CONCEPT MAP WORKSHEET

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) DIAGNOSTIC TESTS (REASON FOR TEST ANDRESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS ANTICIPATED NURSING INTERVENTIONS A stroke, also known as a cerebrovascular accident (CVA), occurs due to a sudden impairment of blood circulation to the brain affecting neurologic function. It is the 5th leading cause of death in the U.S. and the most common cause of neurologic disability. There are two types of classifications for a stroke, hemorrhagic or ischemic. During a stroke, the oxygen supply to the brain is interrupted or diminished. With ischemic stroke, a thrombus or embolus partially or completely occludes cerebral blood flow to an area of the brain; cellular hypoxia occurs, and cell membrane permeability and cell depolarization are affected. As blood flow decreases, focal areas of ischemia occur, followed by infarction to the vascular territory. Changes in membrane permeability lead to an influx of sodium and calcium ions and water, leading to edema. Neurons die from lack of oxygen. With hemorrhagic stroke, blood leaks from a blood vessel or hemorrhage into the brain tissue, causing edema, compression of brain tissue, and spasm of adjacent blood vessels. Intracranial hemorrhage becomes a space-occupying lesion that compromises brain function. Impaired cerebral perfusion causes infarction. Vernon Russell is a 55-yearold Native American man who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He has a history of HTN, CAD, and DM Type 2. He smokes over a pack of cigarettes per day and does not exercise. CBC evaluates overall health and detects diseases and/or infections – low Hb (13) BMP measures the levels of the body’s main electrolytes – low Cl- (96) Coagulation screening determines eligibility for treatment of ischemic stroke – elevated prothrombin time (42) A capillary blood glucose level may determine whether hypoglycemia is the cause of symptoms – normal values • Weakness in the left side of the body • Some sensory loss on left side • Decreased mobility • Weak strength • Change in LOC • Decreased deep-tendon reflexes • Educate the patient on activities, safety, and risk of falls. • Educate the patient on risk of aspiration. • Perform a skin assessment and skin care to prevent pressure injury formation; provide a low-air-loss mattress and pressure-reducing alignment devices. • Position the patient carefully to prevent aspiration and contractures. • Assist the patient with getting out of bed and ambulating; check for orthostatic hypotension when the patient changes positions. • Complete a swallow assessment and institute aspiration precautions, as indicated. Provide enteral feedings if swallowing is impaired. • Institute oral hygiene protocol to reduce the risk of pneumonia. • Follow the physical therapy program and assist the patient with ROM exercises. • Maintain a patent airway and oxygenation; administer supplemental oxygen based on pulse oximetry and arterial blood gas analysis results. vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Hello! My name is Thalia Fortun. I am a student nurse from Nova Southeastern University. I work at Memorial Hospital in the Your name, posi Neurological Unit 0800. tion (RN), unit you are working on SITUATION Vernon Russell is a 55-year-old who was admitted with a stroke with mild left hemiplegia. Patient’s name, age, specific reason for visit BACKGROUND Primary diagnosis is a right-sided stroke. Mr. Russell was admitted on 4/01/2021. Patient is on NPO except for medications. Current Orders: Vital signs and neuro assessment every 4 hrs Activity: up to chair, up to bathroom w/ assistance Fall risk assessment Medications: Aspirin 81 mg PO daily, Metformin 500 mg PO twice daily, Losartan 50mg PO twice daily, Chlorthalidone 25 mg daily, Nicotine patch 1 mg once daily for 6 weeks Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Patient is alert and oriented x3. Current vital signs: HR 96 bpm, RR 12 bpm, BP 134/80 mm Hg, SpO2 97%, Temp 99 F. Pulse is present. Patient continues to have limited range of motion on the left side. There is symmetry when he smiles. Puffing cheeks and tongue movements are normal. Gag reflex is intact. His hands grasps are almost equal but a little weaker on the left side. There is normal sensation in all limbs and the face. Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION Continue to monitor vital signs and perform neuro checks per shift Educate patient on the importance of passive ROM exercises to improve mobility and circulation Educate patient on symptoms and complications of a stroke. Any orders or recommendations you may have for this patient PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Aspirin CLASSIFICATION: Therapeutic class: NSAIDs Pharmacologic class: Salicylates PROTOTYPE: Durlaza, Bayer Aspirin, Ecotrin, Entrophen SAFE DOSE OR DOSE RANGE, SAFE ROUTE To reduce risk of recurrent TIAs and stroke or death in patients at risk Adults: 50 to 325 mg PO daily. Or, 162.5 mg extended-release capsule PO daily. Acute ischemic stroke Adults: 50 to 325 mg PO daily, started within 48 hours of stroke onset; continue indefinitely. PURPOSE FOR TAKING THIS MEDICATION Thought to produce analgesia and exert its anti-inflammatory effect by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heat-regulating center. In low doses, drug also appears to interfere with clotting by keeping a platelet-aggregating substance from forming. PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Tell patient who’s allergic to tartrazine to avoid aspirin. • Advise patient on a low-salt diet that 1 tablet of buffered aspirin contains 553 mg of sodium. • Advise patient to take drug with food, milk, antacid, or large glass of water to reduce GI reactions. • Tell patient not to crush or chew enteric-coated or extended-release forms but to swallow them whole. • Advise patient to take extended-release capsules at same time each day. • Warn patient not to drink alcohol 2 hours before or 1 hour after taking extended-release capsule and not to take extra capsule to make up for a missed dose. • Remind patient taking drug for a chronic condition not to stop drug without first discussing with prescriber. • Instruct patient to discard aspirin tablets that have a strong vinegar-like odor. • Tell patient to consult prescriber if giving drug to children for longer than 5 days or adults for longer than 10 days. • Advise patient receiving prolonged treatment with large doses of aspirin to watch for small, round, red pinprick spots; bleeding gums; and signs of GI bleeding; advise patient to drink plenty of fluids. Encourage use of a soft-bristled toothbrush. • Because of the many drug interactions with aspirin, warn patient taking prescription drugs to check with prescriber or pharmacist before taking aspirin or OTC products containing aspirin. • Ibuprofen can interfere with the antiplatelet effect of low-dose aspirin therapy, negating its effect. Teach patient how to safely use ibuprofen in relation to aspirin therapy. • Drug is a leading cause of poisoning in children. Caution parents to keep drug out of reach of children. Encourage use of child-resistant containers. PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Metformin Hydrochloride CLASSIFICATION: Therapeutic class: Antidiabetics Pharmacologic class: Biguanides PROTOTYPE: Glucophage, , Glucophage XR, , Glumetza, , Riomet SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: If using immediate-release tablets or oral solution, initially 500 mg PO b.i.d. given with morning and evening meals, or 850 mg PO once daily given with morning meal. Titrate immediate-release forms in increments of 500 mg weekly or 850 mg every other week to maximum dose of 2,550 mg PO daily in divided doses. If using extended-release formulation, start therapy at 500 mg PO once daily with the evening meal. May increase dose as tolerated weekly (every 1 to 2 weeks for Glumetza) in increments of 500 mg daily, up to a maximum dose of 2,000 mg once daily. If higher doses are required, consider a trial of 1,000 mg b.i.d. or using the regular-release formulation up to its maximum dose. PURPOSE FOR TAKING THIS MEDICATION Decreases hepatic glucose production and intestinal absorption of glucose and improves insulin sensitivity (increases peripheral glucose uptake and use). PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Instruct patient about nature of diabetes and importance of following therapeutic regimen, adhering to specific diet, losing weight, getting exercise, following personal hygiene programs, and avoiding infection. Explain how and when to monitor glucose level. Teach evidence of low and high glucose levels. Explain emergency measures. Black Box Warning: Instruct patient to stop drug and immediately notify prescriber about unexplained hyperventilation, muscle pain, malaise, dizziness, light-headedness, unusual sleepiness, unexplained stomach pain, feeling of coldness, slow or irregular HR, or other nonspecific symptoms of early lactic acidosis. Black Box Warning: Warn patient against excessive alcohol intake while taking drug. • Tell patient not to change drug dosage without prescriber’s knowledge. Encourage patient to report abnormal glucose level test results. • Alert: Advise patient not to cut, crush, or chew extended-release tablets; instruct patient to swallow them whole. • Tell patient that inactive ingredients may be eliminated in the stool as a soft mass resembling the original tablet. • Advise patient not to take other drugs, including OTC drugs, without first checking with prescriber. • Instruct patient to carry medical identification at all times. PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Losartan Potassium CLASSIFICATION: Therapeutic class: Antihypertensives Pharmacologic class: ARBs PROTOTYPE: Cozaar SAFE DOSE OR DOSE RANGE, SAFE ROUTE For HTN Adults: Initially, 50 mg PO daily. Maximum daily dose is 100 mg. Nephropathy in patients with type 2 diabetes Adults: 50 mg PO once daily. Increase dosage to 100 mg once daily based on BP response. To reduce risk of stroke in patients with HTN and left ventricular hypertrophy Adults: Initially, 50 mg PO once daily. Adjust dosage based on BP response, adding hydrochlorothiazide 12.5 mg once daily, increasing losartan to 100 mg daily, or both. If further adjustments are required, may increase the daily dosage of hydrochlorothiazide to 25 mg. PURPOSE FOR TAKING THIS MEDICATION Inhibits vasoconstrictive and aldosterone-secreting action of angiotensin II by blocking angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells. PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Tell patient to avoid salt substitutes; these products may contain potassium, which can cause high potassium level in patients taking losartan. • Inform female patient of childbearing potential about consequences of taking drug while pregnant. Advise her to notify prescriber immediately if she suspects she is pregnant. • Advise patient not to breastfeed while taking drug. • Advise patient to report all adverse reactions and to immediately report swelling of face, eyes, lips, or tongue or breathing difficulty. PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Acetaminophen CLASSIFICATION: Therapeutic class: Analgesics Pharmacologic class: Para-aminophenol derivatives PROTOTYPE: Tylenol SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: 325 to 650 mg PO every 4 to 6 hours. Or, two extended-release caplets PO every 8 hours. Maximum, 3,250 mg daily unless under health care provider supervision, when 4 g daily (immediaterelease) may be used. For long-term therapy, don’t exceed 2.6 g daily unless prescribed and monitored closely by health care provider. PURPOSE FOR TAKING THIS MEDICATION Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heat-regulating center. PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Tell parents to consult prescriber before giving drug to children younger than age 2. • Advise parents that drug is only for short-term use; urge them to consult prescriber if giving to infants for longer than 3 days, children for longer than 5 days, or adults for longer than 10 days. Black Box Warning: Advise patient or caregiver that many OTC products contain acetaminophen and should be counted when calculating total daily dose. • Tell patient to consult prescriber for fever lasting longer than 3 days or recurrent fever. • Alert: Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage. Caution long-term alcoholics to limit drug to 2 g/day or less. • Caution patient to contact health care provider if signs and symptoms of liver damage (illogical thinking, severe dyspepsia, jaundice, inability to eat, weakness) occur. • Tell breastfeeding patient that drug appears in human milk in low levels. Drug may be used safely if therapy is short-term and doesn’t exceed recommended doses. • Alert: Warn patient to stop drug and seek medical attention immediately if rash or other reactions occurs while using acetaminophen. PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Warfarin Sodium CLASSIFICATION: Therapeutic class: Anticoagulants Pharmacologic class: Coumarin derivatives PROTOTYPE: Coumadin, Jantoven SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: 2 to 5 mg PO daily for 2 to 4 days; then dosage based on daily PT and INR until stable in the therapeutic range. Usual maintenance dosage is 2 to 10 mg PO daily. Base dosages on INR target goals and other clinical factors. PURPOSE FOR TAKING THIS MEDICATION Inhibits vitamin K-dependent activation of clotting factors II, VII, IX, and X, formed in the liver. Also inhibits anticoagulant proteins C and S. PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Stress importance of complying with prescribed dosage and follow-up appointments. Tell patient to carry a card that identifies patient’s increased risk of bleeding. Black Box Warning: Tell patient and family about measures to prevent bleeding, to watch for signs of bleeding or abnormal bruising, and to call prescriber at once if they occur. • Warn patient to avoid OTC products containing aspirin, other salicylates, or drugs that may interact with warfarin unless ordered by prescriber. • Alert: Advise patient to consult prescriber before initiating any herbal therapy as many herbs have anticoagulant, antiplatelet, or fibrinolytic properties. • Tell patient to consult prescriber before using miconazole vaginal cream or suppositories. Abnormal bleeding and bruising have occurred. • Instruct female patient to notify prescriber if menstruation is heavier than usual; she may need dosage adjustment. • Tell patient to use electric razor when shaving and to use a soft toothbrush. • Tell patient to read food labels. Food, nutritional supplements, and multivitamins that contain vitamin K may impair anticoagulation. • Tell patient that consuming foods high in vitamin K can decrease anticoagulant effects. Tell patient to eat a balanced diet without large amounts of green, leafy vegetables and to notify prescriber before making any dietary changes. • Tell patient to inform all health care providers about taking warfarin and to inform warfarin prescriber of new medication orders and upcoming surgeries or procedures. PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Chlorthalidone CLASSIFICATION: Therapeutic class: Antihypertensive, diuretics Pharmacologic class: thiazide diuretics PROTOTYPE: Coumadin, Jantoven SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: 2 to 5 mg PO daily for 2 to 4 days; then dosage based on daily PT and INR until stable in the therapeutic range. Usual maintenance dosage is 2 to 10 mg PO daily. Base dosages on INR target goals and other clinical factors. PURPOSE FOR TAKING THIS MEDICATION • Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule. • Promotes excretion of chloride, potassium, magnesium, and bicarbonate. • May produce arteriolar dilation. • Lowers of BP in hypertensive patients and diuresis with mobilization of edema. PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Stress importance of complying with prescribed dosage and follow-up appointments. Tell patient to carry a card that identifies patient’s increased risk of bleeding. Black Box Warning: Tell patient and family about measures to prevent bleeding, to watch for signs of bleeding or abnormal bruising, and to call prescriber at once if they occur. • Warn patient to avoid OTC products containing aspirin, other salicylates, or drugs that may interact with warfarin unless ordered by prescriber. • Alert: Advise patient to consult prescriber before initiating any herbal therapy as many herbs have anticoagulant, antiplatelet, or fibrinolytic properties. • Tell patient to consult prescriber before using miconazole vaginal cream or suppositories. Abnormal bleeding and bruising have occurred. • Instruct female patient to notify prescriber if menstruation is heavier than usual; she may need dosage adjustment. • Tell patient to use electric razor when shaving and to use a soft toothbrush. • Tell patient to read food labels. Food, nutritional supplements, and multivitamins that contain vitamin K may impair anticoagulation. • Tell patient that consuming foods high in vitamin K can decrease anticoagulant effects. Tell patient to eat a balanced diet without large amounts of green, leafy vegetables and to notify prescriber before making any dietary changes. • Tell patient to inform all health care providers about taking warfarin and to inform warfarin prescriber of new medication orders and upcoming surgeries or procedures. Clinical Worksheet Date: 04/02/2021 Student Name: Thalia Fortun Assigned vSim: Vernon Russell Initials: VR Age: 55yo M/F: Male Code Status: Full Code Diagnosis: Right-sided Stroke Length of Stay: 0.7 days Allergies: NKA HCP: Lonny Washington Consults: Speech therapist Isolation: Standard Fall Risk: High Transfer: Assistance needed for ambulation IV Type: Peripheral Location: Right arm Fluid/Rate: Normal saline 100 mL/hr Critical Labs: ClHb Prothrombin time Other Services: N/A Consults Needed: Speech therapist Why is your patient in the hospital? (Answer in your own words and include the history of present illness) Mr. Russell was admitted to the hospital yesterday afternoon due to a stroke with mild left hemiplegia. Health History/Comorbidities (that relate to this hospitalization): Mr. Russell has a history of hypertension, coronary artery disease, diabetes mellitus type 2, smoking, and lack of exercise. Shift Goals/ Patient EducationNeeds: Path to Discharge: Patient will regain his swallowing reflex and demonstrate knowledge on fall risks and safety. Path to Death or Injury: Patient will not regain his swallowing reflex leading to recurrent choking. Patient may fall due to unsteady gait and injury himself. 1. Patient will tolerate ROM exercises to aid in mobility and increase circulation. 2. Patient will demonstrate understanding regarding fall prevention and safety. 3. Patient will understand complications of a stroke. 4. Patient will call for assistance if he needs to be ambulated. Clinical Worksheet Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Aspiration 2. Neurologic status 3. Coagulation status What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Pain assessment 2. Neurological assessment 3. Vital signs List Complications that may occur related to dx, procedure, comorbidities: 1. Recurrent strokes 2. Aspiration 3. Pneumonia What nursing or medical interventions may prevent the above Alert or complications? 1. Vital signs 2. Neurological assessment 3. Assist the patient to a High Fowler’s position 4. Passive ROM exercises Management of Care: What needs to be done for this Patient Today? 1. Vital signs 2. Neurological Assessment 3. Patient education on risk of aspiration 4. Patient education on fall prevention 5. Administer medications 6. Ambulation assistance Priorities for Managing the Patient’s Care Today 1. Vital signs 2. Neurological assessment 3. Education on fall risk prevention 4. NPO until speech therapist assessment What aspects of the patient care can be Delegated and who can do it? The CNA can assist with ROM exercises, monitoring of vital signs, documentation of I & O, and supervising with patient ambulation PRN. Reflection Questions Paste your reflection questions in the box below Opening Questions How did the simulated experience of Vernon Russell’s case make you feel? I felt confident in this vSim, except the patient started choking… wasn’t expecting that. Talk about what went well in the scenario. I was able to assist the patient in clearing his airway then contacted the provider immediately. Reflecting on Vernon Russell’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change? I wouldn’t do anything different. Scenario Analysis Questions* à What priority problem(s) did you identify for Vernon Russell? Risk of aspiration, dysphagia, and hemiplegia on the left side of the body. à Correlate the abnormal coagulation studies results to Vernon Russell’s current treatment that has been initiated thus far. The need to wait for his coagulation screening before giving Mr. Russell his Warfarin was to ensure it wouldn’t affect his bleeding or interact with any other medications. à What resources are available to the interprofessional health care team to guide the care of Vernon Russell and/or any stroke patient? Stroke support groups; speech, physical, and occupational therapy. à Discuss the rationale for Vernon Russell being placed on NPO status? A stroke incidence tends to have a negative effect on the muscles and nerves that aid in passing food contents through the throat. The patient was having difficulty swallowing and was at risk for aspiration, he was placed NPO except oral meds but he started choking as we were administering Losartan 50mg, therefore the HCP placed him on strict NPO. à How did you respond to Vernon Russell’s question related to why he needs someone to help him walk, and what is your rationale for your response? Mr. Russell needed assistance walking due to being hemiplegic on his left side, this can cause an unsteady gait and the patient might lose balance, causing him to fall and injure himself. Therefore, assistance is needed to support his weaker side. The patient is also at high risk of bleeding. à Utilizing Vernon Russell’s health history identify factors that predisposed him to having a stroke. Hypertension, CAD, Diabetes Mellitus Type 2, smoking a pack of cigarettes for the past 35 years and lack of exercise. à Discuss why the referral for speech therapy is important in Vernon Russell’s care. Speech therapy will assist the patient in helping regain his swallow reflex and portion his foods to prevent risk of aspiration. Concluding Questions à Describe how you would apply the knowledge and skills that you acquired in Vernon Russell’s case to an actual patient care situation. I would instruct the patient to call for assistance if he/she needs to be ambulated and also take all necessary precautions to avoid risk of aspiration. Additionally, I would implement the need to assess the patient’s neurological status every 4 hours to check their level of consciousness. Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Noticing: Focused Observation: E A D B Recognizing Deviations from Expected Patterns: E A D B Information Seeking: E A D B Total for category: Score: vSim 1 E E E E 16 Score: vSim 2 Score: vSim 2 Interpreting: Prioritizing Data: E A D B Making Sense of Data: E A D B Total for category: E E 8 Responding: Calm, Confident Manner: E A D B Clear Communication: E A D B Well-Planned Intervention/Flexibility: E A D B Being Skillful E A D B Total for category: E E E A 15 Reflecting: Evaluation/Self-Analysis: E A D B Commitment to Improvement: E A D B Total for category: E E 8