A case study

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A case study
2
Patients presentation

• Female, age 72, known hypertension, taking
  aspirin and a statin. Previous coronary problems
  but independent, living with her husband.
• Sudden onset of dysphasia with partial right
  hemiparesis 1000hrs. Witnessed by husband

3
The hospital journey

• Emergency admission via GP 1210hrs
• CT reported 1245hrs. No evidence of haemorrhage
  or focal infarct seen

4
Treatment

• NIHSS 16, mainly due to dysphasia, patient
  transferred onto bed independently
• Assent obtained for treatment from family
• Bolus given 1300
• Infusion commenced 1310

5
Post infusion

• 1500hrs NIHSS 11
• BP170/75
• Dysphasia persists but patient opening eyes
  spontaneously obeying commands

6
What happened next

• 1900hrs rise in BP noted, nil else of note
• Doctors informed, nurses expressed concerns that
  patient becoming receptively dysphasic.
  (frequency of obs increased)
• 2100hrs sudden drop in GCS and increased BP.
  Urgent CT requested

7
CT report

• CT reported Within the left fronto-temporal
  region is a large parenchymal haemorrhage which
  is heterogenous and contains layering. There is
  extention of the haemorrhage into the ventricular
  system
• Large left temporal acute intercerebral
  haemorrhage with significant mass

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The obs charts
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The Outcome

• Transferred to Neuro ITU, family with patient.
• Situation discussed with family who requested
  support be withdrawn.
• RIP 0445hrs

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Family's concerns

• Did she suffer pain?
• Why did they need to make the decision to treat?
  Was this the right decision?
• They felt rushed into the decision.

12
Our concerns

• Could we have detected the change quicker?
• The nurses instincts were not reflected in the
  observations or accepted by the doctors.