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Immediate Nursing Priorities– Stroke Nursing Care in ICU

by Rhonda Lawes

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    00:01 Here we are. Mr. Johnson has arrived with the ER nurse, that's the nurse represented here in the black scrubs. Now we've got the ICU nurse who that's the role that I want you to see yourself in, in this part of the case study. So, our priorities.

    00:15 Let's talk about what do you do when you're an ICU nurse and you receive a patient from ER? Well, one of the first things you want to do is make sure you safely transfer Mr. Johnson from the TEC, the trauma emergency, gurney and their monitors to the intensive care unit bed and your monitors. So, you can transfer it from the gurney to your bed and get them on the monitors. Now, this is one of my favorite parts of teamwork of working in critical care, and that's where I hung out mostly.

    00:44 That you have, when a new admit comes in, when you work with a good team, people descend, and everyone will help you get Mr. Johnson safely settled on the monitor, transfer his oxygen over, and get him all set up.

    00:57 Now, you're still prioritizing A, B, and C.

    01:02 So, you want to make sure that you get a set of vitals on him, you're noting his cardiac rhythm, and you're looking at his blood pressure.

    01:08 Most critical care nurses can just look at the monitor and see what the rhythm is.

    01:13 But eventually, you'll print out a strip or look at it in the electronic record and measure things to make sure you have a clear picture of exactly what the rhythm is. Now, the concept here that's most important is continuity of care.

    01:26 Right now, the professional who knows the most about Mr. Johnson is the ER nurse. So it's the ER nurse's job and their role to clearly, concisely communicate the most important points of the care that was provided for Mr. Johnson in ER. So, the ER nurse will give the situation, the background, and all the assessment information, including the procedures that Mr. Johnson experienced downstairs.

    01:52 Remember, he had a CAT scan, he got thrombolytics, and this is the time where the ICU nurse can receive the information, also see Mr. Johnson, verify any questions that they have in a bedside report. So, hopefully, you get that opportunity with a TEC nurse to do a a bedside report, verify the neuro assessment, make sure this looks similar to what it was when he left ER. Look at IVs and rates, any of those things, and discuss are there any of the physician's orders that have already been completed? Because when a patient transfers from 1 unit to the other, sometimes some of the orders are done in that unit before they come.

    02:29 Sometimes they're not. That's why it takes the 2 nurses iscussing with each other, so it's very clear what has been completed, and what's left to do.

    02:40 Now, as the ICU nurse, after the ER nurse has left and you have exchanged information, you'll do an initial assessment head to toe.

    02:48 You look at the healthcare provider's orders, and you'll start prioritizing care for this shift. Okay, so, what were your immediate nursing priorities? Picture in your mind Mr. Johnson comes in, safe transfer to your bed, your monitors, your oxygen, making sure he's stable A, B and C.

    03:07 Ensuring continuity of care by getting a specific report and asking any questions that you have with the ER nurse, verifying IV rates, etc., then doing your initial assessment, looking at the healthcare provider orders, and prioritizing your care for this shift.

    03:23 Now, I want you to know that the ICU admit vital signs, just jot these down.

    03:28 For Mr. Johnson, he still remains in atrial fib. Now, a lot of times, we just write that as AFib, and that means atrial fibrillation.

    03:37 He's got a rate of 108, which really isn't that bad for atrial fibrillation.

    03:43 His blood pressure is 172/88.

    03:47 Whoa, usually, we'd be a little excited about that, but we're not so concerned, because we know it's okay to leave that blood pressure elevated because he has an ischemic stroke. We'll talk a little bit more about that later on.

    03:59 His respirations are 20, that's normal. His pulse ox is 97% on 2 liters, nasal cannula. Well, you know, the order said to keep it at 94% or above, so we're great there, and his temperature is 99.9°F.

    04:14 That's a little bit up, but he's been through lots of things, so we'll just keep an eye on that. But make sure you have those written down. Let me say it 1 more time.

    04:23 Atrial fib, heart rate of 108, blood pressure, 172/88, respiration's 20.

    04:32 Pulse ox, 97% on 2 liters nasal cannula, and we usually write that as NC.

    04:39 And his temperature is 99.9°F. Okay. So you've got those written down.

    04:47 e're looking at the orders. We're figuring out what are the top priorities.


    About the Lecture

    The lecture Immediate Nursing Priorities– Stroke Nursing Care in ICU by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient.


    Included Quiz Questions

    1. Assessment of ABCs
    2. Complete neurological assessment
    3. Obtaining report at the bedside
    4. Calling the health care provider for establishment of care
    1. By completing report at the client's bedside
    2. By completing report at the main nurses station
    3. By completing report over the phone
    4. By referring to the electronic health record for handoff report

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

     Rhonda Lawes

    Rhonda Lawes


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