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Vernon Russell Clinical vSim-1
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Vernon Russell Clinical vSim-1
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CONCEPT MAP WORKSHEETDESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
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.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
CBC evaluates overall health and Vernon Russell is a 55-year-
detects diseases and/or infections – low old Native American man • Weakness in the left side of
Hb (13) who was admitted with a the body
BMP measures the levels of the stroke with mild left • Some sensory loss on left
body’s main electrolytes – low Cl- (96) hemiplegia yesterday side
Coagulation screening determines afternoon. He has a history of • Decreased mobility
eligibility for treatment of ischemic HTN, CAD, and DM Type 2. • Weak strength
stroke – elevated prothrombin time He smokes over a pack of • Change in LOC
(42) cigarettes per day and does • Decreased deep-tendon
A capillary blood glucose level may not exercise. reflexes
determine whether hypoglycemia is
the cause of symptoms – normal
values
ANTICIPATED NURSING INTERVENTIONS
• 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, position (RN), unit you are Neurological Unit 0800.
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.
Patient’s primary diagnosis, date of Current Orders:
admission, current orders for patient 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
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
Current pertinent assessment data using headto present.
toe approach, pertinent diagnostics, vital signs 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.
RECOMMENDATION Continue to monitor vital signs and perform neuro checks per shift
Educate patient on the importance of passive ROM exercises to
Any orders or recommendations you mayhave for improve mobility and circulation
this patient Educate patient on symptoms and complications of a stroke.
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