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Immediate Nursing Priorities – Stroke Nursing Care in ER

by Rhonda Lawes

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    00:00 So now we're going to look at an acute stroke.

    00:02 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.

    00:21 "Mr. Johnson, 67-year-old male who was brought into the Trauma Emergency Center by the ambulance at 9:30.

    00:27 Mr. Johnson's wife called 911 this morning because her husband suddenly became confused. His speech was very difficult to understand.

    00:33 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.

    00:46 "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.

    01:01 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.

    01:09 "Mrs. Johnson indicated that the symptoms started at 8:15 this morning. She called 911 at 8:30.

    01:16 His last vitals at 9:20 were atrial fibrillation with a heart rate of 122.

    01:22 Blood pressure 194/98. Respiration's 24.

    01:27 Pulse ox 96% on 2 liters nasal cannula, temp 37.8°C or 100.1°F.

    01:36 Right-sided weakness of arm and leg continue." Okay.

    01:41 Now, as the nurse, you've got all these things listed out.

    01:45 And as an ER nurse as you're receiving all this information, you're already categorizing as normal, abnormal, normal, abnormal, high or low.

    01:53 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.

    02:04 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 nursing parties.

    02:18 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.

    02:44 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.

    03:16 You're going to make sure that what you're observing and your first assessment matches what you just heard in report.

    03:23 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.

    03:44 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.

    04:01 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.

    04:12 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.

    04:30 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.

    04:46 We make sure ABCs or in order. We get some vitals.

    04:50 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.

    05:02 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.

    05:11 And paramedics in the field can intubate patients.

    05:15 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.

    05:37 Now we're going to try and keep their O2 sat about 94% or higher.

    05:42 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.

    05:55 So, your job is to protect that patient from risk of aspiration.

    05:59 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.


    About the Lecture

    The lecture Immediate Nursing Priorities – Stroke Nursing Care in ER by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient. It contains the following chapters:

    • Immediate Nursing Priorities
    • Airway and Breathing

    Included Quiz Questions

    1. The first 24 hours after a stroke
    2. A stroke that a client has never had before
    3. A stroke that has a completely different treatment plan than a chronic stroke
    4. The first few hours leading up to a stroke
    1. Time that the client was last seen acting like normal
    2. Time that the emergency medical services was called
    3. Time that the family noticed the client was not acting like normal
    4. Time that the paramedics arrived at the ER with the client
    1. As the vital signs are read off, the nurse should be thinking, "Are these normal, abnormal, high, or low?"
    2. The nurse does not need to know prior vital signs because client status changes so much.
    3. EMS will give a new set of vital signs when they arrive and report those to the nurse.
    4. Vital signs during an acute stroke do not matter as much because the nurse only needs to pay close attention to the neurological symptoms.

    Author of lecture Immediate Nursing Priorities – Stroke Nursing Care in ER

     Rhonda Lawes

    Rhonda Lawes


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