Sharpen skills to treat stroke patients
With new stroke pathways and treatments that call for acute intervention in the ED, nurses need to re-evaluate their clinical skills.
"Just as nurses had to bone up on interpreting EKGs and managing chest pain, the same now holds true for the neurological patient," says Patti Bratina, RN, BSN, clinical research coordinator for the stroke treatment team at the University of Texas in Houston.
Here are some aspects of clinical practice that ED nurses should re-evaluate:
• Triage assessment.
The triage nurse has to ask in-depth questions to determine the onset time of symptoms.
"When someone comes in complaining of a focal deficit, [the nurse] needs to find out if it’s acute or if it’s been going on for a day or so," explains Bratina. "Instead of asking when the symptoms started, a better question to ask is, When was the last time you were totally normal?’"
Some patients will respond that the last time they were normal was before going to sleep the night before.
"Most of the time, those patients won’t be eligible for treatment, but that isn’t always the case," notes Bratina. It’s not uncommon for patients to take naps in the middle of the day, wake up with stroke symptoms, and still be within the time limit for treatment, she says.
• Continuous assessment of blood pressure.
If patients’ blood pressures are too high, they may not be eligible for treatment. "Blood pressure is critical for good decision making, and nurses are the ones entrusted with assessing it over and over again," says Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of neurology at University Hospital, University of Cincinnati Medical Center.
• Awake neurological exams.
Previously, most acute-driven care was done for patients who weren’t awake.
"Nurses need to beef up their awake neurologic assessment skills," stresses Spilker.
Using the Glasgow Coma Scale is not the most effective way to assess a stroke patient, emphasizes Laura R. Sauerbeck, RN, BSN, CEN, clinical research coordinator for the Greater Cincinnati/Northern Kentucky Stroke Team in Cincinnati. "That is basically a trauma or coma scale and doesn’t measure deficits in an awake neurologic patient," she says. "For most stroke patients, unless speech is affected, we’ll get a score of 15, which nowhere near demonstrates the severity of their deficit."
Quick version is a time saver
The NIH Stroke Scale, a tool developed by the National Institutes of Health (NIH) for awake neurologic assessment of stroke patients, is a much better tool to use, Spilker maintains. Because the NIH scale is several pages long, a more concise version was developed to make the tool more user-friendly. (See Quick and Easy Version of the NIH Stroke Scale, inserted in this issue.) The Quick and Easy Version of the scale can be done in five minutes.
"It gives you a snapshot picture of what the patient is doing at that time," says Sauerbeck. "It’s great to have it pre- and post-thrombolytics because sometimes 10 minutes into the infusion [patients] who were totally flaccid on one side are moving their arms and talking clearly, and you can document that change."
• Recognition of stroke symptoms.
Because the window of time for treatment is just three hours, nurses need to rapidly determine if a patient has stroke symptoms, as opposed to a hypoglycemic attack, heart attack, or Todd’s paralysis, recommends Karen Rapp, RN, BSN, CCRN, clinical coordinator of the University of California-San Diego Stroke Center. (See signs and symptoms of stroke, p. 24.)
• Preordering of tests for stroke patients.
Tests should be ordered in advance of the stroke patient’s arrival to speed the process. Having a pathway in place legitimizes this practice, says Sauerbeck.
"If the medical staff has a standardized protocol in place for treating stroke patients, then nurses can preorder before the doctor can get into the room," she explains. "The sooner the nurse gets CT notified, the better the patient’s chance to be eligible to receive thrombolytic therapy."
• Patient education.
A telephone survey of patients conducted at the University of Cincinnati Medical Center revealed that considerable education is needed to increase the public’s awareness of stroke symptoms.1 Of 1,880 respondents, more than 25% couldn’t name a single warning sign of a stoke. Elderly people, who are at highest risk for stroke, were most likely to be unable to name a single warning sign. Patients should be told to come to the ED immediately if they perceive any symptoms of a stroke.
"The trouble is most stroke patients wait at home thinking it’s going to go away, and by the time they come in, there’s not much we can do for them," says Teri McClean, RN, CEN, an emergency nurse at University of California-San Diego Stroke Center. "We have a lot of transient ischemic attacks, which are often precursors to strokes, when a hand goes numb and then gets better. We do a lot of education with those patients."
Reference
1. Pancioli A, Broderick J, Kothari R, et al. Public perception of stroke warning signs and potential risk factors. Stroke 1997; 28:1,236.
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