Mrs. C, a healthy 80 year old with moderate dementia, walked and ate independently. This morning it takes two staff to get her out of bed. She has difficulty following directions and walking the short distance to the dining room. She needs assistance to eat. You notice she takes a long time to chew her food, and seems reluctant to swallow. Her words are a bit garbled.
What would you do and why?
1. Do nothing. Just observe to see if her symptoms are going to worsen. She’s demented with a DNR so the family would not want any aggressive treatment. Often in these cases the doctor/nurse practitioner just wants us to observe.
2. Do vital signs and a neuro check because this is an acute change. She might have an infection, a heart or lung problem or a transient ischemic attack (TIA) or cerebral vascular accident (CVA) needing immediate attention.
3. Inform the doctor/nurse practitioner of the acute changes.
If you answered, number one, you are not doing your job. Your patient has had an acute change in condition. As Mrs. C’s nurse, it is up to you to gather more data to see if she needs emergency treatment. You are making an assumption that she has a condition for which the family would not want to treat. What do you gain by waiting and observing further?
If you answered, number three, you are not doing your job. You can report the changes, but you have not gathered critical information or done any exams that would lead the NP/doctor to know what direction to go in for evaluation and treatment.
Good for you if you answered number two. You have started the nursing assessment.
What actually happened:
You find that her vital signs are within normal limits. (WNL) One side of her face seems to be drooping. Her hand grips are equal. She is following directions now and starting to speak clearer. When you pick up Mrs. C’s left arm, it drops. The same happens with her left arm, but the right arm and leg do not. You know these are signs of a TIA or CVA. Without a CT scan, it would be impossible to tell the difference. If it is a stroke, Mrs. C needs to get to the emergency room as soon as possible after the start of her symptoms for treatment to be effective. You think you should call Mrs. C’s daughter and see if she wants her mother transported to the hospital. Since she seems to be doing better, one of your fellow nurses suggest you wait. What do you do?
I hope you answered that you called Mrs. C’s daughter despite the other nurse’s suggestion. The daughter states that her mother did have a history of TIAs in the past and wants her transported to the hospital. At the emergency room, a CT scan of her brain reveals Mrs. C suffered a stroke. She is admitted for treatment.
What you can learn from this case:
1. Don’t ignore acute changes in your patients despite the patient’s diagnosis or DNR status.
2. Don’t assume the family/physician/nurse practitioner want to do nothing.
3. Do your job by following the nursing process of assessment, diagnosis and plan.
4. Don’t let peers make you second guess your conclusions/judgment. Take action when your nursing assessment tells you it is the right thing to do.