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Code Brain AttackCode Brain Attack
Good Samaritan HospitalGood Samaritan Hospital
Written by:Written by:
Diane King, Staff...
Goals andGoals and Objectives
GoalsGoals
By the end of this presentation will be able toBy the end of this presentation wi...
Goals and ObjectivesGoals and Objectives
ObjectivesObjectives
What will learn and skills aught in this training deliver si...
Goals and ObjectivesGoals and Objectives
Objectives:
6. Relationships-Working together with staff members and other6. Rela...
Explaining StrokeExplaining Stroke
Stroke FactsStroke Facts- Did you know?- Did you know?
 There are more than 700,000 strokes each year in the U.S.There ar...
Types of StrokeTypes of Stroke
 Ischemic-83%Ischemic-83%
(Thrombosis 52%, Embolism 31%)(Thrombosis 52%, Embolism 31%)
 H...
Clinical Implications ofClinical Implications of
RelevanceRelevance
NIHSS CertificationNIHSS Certification
(National Insti...
How ED Staff MembersHow ED Staff Members
affect Patient Outcomesaffect Patient Outcomes
Sequence of EventsSequence of Even...
Source: http://www.strokeassociation.org/presenter
Cell and Nerve DeathCell and Nerve Death
That Occurs During aThat Occurs During a
StrokeStroke
 During the first second 3...
Cell and Nerve DeathCell and Nerve Death
That Occurs During aThat Occurs During a
StrokeStroke
 A pea sized piece of brai...
Cardiovascular disease mortality trends for males andCardiovascular disease mortality trends for males and
femalesfemales ...
Prevalence of stroke by age and sexPrevalence of stroke by age and sex (NHANES: 1999-2004).(NHANES: 1999-2004).
Source: NC...
Estimated direct and indirect costs of major cardiovascular
diseases and stroke (United States: 2007).
Source: NHLBI.
Nati...
Time is BrainTime is Brain
Time Lost is Brain LostTime Lost is Brain Lost
Treatment Options…Treatment Options…
 t-PAt-PA
 CT-AngiogramCT-Angiogram
 RetrievalRetrieval
t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
 Inclusive Criteria (Forms in ED)Inclusive Criteria (Forms in ED)
 Must...
t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
 Awake and alert without significantAwake and alert without significant
...
t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Absolute Contraindications:Absolute Contraindications:
 Evidence of IC h...
t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Relative Contraindications:Relative Contraindications:
 Minor or rapidly...
t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Relative Contraindications:Relative Contraindications:
 Recent (within 3...
t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Relative Contraindications:Relative Contraindications:
 History of intra...
t-PA Administrationt-PA Administration
Goal is door to t-PA time < 1 hourGoal is door to t-PA time < 1 hour
t-PA Administrationt-PA Administration
NIH stroke scale upon ER admissionNIH stroke scale upon ER admission
and prior to t...
t-PA Administrationt-PA Administration
 Make sure that no other solutions orMake sure that no other solutions or
medicati...
t-PA Administrationt-PA Administration
 Total dose (weight in _kg x 0.9 mgTotal dose (weight in _kg x 0.9 mg
= total dose...
t-PA Administrationt-PA Administration
 Insert catheter tip into port closest toInsert catheter tip into port closest to
...
t-PA Administrationt-PA Administration
Patient ManagementPatient Management
 Patient to be staffed 1:1 ratio while in ERP...
Time ClockTime Clock
The time clock should be started whenThe time clock should be started when
the brain attack is called...
Calling a Brain AttackCalling a Brain Attack
 YES, a Nurse can call a Brain AttackYES, a Nurse can call a Brain Attack
 ...
Stroke CoordinatorsStroke Coordinators
 Automatically paged by GSH Operator and will be calling EDAutomatically paged by ...
What Can Good Samaritan Hospital EDWhat Can Good Samaritan Hospital ED
Nurses Can Do To Increase AwarenessNurses Can Do To...
ReferencesReferences
Fitzgerald, Ronald. (2007). Good Samaritan Hospital (personal Interview)
February 27, 2008.
National ...
ReferencesReferences
National Stroke Association. (2007). Explaining Stroke [Brochure].
Retrieved from:
www.stroke.org/pub...
The EndThe End
Nurs212 Code Brain Attack
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Transcript of "Nurs212 Code Brain Attack"

  1. 1. Code Brain AttackCode Brain Attack Good Samaritan HospitalGood Samaritan Hospital Written by:Written by: Diane King, Staff Nurse IVDiane King, Staff Nurse IV RN, MS, PHN, CENRN, MS, PHN, CEN
  2. 2. Goals andGoals and Objectives GoalsGoals By the end of this presentation will be able toBy the end of this presentation will be able to describe:describe: 1.1. Basic stroke facts.Basic stroke facts. 2.2. Types of stroke.Types of stroke. 3.3. How staff members affect patient outcomes.How staff members affect patient outcomes. 4.4. Roles and responsibilities of primary nurseRoles and responsibilities of primary nurse during. patient management.during. patient management.
  3. 3. Goals and ObjectivesGoals and Objectives ObjectivesObjectives What will learn and skills aught in this training deliver significantWhat will learn and skills aught in this training deliver significant improvement in areas such as:improvement in areas such as: 1.1. Performance-Clinical implications of relevance.Performance-Clinical implications of relevance. 2.2. Productivity-Time lost is brain lost.Productivity-Time lost is brain lost. 3.3. Teamwork-Calling a brain attack, EKG, CT, Lab work, etc.Teamwork-Calling a brain attack, EKG, CT, Lab work, etc. 4.4. Change Management-Agreement with other team membersChange Management-Agreement with other team members when patient situations change or resolve.when patient situations change or resolve. 5.5. Quality-Productive processes that are eagerlyQuality-Productive processes that are eagerly implemented, such as door to t-PA time <1 hr.implemented, such as door to t-PA time <1 hr.
  4. 4. Goals and ObjectivesGoals and Objectives Objectives: 6. Relationships-Working together with staff members and other6. Relationships-Working together with staff members and other departments effectively to improve patient outcomes.departments effectively to improve patient outcomes. 7. Safety-Review of t-PA administration and patient7. Safety-Review of t-PA administration and patient management.management. 8. Diversity-Review of Inclusion/Exclusion criteria.8. Diversity-Review of Inclusion/Exclusion criteria. 9.Meetings-Stroke coordinators are here to work together with us9.Meetings-Stroke coordinators are here to work together with us and willing to help solve obstacles and listen to constructiveand willing to help solve obstacles and listen to constructive feedback.feedback. 10. Technology-Learn what Good Samaritan Hospital is currently10. Technology-Learn what Good Samaritan Hospital is currently using for treatment options.using for treatment options.
  5. 5. Explaining StrokeExplaining Stroke
  6. 6. Stroke FactsStroke Facts- Did you know?- Did you know?  There are more than 700,000 strokes each year in the U.S.There are more than 700,000 strokes each year in the U.S.  28% of strokes occur in people under age 6528% of strokes occur in people under age 65  Over the age of 55, stroke risk doubles every 10 yearsOver the age of 55, stroke risk doubles every 10 years  There are more than 4 million stroke survivors alive today inThere are more than 4 million stroke survivors alive today in the U.S.the U.S.  Stroke is the leading cause of long-term disability in the U.S.Stroke is the leading cause of long-term disability in the U.S.  Stroke is the 3rd largest cause of death in the U.S., rankingStroke is the 3rd largest cause of death in the U.S., ranking behind diseases of the heart and cancerbehind diseases of the heart and cancer  Stroke kills more women than breast cancerStroke kills more women than breast cancer Source:Source: http://www.uwmedicine.org/Facilities/Harborview/CentersOfEhttp://www.uwmedicine.org/Facilities/Harborview/CentersOfE mphasis/Neuro/StrokeCentermphasis/Neuro/StrokeCenter
  7. 7. Types of StrokeTypes of Stroke  Ischemic-83%Ischemic-83% (Thrombosis 52%, Embolism 31%)(Thrombosis 52%, Embolism 31%)  Hemorrhagic-17%Hemorrhagic-17% (Intracerebral Hemorrhage 10%, Subarachnoid(Intracerebral Hemorrhage 10%, Subarachnoid hemorrhage 7%)hemorrhage 7%) Source: National Stroke AssociationSource: National Stroke Association
  8. 8. Clinical Implications ofClinical Implications of RelevanceRelevance NIHSS CertificationNIHSS Certification (National Institute of Health Stroke Scale)(National Institute of Health Stroke Scale) Emergency DepartmentEmergency Department Medical Surgical Intensive CareMedical Surgical Intensive Care Mandatory EducationMandatory Education
  9. 9. How ED Staff MembersHow ED Staff Members affect Patient Outcomesaffect Patient Outcomes Sequence of EventsSequence of Events  AssessmentAssessment  NIHSSNIHSS  Stat Lab DrawStat Lab Draw  CTCT  EKG (rule out A Fib)EKG (rule out A Fib)  Possible CT-Angiogram (EDRN mustPossible CT-Angiogram (EDRN must accompany the patient)accompany the patient)
  10. 10. Source: http://www.strokeassociation.org/presenter
  11. 11. Cell and Nerve DeathCell and Nerve Death That Occurs During aThat Occurs During a StrokeStroke  During the first second 32,000 brain cellsDuring the first second 32,000 brain cells diedie  Next second 1.9 billion cells dieNext second 1.9 billion cells die  Each minute delay the brain loses 1.9Each minute delay the brain loses 1.9 million neurons, 14 billion synapses and 7.5million neurons, 14 billion synapses and 7.5 miles of myelinated fibersmiles of myelinated fibers  If a stroke runs it’s full course (10 hours) theIf a stroke runs it’s full course (10 hours) the brain loses 1.2 billion neurons, 8.3 trillionbrain loses 1.2 billion neurons, 8.3 trillion synapses, and 4470 miles of myelinatedsynapses, and 4470 miles of myelinated fibersfibers Fitzgerald, Ronald. (2007). Good Samaritan Hospital Meditech Intranet: Retrieved February 27, 2008.
  12. 12. Cell and Nerve DeathCell and Nerve Death That Occurs During aThat Occurs During a StrokeStroke  A pea sized piece of brain dies withA pea sized piece of brain dies with every 12 minute delay.every 12 minute delay.  Brain tissue the size of a 1.5 pingBrain tissue the size of a 1.5 ping pong ball are irretrievably lost if apong ball are irretrievably lost if a typical stroke runs it’s full coursetypical stroke runs it’s full course without treatment.without treatment. Fitzgerald, Ronald. (2007). Good Samaritan Hospital Meditech Intranet: Retrieved February 27, 2008.
  13. 13. Cardiovascular disease mortality trends for males andCardiovascular disease mortality trends for males and femalesfemales (United States: 1979-2004).United States: 1979-2004). Source: NCHS.Source: NCHS. 380 400 420 440 460 480 500 520 79 80 85 90 95 00 04 Years Deaths in Thousands Males Females 0 National Coalition on Health Care
  14. 14. Prevalence of stroke by age and sexPrevalence of stroke by age and sex (NHANES: 1999-2004).(NHANES: 1999-2004). Source: NCHS.Source: NCHS. 0.5 1.2 6.5 0.5 2.3 6.2 12.4 14.8 0 2 4 6 8 10 12 14 16 20-39 40-59 60-79 80+ Percent of Population Men Women National Coalition on Health Care
  15. 15. Estimated direct and indirect costs of major cardiovascular diseases and stroke (United States: 2007). Source: NHLBI. National Heart Lung and Blood Institute
  16. 16. Time is BrainTime is Brain Time Lost is Brain LostTime Lost is Brain Lost
  17. 17. Treatment Options…Treatment Options…  t-PAt-PA  CT-AngiogramCT-Angiogram  RetrievalRetrieval
  18. 18. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion  Inclusive Criteria (Forms in ED)Inclusive Criteria (Forms in ED)  Must be 18 years or olderMust be 18 years or older  Stroke symptoms onset <3 hoursStroke symptoms onset <3 hours  For IV t-PA within 2.5 hoursFor IV t-PA within 2.5 hours  For Intra-arterial t-PA/ThrombectomyFor Intra-arterial t-PA/Thrombectomy (Within 5 hours)(Within 5 hours)
  19. 19. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion  Awake and alert without significantAwake and alert without significant reduction of LOCreduction of LOC  Stroke symptoms ONE OR MOREStroke symptoms ONE OR MORE of the following: Muscle Weakness,of the following: Muscle Weakness, speech problems, facial droopspeech problems, facial droop  12 lead EKG done (rule out A Fib)12 lead EKG done (rule out A Fib)  Labs: CBC, Chem 7, INR & PTTLabs: CBC, Chem 7, INR & PTT
  20. 20. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion Absolute Contraindications:Absolute Contraindications:  Evidence of IC hemorrhage onEvidence of IC hemorrhage on pretreatment evaluationpretreatment evaluation  Evidence of SubarachnoidEvidence of Subarachnoid hemorrhagehemorrhage
  21. 21. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion Relative Contraindications:Relative Contraindications:  Minor or rapidly improving signs orMinor or rapidly improving signs or symptomssymptoms  Active malignancy, brain or elsewhereActive malignancy, brain or elsewhere  Recent MI or pericarditis, within theRecent MI or pericarditis, within the past 2 weekspast 2 weeks  Recent (30 days) surgery, biopsy, orRecent (30 days) surgery, biopsy, or arterial puncture (n/a for IA t-PA)arterial puncture (n/a for IA t-PA)
  22. 22. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion Relative Contraindications:Relative Contraindications:  Recent (within 30 days) any activeRecent (within 30 days) any active hemorrhagehemorrhage  Glucose <50 or >400 mg/dlGlucose <50 or >400 mg/dl  SBP >185 or DBP >110SBP >185 or DBP >110 (antihypertensive treatment OK)(antihypertensive treatment OK)  Pregnancy, lactation, or parturitionPregnancy, lactation, or parturition (childbirth) within previous 30 days(childbirth) within previous 30 days
  23. 23. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion Relative Contraindications:Relative Contraindications:  History of intracranial hemorrhageHistory of intracranial hemorrhage  History of major trauma in the last 2History of major trauma in the last 2 weeksweeks  Seizure at onset of strokeSeizure at onset of stroke  Active bacterial endocarditisActive bacterial endocarditis
  24. 24. t-PA Administrationt-PA Administration Goal is door to t-PA time < 1 hourGoal is door to t-PA time < 1 hour
  25. 25. t-PA Administrationt-PA Administration NIH stroke scale upon ER admissionNIH stroke scale upon ER admission and prior to t-PAand prior to t-PA  Establish 2 IV linesEstablish 2 IV lines Primary line for t-PAPrimary line for t-PA  Connect directly to IV tubing to infuse viaConnect directly to IV tubing to infuse via pumppump  Do not use t-PA as piggyback bag withDo not use t-PA as piggyback bag with .9NS as primary bag. Flush after t-PA is.9NS as primary bag. Flush after t-PA is complete.complete.
  26. 26. t-PA Administrationt-PA Administration  Make sure that no other solutions orMake sure that no other solutions or medications are running through t-PAmedications are running through t-PA line.line.  Secondary line with .9NSSecondary line with .9NS  Obtain established or actual bodyObtain established or actual body weight in kgweight in kg  Complete Inclusion/Exclusion criteriaComplete Inclusion/Exclusion criteria for t-PAfor t-PA
  27. 27. t-PA Administrationt-PA Administration  Total dose (weight in _kg x 0.9 mgTotal dose (weight in _kg x 0.9 mg = total dose.= total dose. Not to exceed 90 mgNot to exceed 90 mg  t-PA bolus 10% of total calculatedt-PA bolus 10% of total calculated dose given IV push over 1 minutedose given IV push over 1 minute  t-PA remainder dose infused viat-PA remainder dose infused via separate pump/separate channel overseparate pump/separate channel over 60 minutes60 minutes
  28. 28. t-PA Administrationt-PA Administration  Insert catheter tip into port closest toInsert catheter tip into port closest to IV insertion siteIV insertion site  Visual confirmation of t-PA infusionVisual confirmation of t-PA infusion every 15 minutes until infusionevery 15 minutes until infusion completecomplete  When t-PA infusion complete, followWhen t-PA infusion complete, follow with 50 ml .9NS at t-PA infusion ratewith 50 ml .9NS at t-PA infusion rate through t-PA tubingthrough t-PA tubing
  29. 29. t-PA Administrationt-PA Administration Patient ManagementPatient Management  Patient to be staffed 1:1 ratio while in ERPatient to be staffed 1:1 ratio while in ER  Vital signs TPR/BP, neuro checks everyVital signs TPR/BP, neuro checks every 15 minutes for 2 hours, then every 3015 minutes for 2 hours, then every 30 minutesminutes  No automatic BP’s to be used until 24No automatic BP’s to be used until 24 hours after t-PAhours after t-PA  NIHSS every shift and STAT for significantNIHSS every shift and STAT for significant changeschanges
  30. 30. Time ClockTime Clock The time clock should be started whenThe time clock should be started when the brain attack is called. The goal isthe brain attack is called. The goal is door to t-PA time <1 hourdoor to t-PA time <1 hour
  31. 31. Calling a Brain AttackCalling a Brain Attack  YES, a Nurse can call a Brain AttackYES, a Nurse can call a Brain Attack  Call 55 and ask the GSH Operator toCall 55 and ask the GSH Operator to call a code Brain Attack-EDcall a code Brain Attack-ED  On Call Neurologist & StrokeOn Call Neurologist & Stroke Coordinator will call the EDCoordinator will call the ED
  32. 32. Stroke CoordinatorsStroke Coordinators  Automatically paged by GSH Operator and will be calling EDAutomatically paged by GSH Operator and will be calling ED for information for possible clinical trial study or t-PA.for information for possible clinical trial study or t-PA.  It is urgent that they speak to EDMD or Primary Nurse ASAP.It is urgent that they speak to EDMD or Primary Nurse ASAP.  Please don’t place stroke coordinators on hold indefinitely,Please don’t place stroke coordinators on hold indefinitely, hang up on them, or say “it’s too busy right now…” They arehang up on them, or say “it’s too busy right now…” They are on call for the hospitalon call for the hospital  Stroke coordinator’s will ask for: Name, age, symptom onsetStroke coordinator’s will ask for: Name, age, symptom onset and other relevant data for possible clinical trial studiesand other relevant data for possible clinical trial studies  Stroke coordinators are on call 24/7 to help us and ourStroke coordinators are on call 24/7 to help us and our patientspatients
  33. 33. What Can Good Samaritan Hospital EDWhat Can Good Samaritan Hospital ED Nurses Can Do To Increase AwarenessNurses Can Do To Increase Awareness Regarding Stroke Prevention?Regarding Stroke Prevention?  Educate our PatientsEducate our Patients  Attend the annual Stroke SymposiumAttend the annual Stroke Symposium each May at GSH in the Auditoriumeach May at GSH in the Auditorium  Become Involved with the StrokeBecome Involved with the Stroke Health Fair in September ’08Health Fair in September ’08  Obtain your Mandatory NIH StrokeObtain your Mandatory NIH Stroke Certification or Re-Certification in aCertification or Re-Certification in a timely manner for all ED and ICU RN’stimely manner for all ED and ICU RN’s
  34. 34. ReferencesReferences Fitzgerald, Ronald. (2007). Good Samaritan Hospital (personal Interview) February 27, 2008. National Center for Health Statistics. Cardiovascular disease mortality trends for mal and females (United States: 1979-2004). [Power Point Slides]. Retrieved from: www.cdc.gov/nchs. National Center for Health Statistics. Prevalence of stroke by age and sex (NHANES 1999-2004). [Power Point Slides]. Retrieved from: www.cdc.gov/nchs. National Heart, Lung & Blood Institute. Estimated direct and indirect costs of major cardiovascular diseases and stroke (United States: 2007). [Power Point Slides]. Retrieved from: www.cdc.gov/nchs. . National Heart, Lung & Blood Institute. Cardiovascular disease mortality trends for males and females (United States: 1979-2004). [Power Point Slides]. Retrieved fro www.nhlbi.nih.gov
  35. 35. ReferencesReferences National Stroke Association. (2007). Explaining Stroke [Brochure]. Retrieved from: www.stroke.org/pubs/consumer/brochure-brochure.pdf. Neuro Stroke Center-Harborview. (2007). Stroke Facts- Did you know? [Power Point Slides]. Retrieved from: www.uwmedicine.org/Facilities/Harborview/CentersOfEmphasis/Neur o/StrokeCenter. Stroke Association (2007). Types of Stroke. [Power Point Slides]. Retrieved from: http://www.strokeassociation.org. Stroke Association (2007). Types of Stroke. [Power Point Slides]. Retrieved from: http://www.strokeassociation.org/presenter.
  36. 36. The EndThe End
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