CONCEPT MAP WORKSHEET

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. A stroke is a sudden impairment of blood circulation to the brain affecting neurologic function which is classified as hemorrhagic or ischemic (thrombotic or embolic). A stroke is the most common cause of neurologic disability which is caused by the oxygen supply to the brain being interrupted or diminished. Ischemic stroke is a thrombus or embolus that 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. A 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. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Barrium Swallow Test - PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS This test will allow us to examine the Pharynx and esophagus which is indicated For this patient. This patient presents with dysphagia which Refers to difficulty swallowing which is the Most common symptom of esophageal Disorders. Patients who have had a stroke Are often tested to make sure that there is No other underlining issues for dysphagia From smoking ANTICIPATED NURSING INTERVENTIONS Nurse will take vital signes and perform a neurological assessment. There will also be discussion about safety with Mr Russell on risk and prevention of aspiration. If his morning medications are up they will be administered as long as it Is safe for the patient to take. Any complications shall be called into the provider. Because of Mr. Russell’s history one of the anticipated physical findings would be some weakness on one side of his body when completing that neurological exam. Also expecting to find complications due to diabetes and smoking. Mr. Russell is a 55 yr old Native American. Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise. This study source was downloaded by from CourseH on :31:26 GMT -05:00 This study resource was shared via CourseH vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Good Morning Dr. This is Cathy Umrichin calling from Neurological Unit 0800 Your name, position (RN), unit you are working on SITUATION I am calling to tell you that Mr. Vernon Russell was unable to take his oral medications this morning due to not being able to swallow. Patient’s name, age, specific reason for visit BACKGROUND Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had a head CT and received thrombolytic therapy in the ED. He is nothing by mouth except for medications until the speech therapist has completed a bedside evaluation, which is scheduled for later this morning. He is scheduled for physical therapy later today. Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise. Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT We have already checked his blood glucose level this morning. His vital signs were puls 97 BP 133/79 Resp. 12 pulse Ox 97% and temp of 99*. Administration of oral medications were tried but pt. began choking and was unable to swallow. Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION I recommend that we change Mr. Russells medications to IV only and hold off on any other meds if possible until the barium swallow test is completed. If meds are needed to be given that we administer them an alternate route other than orally. Any orders or recommendations you may have for this patient This study source was downloaded by from CourseH on :31:26 GMT -05:00 This study resource was shared via CourseH PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: CLASSIFICATION: PROTOTYPE: SAFE DOSE OR DOSE RANGE, SAFE ROUTE PURPOSE FOR TAKING THIS MEDICATION PATIENT EDUCATION WHILE TAKING THIS MEDICATION This study source was downloaded by from CourseH on :31:26 GMT -05:00 This study resource was shared via CourseH Date: 10/4/2020 Student Name: Cathy Umrichin Assigned vSim: Vernon Russell Initials: VR Age: 55 M/F: M Code Status: NA Diagnosis: stroke with mild left hemiplegia Length of Stay: 1 Day Allergies: None HCP: unknown Consults: ED Isolation: No Fall Risk: Yes Transfer: From ED IV Type:Nor/Sal Location: Right Hand Fluid/Rate: 100mL/hr Critical Labs: Hb 13 Cl- 96 Prothrombintime 42 Other Services: Consults Needed: Primary Provider and Radiologyfor Barium Testing Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Pt was admitted to the ED due to having a stroke with left side weakness. Health History/Comorbities (that relate to this hospitalization): Pt has a history of Type 2 diabetes and is a smoker which may have contributed to this hospitalization. Because of pt’s stroke pt has a hard time swallowing any oral medications. Shift Goals/ Patient Education Needs: 1. Monitor pt’s tolerance to swallowing water to ensure no choking 2. Monitor pt for any decrease in mental status or further deficiet to left side. 3. Educate patient further on the risks of choking and swallowing post stroke 4. Educate patient to continue use of walker to prevent any falls due to weakness on left side from stroke Path to Discharge: Upon results of further testing work with patient to be able to swallow again. Start with liquid diet and work up to solid soft foods. Encourage pt. to actively participate in physical therapy in order to gain more strength and mobility. Path to Death or Injury: Pt. may continue not being able to swallow and unable to absorb nutrients needed to promote healing and movement. Infrequent checks on pt could lead to discovering decreased mental and neurological status. Clinical Worksheet This study source was downloaded by from CourseH on :31:26 GMT -05:00 This study resource was shared via CourseH Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Changes to mental status - not AO x3 2. Difficulty Breathing 3. Change in pt’s mobility What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Frequent neurologica tests when taking vital signs to ensure constant mental status and no further deficits. 2. Ensure that pt is in a comfortable position to encourage circulation and easy inhalation for no difficulty breathing 3. Assist pt with movement to and from bathroom and observe pt’s gait when walking with walker. Also access any fluid retention when sitting and lying in bed. List Complications may occur related to dx, procedure, comorbidities: 1. Pt. may have an adverse reaction to the barium post test and will require constant monitoring 2. Pt. may have another stroke despite current interventions. 3. Pt. may become depressed with the inability to walk with without a walker and with the left side weakness What nursing or medical interventions may prevent the above Alert or complications? 1. Good physical head to toe assessment with neurological assessment 2. Encourage the pt. to call when wanting to get out of bed to walk with nurse help and gain strength. 3. Counsel the pt on the risk of choking or aspiration of liquids along with the risks of falling and encourage pt to use the walker and to thoroughly chew foods. 4. Provide good communication with nurses during SBAR to give good detailed report to ensure pt’s safety into the next shift. Management of Care: What needs to be done for this Patient Today? 1. Barrium Swallow test 2. New medication orders due to the fact of choking on pill when tried to swallow oral medications 3. Continuous vital sign assessments 4. Continuous neurological assessments 5. Further education on aspiration and fall risks 6. Repeat labs upon providers orders Priorities for Managing the Patient’s Care Today 1. Ensure open and clear airway 2. Ensure that there is no loss of alertness and orientation of patient 3. Ensure that pt can receive medications properly for his diabetes but in the best route that the pt can tolerate 4. Address any concerns the patient may have with his treatment. What aspects of the patient care can be Delegated and who can do it? The nurse should conduct the neurological examinations however the nursing assistant can handle taking the vital signs ans assisting pt to and from the bathroom. Medications will only be administered by the nurse. 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