep monitoring his oxygen saturation. Remember, it's only been a couple days since Mr. Johnson had a stroke. We want to make sure that we keep him > 94%. The healthcare provider took the time to let us know, "Hey, monitor that sat and this is the mark, this is the target that I want you to maintain that sat at.

    02:34 " If he's dropping below 94% very often, we're going to need to really look at the next step and letting the healthcare provider know.

    02:42 Now, this is where Mr. Johnson is going to get lots of therapy.

    02:46 We're going to meet with all kinds of team members and this is where it gets really interesting because you get to work with other professional colleagues in specialties. So he's got orders for physical therapy, speech therapy, occupational therapy, and a registered dietician consult.

    03:02 ow, these inter-department professionals will come to the unit, to your floor, they'll meet Mr. Johnson, and they will assess him.

    03:10 And then they'll make some recommendations to the physician. They'll work together.

    03:14 The physician will read the recommendations and then he'll decide or how long or how often they want each one of these therapies.

    03:21 So, how often Mr. Johnson will get physical therapy, what they want from speech therapy, how often occupational therapy will come.

    03:28 So, speech therapy may do an eval and decide if they need to continue seeing the patient or not. Occupational therapy is the one that's going to help Mr. Johnson learn how to do the activities of daily living. They really help the quality of life. Physical therapy is going to keep him safe as in walking and as he -- can he transfer from the bed to the chair, and can he stand up and can he walk. So, the physician might write some very specific orders right from the beginning, or he might just ask for a consult, and then he'll work from there.

    04:01 Now, we've got specific orders on when the blood pressure is going to be monitored.

    04:06 So here it says, "Monitor blood pressure every 4 hours for the first 24 hours, then every 8 hours." The physician lets you know when she wants to be connected. Look, "Notify health care practitioner if blood pressure is above 180/105 mm Hg.

    04:22 " So, you know, this is what the goal is because they're new and just going through the transfer to another unit. At first, the physician wants the blood pressure every 4 hours, just for the first 24. Then once we hit that 24-hour mark, e can just take it once every 8 hours. Now it's really important for a stroke patient recovering and for all patients, try not to interrupt their sleep. So try to get that blood pressure right when you get on shift, so you have a good feel of what's going on for the patient and you don't disrupt their sleep if you're a night shift nurse.

    04:53 Okay. So, we know those parameters. Now it says, "Normal saline at 75 mL/hour until patient is cleared by speech therapy to take oral fluids.

    05:04 " This is because we don't want Mr. Johnson to get dehydrated, right? If he is dehydrated, he's going to have less volume in his intravascular space, and we really don't want his blood pressure to get too low. We want him to maintain a healthy blood pressure that's going to keep perfusing his brain well.

    05:22 Now, "Discontinue the saline if patient able to drink fluids." So, this is an example of one of those orders where you're not going to have to keep contacting the healthcare provider. What they've told you is, "Hey, once speech therapy comes and he can drink fluids, stop this IV," because we don't want to keep giving him extra fluids if he's able to take IV.

    05:40 And in the nursing world, and the NCLEX world, the goal is to keep the patient as independent as possible. So, do we want an IV or a patient drinking liquids? We would much prefer the patient be able to drink liquids, like normal.

    05:56 Okay. So, that's a few of the orders. We've got those initial orders and what we're going to be doing with the patient. They also would probably write specific medication orders and etc.

    06:05 So we didn't include those. We just want to give you some good general orders to get a feel for what it might look like when someone comes from an intensive care unit to a telemetry unit.

    About the Lecture

    The lecture Collaborating with HCP: Initial Orders – Stroke Nursing Care in ER by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient.

    Included Quiz Questions

    1. STAT noncontrast brain CT or MRI
    2. Finger-stick blood glucose
    3. Monitor troponin levels every 8 hours
    4. 12-lead ECG
    1. Prothrombin time
    2. Troponin
    3. CBC
    4. Creatinine
    5. Blood gas
    1. At or slightly below 180/105 mm Hg
    2. At or slightly above 120/80 mm Hg
    3. At or above 150/90 mm Hg
    4. At or slightly above 180/105 mm Hg

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

     Rhonda Lawes

    Rhonda Lawes

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