More Neuro Nursing

Two short snippets of patient scenarios that I thought I'd share: 

“Rhonda! Rhonda!” we crowd around her bed yelling. “Wake up! Open your eyes!” She doesn’t respond. I take a piece of skin and muscle beside her neck and twist it hard. Rhonda groans but still doesn’t open her eyes or try to push my hand away. I shine a flashlight in her eyes – her pupils don’t react. The left side of her body continues to twitch. Rhonda is having a seizure. She was a little drowsy this afternoon but just hours before was walking around, as coherent as you and I. In the neuro world, things can change in a matter of minutes.  Her vital signs are ok but her oxygen saturation level is dropping. Someone runs to grab a venti mask and I hook it up, turning the dial on the oximeter up to 8L, delivering oxygen at 35%. Her sats climb up to 98%. Good. I’m not Rhonda’s nurse tonight but I came out of our step down unit to help.  “Has the resident paged back yet? If he hasn’t, can someone please page RACE*?”

The doctor orders a stat CT scan of her head and another nurse gets her ready to go downstairs. I prepare 1mg of Ativan to hang through her IV to stop the seizure and a loading dose of the anti-convulsant Dilantin will be hung next. If Rhonda slips further into unconsciousness, she may lose the drive to protect her airway and she’ll need to be intubated and cared for in the ICU while hooked up to a ventilator.  

“Are there any patients in step down who can come out?” Our Level II step down unit on the neurosurgical ward has 7 beds and is almost considered a mini-ICU, only our patients are not sedated or on ventilators.  Yes, one of our patients in step down can come out to the ward so an Environmental Aid is paged to clean the rooms and the two patients are swapped. Thankfully the Ativan has taken effect and Rhonda has stopped seizing. She still is not responding however, but she will be cared for and monitored much more closely in our step down unit. 

*The Rapid Assessment of Critical Events team at my hospital can be called at any time to help support ward patients who have become clinically unstable and determine what further level of care they need.

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"Georgiana! WHAT have you done!?” Blood covers her gown.  “Uh… um… it wasn’t me!” she says with a guilty expression on her face.

I call behind my shoulder to another nurse, “Can you throw me some gauze? She pulled her art line out.” I rip open a package of gauze and apply firm pressure to her radial artery.  Five minutes later I check the site. Good, it has stopped bleeding. “Georgiana, Georgiana, what am I going to do with you? You know I’m going to have to tie your hands down if you keep this up and you and I both won’t like that!” Georgiana suffered a subarachnoid hemorrhage* a week ago and has been monitored in our step down unit since. With these types of patients we need to monitor their blood pressure closely. Our goal of care is to keep their blood pressure high and blood vessels nice and wide open to prevent any blood vessels in their brain from going into vasospasm. We do this through a variety of oral medication and IV fluids.

Georgiana is alert and obeys commands but is pleasantly confused and somewhat restless at times. An arterial line provides real time monitoring as it displays a continuous reading of the patient’s blood pressure on the cardiac monitor. An arterial line is similar to an intravenous catheter except it is inserted in an artery and not a vein; nurses are not able to insert these. In some cases patients are unable to maintain a high enough blood pressure so we have to administer inotropic IV medications to control it. These medications work within a matter of seconds so it’s essential that they have an arterial line inserted. However, Georgiana hasn’t had any trouble with keeping her blood pressure high so I’m hoping the doctor won’t find it necessary to re-insert an art line.  My wishes are met and Georgiana is allowed to remain art line free – lucky for her as I will not need to tie her hands down to prevent further mishaps!

*a bleed in the arachnoid layer lining your brain where many of the blood vessels are located