When a 57-year-old man walked into the ED at North Broward Medical Center in Fort Lauderdale, FL, with slurred speech and left facial drooping, his wife told nurses that the symptoms had started about 30 minutes earlier. "We immediately assumed the worst case scenario: that it was a stroke," says Sharon S. Cohen, RN, MSN, CEN, CCRN, trauma clinical nurse specialist.
According to the ED’s stroke protocol, nurses immediately took steps to determine if the man was a candidate for thrombolytics. "We asked his wife if he was taking any anticoagulant medication; because if so, he wouldn’t qualify for treatment. We started IVs and checked his blood sugar at the bedside," Cohen says. "Within 10 minutes, we were ready to send him to CT [computed tomography] scan."
At that point, the patient’s blood sugar came back with a level of 33, far lower than the normal range of 80 to 100. "It turned out that he was a new-onset diabetic and had an acute glycemic reaction," says Cohen. "Once we fixed his blood sugar, all his symptoms subsided. He was able to tell us that he felt weak and dizzy but never had a headache." If nurses hadn’t intervened rapidly, the patient’s blood sugar would have kept dropping, and he could have gone into an irreversible coma, says Cohen.
Always do a quick check
Triage nurses at her facility always perform a quick assessment to check for any neurological deficits, says Cohen. "We do a basic neuro check for every patient who walks in the door, like taking vital signs," she says. This can identify life-threatening conditions that might otherwise go undetected, Cohen adds. (See the facility’s Emergency Department Record/Adult assessment form.)
Cognitive assessments usually reveal a change in neurologic function before physical signs such as pupil changes, adds Patricia Carroll, RN, BC, CEN, MS, former ED nurse at Manchester (CT) Memorial Hospital and founder of Educational Medical Consultants, a Meriden, CT-based consulting company specializing in educational programs for health care professionals.
You should add a "D" for disability caused by neurological deficits to the "A, B, C" tenets of airway, breathing, and circulation, recommends Cohen. Your goal is to determine if the patient is awake, alert, and oriented, says Cohen. "If not, you need to go back and figure out why," she says. Here are items to consider:
• Use the information to determine the accuracy of the history. Doing a quick neuro check’ allows you to assess if the information provided by the patient can be relied on to provide clinical care, says Cohen. "If the patient has delusions or goes off on tangents, you have to question his history and look for additional sources, or do a different style of workup," she explains.
• Check all patients with a history of trauma. These patients always should have regular neurological checks as long as they are in the ED, even if their initial assessments are perfectly normal, says Carroll. This includes motor vehicle crashes, falls, bicycle accidents, and assaults, she says.
In addition, patients at risk for neurologic impairment from conditions such as high blood pressure, cardiac dysrhythmias and myocardial infarction, electrolyte imbalances, and illnesses that can cause hypoxia should have an initial neurological assessment, says Carroll. Even if their initial assessment is normal, they should have follow-up assessments to determine if their underlying medical condition is affecting their neurologic status, she adds.
In overcrowded EDs that also face nursing shortages, it may not be practical to perform neuro checks on every patient, acknowledges Carroll. "Remember, in legal circles, your care will be held up to the standard of what another reasonably prudent’ nurse would have done in the same circumstances," she says.
To determine if a patient needs a neuro check, you need to consider mechanism of injury and pathophysiology of disease, says Carroll. She gives the example of a 30-year-old man who tells you he cut his hand when he accidentally grabbed the sharp edge of a dog food can to pull it off the magnet on the can opener. "If the location and nature of the laceration is consistent with his description of the mechanism of injury, a neuro examination is not essential," says Carroll. However, if his story does not match the injury you see, you smell alcohol on his breath, his speech is slurred, or he has an ataxic gait, you’ll need to do a more comprehensive neuro assessment, and follow up with repeat assessments to determine if any impairment is getting better or worsening, she says.
Differential diagnosis is huge'
• Determine the cause of the patient’s altered mental status. Possible causes for altered mental status include cardiac dysrhythmias, electrolyte imbalances, anemia, stroke, brain tumor, and hypoxia, says Cohen. "There are many things that could alter somebody’s mental status. The differential diagnosis is huge," she says. It also could be a normal status for the patient, she notes. "If the patient doesn’t speak clearly, it could be due to a stroke from three years ago. But if I don’t know that, I have to assume the abnormal speech is of a new nature," says Cohen. You must treat any patient who presents with a change in mental status or slurred speech as a stroke until proven otherwise, stresses Cohen. "This is especially important with an ischemic or embolic stroke, because we can give anticoagulants to treat that," she says.
Resources
For more information about performing a neurological assessment of patients, contact:
• Patricia Carroll, RN, BC, CEN, MS. E-mail: [email protected]. Web: www.nursesnotebook.com.
• Sharon S. Cohen, RN, MSN, CEN, CCRN, Trauma Clinical Nurse Specialist, North Broward Hospital District, 1600 S. Andrews Ave., Fort Lauderdale, FL 33316. Telephone: (954) 355-4990. Fax: (954) 468-5270. E-mail: [email protected].
• A clinical policy on treating patients with altered mental status is available free on the American College of Emergency Physicians web site (www.acep.org). Click on "Clinical Policies," and scroll down to "Clinical Policy for the Initial Approach to Patients Presenting with Altered Mental Status."
• A computer-based version of a Mini Mental State Exam allows you to enter data with automatic scoring, and a hard copy can be printed for the patient’s chart. The form can be accessed at www.medafile.com/mmses.htm.
• A Mini-Mental Status Exam combination kit including a clinical guide, pocket card, user’s guide, and 50 test forms is available for $90 plus $9 shipping and handling. To order, contact Psychological Assessment Resources, 16204 N. Florida Ave., Lutz, FL 33549. Telephone: (800) 331-8378 or (813) 968-3003. Fax: (813) 727-9329. E-mail: [email protected]. Web: www.parinc.com.
You should add a D for disability caused by neurological deficits to the A, B, C tenets of airway, breathing, and circulation. Your goal is to determine if the patient is awake, alert, and oriented.
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