1. 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

2. Advancing 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)

3. Advancing 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

4. Advancing 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

5. Advancing 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

6. Advancing the Vision of the Neurological Institute 6 Patient Experience - MRI

7. Advancing the Vision of the Neurological Institute 7 Patient Experience Endovascular devices Solitaire Penumbra

8. Advancing the Vision of the Neurological Institute 8 Patient Experience Endovascular 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

9. Advancing 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

10. Advancing 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 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

11. Advancing the Vision of the Neurological Institute 11 Patient Experience Diabetes 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

12. Advancing 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

13. Advancing 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

14. Advancing the Vision of the Neurological Institute 14 Patient Experience Discharge Medications ASA Atorvastatin HCTZ Metoprolol Ferrous Sulfate Synthroid Ranitidine Heparin SQ Ciprofloxacin for UTI