So now we're going to look
at an acute stroke.
What happens to a patient in
the first 24 hours,
and what our role is, as nurses,
that we play in that care?
Okay. So, now, you're the nurse. So you're the
ER nurse who receives report
from the paramedics for
an incoming patient. This is what the
paramedics would tell you.
"Mr. Johnson, 67-year-old male who was
brought into the Trauma Emergency
Center by the ambulance at 9:30.
Mr. Johnson's wife called 911 this
morning because her husband
suddenly became confused. His speech
was very difficult to understand.
His mouth was uneven. He also had
extreme difficulty moving his
right arm and right leg."
Okay. Got that? We've got a really quick
report from what's going on from the
paramedics. Now they're going to continue.
"Mrs. Johnson indicated the
symptoms started at 8:15."
Hey, that's important. So as we're
going along, write yourself a note
because when nurses are receiving report,
that's what you want to do is to be taking
notes on what they tell you.
So, hopefully, you have some paper really
close to you. You can write down
key points as we're going along.
That's what nurses do.
"Mrs. Johnson indicated that
the symptoms started at
8:15 this morning. She called 911 at 8:30.
His last vitals at 9:20 were
atrial fibrillation with a heart rate of 122.
Blood pressure 194/98. Respiration's 24.
Pulse ox 96% on 2 liters nasal cannula,
temp 37.8°C or 100.1°F.
Right-sided weakness of arm
and leg continue." Okay.
Now, as the nurse, you've got
all these things listed out.
And as an ER nurse as you're
receiving all this information,
you're already categorizing as normal,
abnormal, normal, abnormal, high or low.
So, as you become accustomed
to receiving report,
you'll be able to do that in your
head, too. For now, keep
writing these things down and thinking
them through at your own pace.
So if you want a second to pause
the video to take a breath,
that's perfectly fine for you to do that.
Then when we come back,
we'll talk about the immediate
Okay. Whether you took a break or not,
let's take a look at the immediate
nursing priorities. As an ER nurse,
when you receive a patient like this,
what are the most important
things that you're going to do? First of
all, we're going to do a safe
transfer of Mr. Johnson from
the ambulance gurney
and the monitors of the ambulance to
the Trauma Emergency Center
bed and monitors. So that's going
to be all hands-on deck.
Depending on how heavy Mr. Johnson
is and who we have available,
that's going to take multiple staff
people to transfer him from
the gurney and their monitors
to your monitors in the ER
and your bed. First up, yeah, I know.
You already knew this one;
ABC. No matter what the patient,
no matter what the diagnosis,
your job is to maintain
airway, breathing, and circulation.
Now, that includes vital signs, so
temperature, pulse, respirations, pulse ox,
cardiac rhythm, and blood pressure.
You're going to make sure that what you're
observing and your first assessment
matches what you just heard in report.
Now, patient status changes all the time.
So, you just want to line up
so there's agreement. "Hey, you guys told me
they were an atrial fib. Now they look like
sinus tach." You exchange information
with the ambulance
paramedics or EMTs at the bedside.
So, while you're standing
at the bedside, you want to get additional
bedside report with the paramedics.
As you're quickly assessing Mr. Johnson,
from head to toe, there's likely going to
be some other questions that
come up for you. And you can
ask the EMT paramedics
right then. Another key point
is to verify the
onset of symptoms time. Now,
we got that in report.
If you don't have that written down, pause
the video, go back and look up that
time, so you have the actual time they
think that the symptoms started.
Now your next priority is to
do an initial assessment,
a real one, from head to toe,
and then you'll be collaborating
with the healthcare provider
in the Trauma Emergency Center. Now you'll
see us use those words back and forth;
emergency room, Trauma Emergency Center.
Different hospitals give them different names.
But let's roll through that. Mr. Johnson
just rolled through your door, right?
He didn't stop at triage because he
came in on an ambulance. So
he came right in, we have a bed for him.
First, we safely get him transferred to
our monitor, our oxygen, our bed.
We make sure ABCs or in order.
We get some vitals.
We get more information from the EMTs and
the paramedics. Now what we're going to do
is do our initial assessment, so we can
give the healthcare provider
their own report. So let's walk through
it. Airway and breathing.
Now, some people may require intubation
and mechanical ventilation
with a stroke. Mr. Johnson doesn't,
but I want you to be aware of that.
And paramedics in the field
can intubate patients.
Now that word, in case you're not familiar
with it, is when you have to put a tube
down into the airway, so in the
mouth, down into the airway,
that gives us really good opportunity
to get oxygen right
down into the lungs, and we
hook them to a ventilator
that will help the patient breathe. Again,
Mr. Johnson didn't need that,
but some patients with a significant
stroke really might.
Now we're going to try and keep their
O2 sat about 94% or higher.
That will be different depending
on the patient's comorbidities
and what the trauma physician
wants. So, you'll work with
those orders or the parameters
at your hospital,
but we're going to use 94% as a reference now.
So, your job is to protect that patient
from risk of aspiration.
Swallowing can be very difficult
and a suspected stroke or a
TIA or after an actual stroke. So
we're not going to give him anything by
mouth. NPO means nothing by mouth,
till we can have some type of swallowing
eval and you have a chance to
assess that patient. Now, it doesn't mean
speech therapy is going to come in and do a
swallowing eval in ER, but you
are going to be holed back
on ice chips and everything else
until you know for sure
what the status is going to be.