Exam (elaborations)
NURSING 341-vsim Vernon Russell
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NURSING 341-vsim Vernon Russell
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CONCEPT MAP WORKSHEETDESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Right sided stroke with mild left hemiplegia. Oxygen supply to the brain is interrupted or dimished.
Ishemic Stroke- thrombus or embolus partially or completely occludes cerebral blood flow to an area od the brain; cellular
Hypoxia results, membrane permeability, cell depolarization are affected. Changes in membrane permeability lead to an influx
Of sodium, calcium and water, causing edema. Neurons die from lack of oxygen. As blood flow decreases, focal areas of
Ischemia occur, followed by infarction to the vascular territory.
Hemorrhagic Stroke- blood leaks from the vessels or hemorrhage into the brain tissue, causing edema, compression of the
Brain tissue, and spasm of adjacent blood vessels. Intracranial hemorrhage becomes a space occupying lesion that compromises
Brain function. Impaired cerebral perfusio causes infarction (Lippincott)
-Blood Glucose- to check glucose levels. Vernon Russell DOB:1/14/65 -Muscle weakness left side
-CBC with differential- complete blood count 55, Native American - possible dysphagia aspiration
INR/PT- How long it takes blood to clot Stroke right side with left hemiplegia -possible high glucose levels
BMP- fluid balance (lippincot) Diabetic, Coronoary Artery Disease - high INR levels
Hypertension, Smokes - high blood pressure
over a pack a day - trouble walking
Does not excercise
(vsim)
PATIENT INFORMATION
Help patient ambulate to bathroom.
Help patient bath as needed
LOC assessment
Nuerological assessments
Monitor i/o
Pattient education on preventative care, changing modifyable risks, proper ambulation with a walker
Vital Signs
Airways assessment
Auscultate lungs
Maintain homeostasis
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Nicole Diana, RN, Neuro
Your name, position (RN), unit you are
working on
SITUATION Vernon Russell, 55, Stroke with mild hemiplegia of the left side
Patient’s name, age, specific reason for visit
BACKGROUND Stroke with mild hemiplegia of the left side, 10/1/2020.
Orders: admit to neuro floor, VS/nuero assessment every 4 hours, NPO
Patient’s primary diagnosis, date of until swallow study tomorrow, Fall risk assessment, Labs:CBC, chem
admission, current orders for patient panel, and prothrombin time. Glucose blood test.
ASSESSMENT BP: 134/80 Temp: 99 Glucose: 84ml/dl PERRLA: Normal
Skin: Normal Gag reflex: intact
Current pertinent assessment data using head Grip Strength: weak on left side
to toe approach, pertinent diagnostics, vital No signs of dehydration.
RR: 12
signs
PT/INR: 42, 4.5 HIGH
BMP: Normal
CBC: Normal
Pulse:95
Sp02:97
Dysphagia present
RECOMMENDATION Cessation of smoking
Exercise program
Any orders or recommendations you may have Healthy diet
for this patient Nutritionist
Physical Therapy or rehabilitation
Ambulating with a walker teaching
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