Okay. Now the physician has written
initial orders for your patient.
Now, if you practice doing SBAR, if it
felt awkward for you, that's okay.
It does for all of us when we start. 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. Doesn't need to be that way.
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. Now if you're
talking to a physician and they ask
you a question, and the doctor ask and
you say, you know, "I apologize,
I don't have that, but I will get it
for you," that's okay.
You just do your homework ahead of time.
Try to make sure you have your ducks
in a row, S, B, A, and R. So, here's the orders,
just like we thought. STAT non-contrast,
brain CT or MRI.
Finger stick blood glucose, monitor continuous
oxygen sat and titrate oxygen to
keep sat > 94%, and a 12 lead ECG.
Well, out of these 4 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's going to be a really good idea.
Finger stick blood glucose. That's
not a bad thing either, right,
because we want to rule out if he has
low blood sugar. Continuous sat.
Hey, we already got that covered, right?
We got him in, we got him on oxygen.
We already have that in there, so that's
essentially already done. 12-lead ECG.
You know, sometimes in ER, the nurses will
do that or have a tech that does that,
but we have him on a heart monitor, so
we already know that he's in atrial fib,
and nothing looked that weird to us.
So 3 and 4 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 3 of these,
but we're going to make sure we make
arrangements to get that patient to a
CAT scan or MRI, quickly. Now, we
probably have some time to do a
quick finger stick blood glucose. And
if there's a tech in the unit,
we wouldn't use them for this, 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, so it would be better
for the nurse to do that.
Now, that may or may not happen that
way in real life, but from an NCLEX
priority, that would be the role.
Okay. Let's talk about
possible lab work. We identified
what the priorities are,
but you can also have lab drawn quickly
as you're getting all this done.
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. Other things
that have to do with bleeding
would include prothrombin time, INR,
aPTT, which is an activated
partial thromboplastin time,
a direct factor Xa activity assay,
if he's been taking
a direct thrombin inhibitor. We'd
also want to look at troponin,
see if maybe something was going
on cardiac. 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.
Now he's going to need
close monitoring of his blood pressure.
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.
What? Yeah. See, here's the
problem with strokes.
We need to keep stroke blood pressures
if he is in fact having a stroke, 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,
but we've learned that you want to keep
a stroke patient's blood pressure
high, so that brain gets perfused. So you'll
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.
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.