Timing Is Imperative For

Stroke Victims

• Outstanding emergency team

– Quick response

– Caring to family members

• Helicopter

– negotiating the electrical lines

Rural

Recovery

History• This patient prior to

stroke

– 100% independent– highly intelligent– walk the elliptic one

mile a day– took care of her own

accounts and estate– lived on the second

floor of her house.

• This 84 year old is diagnosed with Stage-three lung cancer metastasized in the brain. (reason for haircut)

Stage-one vs Stage-three

• It was

determined the patient had Stage-one lung cancer requiring a lobectomy not

Stage-three involvement requiring radiation of the brain.

The results and treatment of the two are quite different.

Two Week Visit•STROKE

• DUE TO HER DR TELLING HER TO STAY OFF HER BLOOD THINNERS UNTIL SUNDAY. THIS WAS THREE DAYS.

• SHE HAD THE STROKE SUNDAY

Coumadin ?• Two week post-operative checkup from

lung removal before stroke – impressive – coumadin was high (5.7)

• Thoracic surgeon recommended suspending coumadin Thursday night then follow doctors orders.

• Told to resume coumadin Sunday.

• Sunday she experienced a 100 % occlusion of the left carotid artery in her brain.

Emergency Room

– The family was called to say their goodbyes.

“The patient would not live through the night.”

– This decision is based on the experience of the emergency room staff.

– Patient had a 100 percent occlusion of the left internal carotid artery.

Aggressive therapy is not an option for this patient due to the stroke victim’s history, although the alternative is death.

• According to David Tong, M.D., medical director of California Pacific’s Stroke Care Center, "The good news is that nearly 50% of patients treated for stroke within a three-hour window experience little, and sometimes no, physical or speech deficit.

• “Ischemic strokes are treated with thrombolytictherapy using recombinant tissue PlasminogenActivator (rTPA). rTPA is a naturally occurring clot-dissolving enzyme.”

• http://www.cpmc.org/about/e-health/2006/4-06-stroke.html

Aggressive Stoke Therapy

HELP ME• A stroke victim may ‘not know’ what is happening.

– Patient must rely on healthcare workers

• Stroke victim may not be able to talk or move.

– Patient must rely on healthcare workers

• Most patients do not have someone to

stay with them and be their advocate.

–Patient must rely on healthcare workers

ALERT Wristbands• A nurse placed a red alert band on this stroke

victim which said:

A DEADLY MISTAKENurse’s reasoning:

Anticoagulant was written under the ‘alert’ heading in the patient’s chart.

The nurse took this to mean no anticoagulants.

This patient can stroke or bleed without anticoagulants.

Allergic to Anticoagulants

Atrial fibrillation

• Also known as A-fib. This is irregular beating

of the heart.

• It leaves the blood in a constant state of clot,

like jello, waiting for an obstacle to catch on,

creating the actual ‘clot’.

• For the blood to stay thin enough, not to clot

blood, thinners must be used.

• Anticoagulants = blood thinners.

• Blood pressure readings are different on the right and left arm during the same period of time. It is important to be consistent as to which arm is used.

• These marks are from the blood pressure cuff.

Flaccid

ArmThis is the stoke effected arm

Elevating Paralyzed Arm

• Affected arm can be elevated to relieve swelling.

• It is important that the edge of this tray is covered or padded.

• Pad the edge so the arm does not lay directly on the hard plastic edge.

Paralyzed

• Many times the paralyzed arm is

forgotten by the patient and the attendants.

• When turning the patient it is

important the affected limb does not gets caught underneath the weight of

the patient causing addition trauma.

Bruising

• Many stroke victims are prescribed anti-coagulants which increase bruising.

• Bruising can be reduced by teaching attendants proper handling of patients.

• Turn the patient with the palm of the hand not fingers this increases surface area reducing pressure that causes bruising.

It is best to move patient with the bottom sheet when moving.

Why?

• This stroke victim has an elastic binding covering a peg tube used for feeding.

• This stroke victims breasts are also bound.

• This binder, which can be cut to size, belongs below the breasts this

additional restriction is unnecessary.

If You Were the Patient

• You are the result of all the years

of your life.

• Now, suddenly someone is

changing your diaper because you cannot move or speak due to a

stroke

• Who makes sure you are cleaned

properly and with respect?

Self Esteem• Importance of dentures

• Importance of glasses

• Importance of being dressed daily

• Importance of a clean diaper

• I cannot speak, I am paralyzed,

• I cannot use the call button

• Your linens, clothes and diaper are removed after soiling.

• You are left uncovered and cold until

supplies are found to clean you.

• In the meantime the attendant’s assistant uses a dry pillowcase to clean you.

• A diaper is replace without cleaning of the skin.

Imagine

• The skilled nursing home sent me to the Emergency Room.

• When released [from the hospital] the doctors orders did not include the pain medicine I had been receiving.

• Now I must ask the nurse for pain

medicine. I can not talk.

How Do I Ask?

Page one

How Do I Ask?

• I see the nurse twice a day as I am administered my medicine.

• I saw the doctor (who goes to twenty-eight other facilities), on admittance, and I see a Physicians Assistant once a week.

• I am paralyzed, I cannot speak, I cannot use the call button.

• How do I ask for medicine or tell them I am in pain?

Page two

Inefficient Due To Overuse

Postings Can Be

Prevention of AspirationThis stroke victim is under doctor’s orders needing

100% supervision due to lost of the gag reflex.

Aspiration can occur.

This stroke victim is unattended.

Note: Patient is feeding herself (unattended). How will she reach the food on the right of the tray with right side

paralysis? Notice the comb in her plate.

• Blood under nailsfrom finger prick glucose testing

• No standardization for hygiene, or cleaning of hands before feeding.

• (rules state patients are scheduled for showers twice a week)

Patient Hygiene

She did not have daily dental care

Feeding• This stroke victim (with

feeding tube) is hand fed by an attendant.

• The elevation of the bed is not adequate to prevent aspiration, ninety degrees is ideal.

• Minimum of thirty five degrees is the suggested level for a patient with a feeding tube.

• Note the location of the emergency call button.

• .

ACTIONS: Throwing pillows off bed, pulling herself from

one side of the bed to the other side of the bed for three

hours. I have had a stroke, I can not speak.

Anxiety or Pain Death: August 18, 2007

This was nine days

earlier, a victim of

metastasized lung

cancer.

The hospital staff is not convinced this patient Is in pain as

she rocks back and forth for hours.

• Rescue team great

• Psychiatrist

• Bluebells kewl

• classesPatient’s ACTIONS: Removal of covers, throwing pillows off the bed,

refusing help. This patient remained this way for eight hours.

The patient was a stroke victim and had chronic back problems. The

patient died ten days later from an intestinal blockage, stage four metastasized lung cancer.

I can not speak.

Self Esteem• Importance of dentures

• Importance of glasses

• Importance of being dressed daily

• Importance of a clean diaper

• Family and friends must grieve.

• This is a natural process.

• Humans are visual animals.

• BUT… When we lose a loved one it is hard

to disassociate the body of our loved one from the spirit.

• Our mom will always be our mom, our dad

always our dad.

• It is important that everyone dealing with our

loved one understands.

B e in v o lv e d in t h e w h o le p r o c e s sD u e t o a b u s y w e e k e n d t h is is t h e o n ly v e h ic le a v a i la b le

t o t r a n s p o r t t h e b o d y f r o m t h e f a m i l i e ’s h o m e t o t h e f u n e r a l h o m e .

Be involved in the whole process

Make your wishes known

y

MyMom