Transcript Slide 1
Advancing the Vision of the Neurological Institute Patient Experience 2014 Julie Fussner BSN, RN, CPHQ, SCRN Advancing the Vision of the Neurological Institute Patient Experience • April 26, 2012 • 49 yo F Hx: HTN, Bipolar • 10:20 L weakness, slurred speech, and collapsed at Vet’s office • Taken to OSH – arrived at 10:40 • VS: B/P 159/63 HR 120, R 20 BS 138 • NIHSS=10 • CT small right parietal hypodensity – did not explain symptoms • UH transfer center called and IV tPA recommended • 11:20 IV tPA started (Door to drug = 40 mins) 2 Advancing the Vision of the Neurological Institute Patient Experience • 12:14 arrival to UH CMC by helicopter • VS: B/P 145/86 HR 112 Pulse ox 96% on 2L NC • Exam: Alert and oriented x3, responding to questions, following commands, looking to the right, visual field cut (Homonymous Hemianopia), no movement on left side, dense sensory loss on left, mild dysarthria, L neglect • NIHSS = 20 • IV tPA infusion finishing • Foley • Menses 3 Advancing the Vision of the Neurological Institute Patient Experience- NIHSS • • • • • • • • • • • • • 1a. LOC - 0 1b. LOC Questions - 0 1c. LOC Commands - 0 2. Best Gaze - 2 3. Visual Fields -2 4. Facial Palsy - 1 5. Motor Arm - 4 6. Motor Leg - 4 7. Limb Ataxia - 0 8. Sensory - 2 9. Best Language - 0 10. Dysarthria - 1 11. Neglect - 2 4 Advancing the Vision of the Neurological Institute Patient Experience Endovascular Intervention • • • • • IV TPA 33% benefit 12:45 Taken for Neuro angio suite 13:05 Groin access (Door to groin = 51 mins) R MCA Occlusion (R Middle cerebral artery) MCA Branches Anterior – occluded Middle - occluded Posterior - patent 5 Advancing the Vision of the Neurological Institute Patient Experience - MRI 6 Advancing the Vision of the Neurological Institute Patient Experience Endovascular devices Solitaire Penumbra 7 Advancing the Vision of the Neurological Institute Patient Experience Endovascular Intervention • • • • • • • • Solitaire #1 Solitaire #2 Penumbra #1 Penumbra #2 TPA – 2 mg IA tPA Penumbra # 3 – successful in the anterior branch TPA – 2.5mg IA tPA Solitaire #3 – Intermittent revascularization of middle branch • Post procedure NIHSS =18 8 Advancing the Vision of the Neurological Institute Patient Experience • Stroke Work up: – Lipid panel: LDL = 99 – HbA1c = 5% – Echocardiogram: EF >65%, No PFO, + atrial septal aneurysm – Troponin leak 0.13 but no EKG changes • Hospital course: – Anemia • Hb = 5.2 due to uterine bleeding- Tx with 2U PRBC’s – Diabetes Insipidus 9 Advancing the Vision of the Neurological Institute Patient Experience Diabetes Insipidus • Kidneys are unable to conserve water as they perform their function of filtering blood. • Amount of water conserved is controlled by antidiuretic hormone (ADH), also called vasopressin. • ADH is a hormone – Produced in the hypothalamus – Stored and released from the pituitary gland, a small gland at the base of the brain. • DI caused by a lack of ADH is called central diabetes insipidus. When DI is caused by a failure of the kidneys to respond to ADH, the condition is called nephrogenic diabetes insipidus 10 Advancing the Vision of the Neurological Institute Patient Experience Diabetes Insipidus (DI) • • • • Hypernatremia - Na = 160’s Urine output 200 - 300cc/ hr TX: DDAVP, hypo osmotic fluids Renal consult: Nephrogenic DI induced by lithium therapy • NSU for 6 days 11 Advancing the Vision of the Neurological Institute Patient Experience • Therapy (PT, OT, ST ) recommending acute rehab – Maximal assist to move in bed and sit up – Able pivot – Poor trunk control • Modified Barium Swallow – Passed for pureed with nectar thick liquids – unable to take in enough calories • PEG placed on May 3 12 Advancing the Vision of the Neurological Institute Patient Experience • • • • • • • • • • Discharged to Acute rehab on May 4, 2012 Alert Ox 2 R gaze but able to cross over to left side L visual field cut LUE – 0/5 LLE – 1/5 L neglect L sensory Dysarthria but no aphasia NIHSS = 16 13 Advancing the Vision of the Neurological Institute • • • • • • • • • Patient Experience Discharge Medications ASA Atorvastatin HCTZ Metoprolol Ferrous Sulfate Synthroid Ranitidine Heparin SQ Ciprofloxacin for UTI 14