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 2014

Julie Fussner BSN, RN, CPHQ, SCRN

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

2

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)

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

3

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

4

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

5

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

6

Patient Experience - MRI

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

7

Patient Experience Endovascular devices

Solitaire Penumbra

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

8

Patient ExperienceEndovascular 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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

9

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

10

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

11

Patient ExperienceDiabetes 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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

12

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

13

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

Advancing the Vision of the Neurological InstituteAdvancing the Vision of the Neurological Institute

14

Patient ExperienceDischarge Medications

• ASA • Atorvastatin• HCTZ• Metoprolol• Ferrous Sulfate• Synthroid• Ranitidine• Heparin SQ• Ciprofloxacin for UTI