NUR 3130 Vernon Russell Clinical vSim

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