J Sparrow, a 70-year-old patient, presents to the emergency department 4 hours after experiencing an ischemic brain attack confirmed on the CT of the head without contrast. The patient is a candidate for intra-arterial thrombolytic therapy to dissolve the blood clot causing the significant stroke symptoms. The patient is scheduled for the emergent cerebral angiogram with possible intra-arterial thrombolytic therapy. The nurse provided patient and family education and received the informed written consent from the patient’s spouse. The patient has intravenous normal saline at 100 mL/hr infusing into the right forearm with an 18-gauge angiocath, which is patent.
Interpretations and findings done by the group:
Most books have cited the importance of the “3-hour window” for administration of thrombolytic therapies. This is to adhere to the fact that irreversible brain injuries usually take place after 3 hours from the onset of stroke, and any intervention to reverse the condition would be deemed useless. But recent studies show that the 3 hour window was extended to 4.5 hours, and was proven to still be therapeutic if the drug was administered up to this time. In the patient’s case, even if it was 4 hours after the onset of stroke, he was still allowed to undergo possible Intra-arterial Thrombolytic therapy following a cerebral angiography since this was indicated for stroke patients with onset of symptoms for more than 3 hours.
CT scan of the head without contrast was done as a differential diagnosis as to what type of stroke patient JS had experienced. This was an important test to determine further interventions needed, and to reduce risks for any complications if the client’s stroke was classified as hemorrhagic.
Cerebral angiography was ordered to identify the exact area of occlusion, so that immediate administration of the thrombolytic drug can be done. Before patient JS became a candidate for thrombolytic therapy, several criteria for eligibility were assessed since not all stroke patients can have this kind of therapy.
What labs should the nurse assess before the procedure and why?
Patient JS is about to undergo cerebral angiography, wherein a contrast dye is to be injected to view the area of occlusion. Before the procedure, certain laboratory tests need to be assessed and reassessed as a standard protocol, and for further procedures which requires it. The cerebral angiography test is done to locate the area of occlusion or infarction to determine the area of administration of Thrombolytics. Since the client is about to undergo EMERGENT cerebral angiography, only the most significant laboratory tests are to be assessed.
Complete blood count with Platelet Count
Hemoglobin count is important to determine the amount of oxygen in the blood. Low oxygen in blood aggravates the condition of the patient (in which a part of the brain is deprived already of oxygen), by depriving other parts of the brain or body of proper oxygen. Hematocrit can also determine if the client experiences alterations in fluid volume, especially within the blood vessels. Assessing these values can determine further interventions needed to be done before the procedure, such as administration of oxygen and increasing the rate of administration of fluids.
Platelet count and other clotting factors are also important to monitor since bleeding may occur at the insertion site.
This is vital for procedures requiring injection of contrast dye. This test can determine the kidney’s ability to excrete the contrast dye. If in case, patient JS’s kidney functions are ineffective (as manifested by abnormal levels of BUN/Creatinine), the procedure can still be continued, but requires rapid administration of fluids (more than 100 cc/hr in patient JS’s case) to easily flush out the contrast dye, which is used for the procedure.
Sodium and Potassium
This is also used to determine the interventions needed to be done when it comes to maintaining fluid and electrolyte imbalance. Alterations in these values can signal the health care provider to increase the rate and amount of fluids to administer.
Other protocol Laboratory tests:
Although the patient is already a candidate for t-PA administration, still, the nurse needs to reassess the following:
Platelet Count (should be greater than or equal to 100,000/mm3); Prothrombin Time ( â‰¤ 15 seconds) and INR (â‰¤ 1.7) to prevent aggravation of bleeding tendencies, since clotting factors are important to maintain homeostasis of a person’s blood.
Glucose levels should be maintained to an optimal level, since there are studies that show that hyperglycemic blood can alter the efficacy of the thrombolytic drug. It should be maintained to optimal levels of 90 – 120 mg/dL to maximize the therapeutic effects of the drug.
What additional preparation should the nurse provide before the patient goes to the procedure?
For cerebral angiography
Verify the client who is about to undergo the said procedure.
The nurse should also again, ask the patient or the significant others if the patient who is about to undergo Cerebral angiography has allergies with iodine, shellfish, sea foods and dye. Not confirming this would greatly cause complications with the patient if in case, he is actually allergic to any of these substances.
Have a Pulse Oximeter, Blood Pressure and Heart performance monitor (ECG) ready at the bedside of the patient.
Ask the patient to empty his bladder before the procedure since this usually takes several hours to complete, including recovery time. If he is unable to get out of the bed, use a bedpan or a diaper. If ordered, use a Foley Catheter to empty the bladder.
Re-educate the client with the procedure he is about to undergo, if needed. He should be immobile while the procedure is being done, and he would expect a brief feeling of warmth in the face behind the eyes or in the jaw, teeth, tongue and lips, and he would have a metallic taste when dye is injected. Educating both the client and the significant others reduces anxiety.
Position the client in a supine position to prepare him for the procedure.
Clean the incision site (femoral artery), where the catheter to be used for Cerebral angiography (and possibly, Thrombolytic therapy) is to be inserted. Shaving the groin area is necessary.
Administer analgesics/ anesthetics (when ordered) near the incision site to reduce the pain and discomfort that would be felt by the patient.
For thrombolytic therapy
Blood pressure (should have systolic pressure of â‰¤185mmHg; diastolic pressure must be â‰¤110mmHg) to prevent aggravation of hemorrhagic tendencies, which is a side effect of Thrombolytic Therapy.
Re-assess the client if there are any factors that may exclude him from the thrombolytic therapy eligibility criteria. This includes factors on any history of anticoagulant drug intake, major surgeries, intracranial hemorrhage, abnormal bleeding, etc.
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