Student Simulation Preparation: Ischemic & Hemorrhagic Stroke
Student Simulation Preparation: Ischemic & Hemorrhagic Stroke Student Learning Objectives: SLO 1-8 9. Perform appropriate neurological assessment. 10. Implement seizure precautions. 11. Prioritize care for increased intracranial pressure. 12. Utilize a communication board. Patient information: Julie Wilson, a 48-year-old female, brought into ER by husband after she collapsed at home. Patient presented confused, complaining of a severe headache and blurred vision. Diagnosed with ischemic stroke and treated with rTPA in the ICU. Is currently being treated on the med/surg floor status post CVA. Preparation for scenario: Completion of Student Worksheet (bring with you to sim lab) Pearson: Perfusion: Read Pearson Module 16.J & 16. M – (PVD & Stroke) Nursing Skills: · Care of a patient with Hemianopsia: Food Tray · Complete Neuro Check Skills Set Up: · Hemianopsia glasses, thickener, Food tray with food I. Data Collection History of Present Problem: Julie Wilson, a 48-year-old female, brought into ER by husband after she collapsed at home this am. Initially was slightly confused. Complaining of severe right temporal lobe headache and blurred vision. Husband reports that she was complaining of headaches and blurred vision that “came & went quickly” over the past 3-4 weeks. CT w/o contrast of right temporal lobe positive for ischemia. Treated in ICU with rTPA. Residual left sided weakness noted. Patient transferred to med/surg floor to begin rehabilitation and for blood pressure stabilization. Patient noted with edema of bilateral lower extremity upon assessment by the med-surg nurse. PMH: HTN, Diabetes – type II, hypercholesterolemia, ½ ppd smoker and peripheral vascular disease (PVD). Personal/Social History: Married for 20 years. Has 3 children who are grown and on their own. Patient works in human resources at a local supermarket. Exercises a couple times a week. What data from the histories is important & RELEVANT; therefore, it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: HTN Peripheral vascular disease (PVD) Metoprolol (Lopressor) 50mg daily Metformin 500mg daily Cilostazol (Pletal) Beta Blocker II. Patient Care: Most Recent VS: WILDA Pain Assessment (5th VS): T: (oral) 99o F Words: No Pain P: 102 Intensity: n/a R: 22 Location: n/a BP: 174/104 Duration: n/a O2 sat: 96% on RA Aggravate: Alleviate: n/a What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Resting in bed, visibly upset about diagnosis and lifestyle changes. RESP: Breath sounds clear with equal aeration bilaterally CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4), neuro check: eyes open to speech, inappropriate words, abnormal flexion, severe weakness left arm and severe weakness left leg GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. BM this shift GU: Foley catheter with c/y/u SKIN: Erythema on buttocks and bilateral lower extremity with edema. What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: Nursing Interventions: Rationale: Expected Outcome: Neuro checks Monitor VS Reinforce PT/OT recommendations Evaluate anxiety Turn and Repo q2 Educate about assistive devices (i/e- communication board) Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome: Labetalol 10mg IVP for systolic BP >160 Seizure precautions Speech therapy PT/OT Neuro Checks q4hours Continuous oxygen sat monitoring. PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1. 2. 3. 4. 5. 6. Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Labatelol 10mg IVP prn, every 2 hours for systolic BP >160 Acetaminophen (Tylenol) 650mg PO, prn every 4 hours for temp> 101.4oF Radiology Reports: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: CT w/o contrast Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? WBC (4.5-11.0 mm 3) 4.6 Hgb (12-16 g/dL) 13 Platelets (150-450 x103/µl) 155 Neutrophil % (42-72) 44 Band forms (3-5%) 4 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Sodium (135-145 mEq/L) 138 Potassium (3.5-5.0 mEq/L) 3.8 Chloride (95-105 mEq/L) 96 CO2 (Bicarb) (21-31 mmol/L) 22 Anion Gap (AG) (7-16 mEq/l) 15 Glucose (70-110 mg/dL) 174 Calcium (8.4-10.2 mg/dL) 8.6 BUN (7-25 mg/dl) 22 Creatinine (0.6-1.2 mg/dL) 1.0 RELEVANT Lab(s): Clinical Significance: Misc. Labs: Current: High/Low/WNL? Magnesium (1.6-2.0 mEq/L) 1.8 Coags: Prothrombin Time (9.5 – 11.6 seconds) 10.8 INR (0.7 – 1.8) 0.82 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WNL Revised from http://www.ksbn.org/education/Scenario/SimulationScenarioLibrary.htm Situation: Background: Assessment: Recommendation: SCIENCE HEALTH SCIENCE NURSING
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