CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Stroke occurs when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from
getting oxygen and nutrients. Brain cells begin to die in minutes. Two main causes of stroke are a blocked artery
known as ischemic stroke or leaking or bursting of a blood vessel known as hemorrhagic stroke. Some people may
have only a temporary disruption of blood flow to the brain, known as a transient ischemic attack (TIA), that
doesn't cause lasting symptoms.
Mayo Clinic. (2020, June 03). Stroke. Retrieved August 02, 2020, from https://www.mayoclinic.org/diseases-
conditions/stroke/symptoms-causes/syc-20350113
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and
management of clinical problems. St. Louis, MO: Elsevier.
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ANTICIPATED PHYSICAL
Vernon
Russel is a 55-yearFINDINGS
old male admitted to the
hospital 2 weeks ago for a
DIAGNOSTIC TESTS (REASON
FOR TEST AND RESULTS)
Tomography scan
INFORMATION
Blood Glucose testPATIENT
to
check blood sugar levels
HgbA1c1
CBC
BMP
PT
INR
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stroke with mild left
hemiplegia.
weakness in the left side
of the body
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some sensory losses in
left side
pupils are equal
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ANTICIPATED NURSING
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Perform neuro assessment and vital signs per shift
Bedside blood glucose checks twice daily before breakfast and at bedtime
Medication as ordered by provider
Labs: CBC, BMP, PT, and INR
Patient will be educated on risk and prevention of falls.
Educate on the importance of passive range of motion exercises to increase mobility and circulation.
Physical therapy and Occupational therapy two times a day
Patient will be educated on how to manage symptoms or complications after stroke
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION
Aurora Vera primary nurse at the transitional care unit
Your name, position (RN), unit
you are working on
SITUATION
Vernon Russel is a 55-year-old male admitted to the hospital 2 weeks ago for
a stroke with mild left hemiplegia.
Patient’s name, age, specific reason for
visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
Admitted on 07/31/2020,
Current Orders:
Current Orders:
Activity: Up with walker
Vital signs and neuro-checks per shift
Bedside blood glucose checks twice daily before breakfast and at bedtime
Hgb A1c1
Diet as tolerated
Labs: CBC, BMP, PT, and INR
Medications: Aspirin 81 mg orally daily, Metformin 500 mg orally twice daily, Losartan 50 mg
orally twice daily, Nicotine patch 1 mg once daily for 6 weeks, Chlorthalidone 25 mg daily
ASSESSMENT
Current pertinent assessment data
using head to toe approach, pertinent
diagnostics, vital signs
RECOMMENDATION
Any orders or recommendations you
may have for this patient
Patient has limited range of motion of the left shoulder to 160 degrees.
Limited range of motion of the left elbow to 140 degrees. Full range of
motion of the other joints in the arms. Normal sensation for touch and pain
on patient’s arms and hands. Active range of motion against gravity in the
left arm. Active range of motion against full resistance in the right arm. 3 out
of 5 strength in the left arm and hand grasp, and 5 out of 5 in the right arm
and hand grasp. All skin free of lesions or scars; regular color and odor. Nails
were smooth, clean, intact, with no signs of cyanosis or clubbing. Active
motion against gravity in the left leg and active motion against full resistance
in the right leg. Left hip flexion is limited to 80 degrees with full ROM in the
other joints of the leg. Active ROM against no resistance in left foot and
active ROM against full resistance in the right foot. the patient’s vital signs
were as follows: BP: 144/84 HR: 90 bpm RR: 16 SpO2: 98% Oral temp: 99F.
Perform neuro assessment and vital signs per shift
Bedside blood glucose checks twice daily before breakfast and at bedtime
Medication as ordered by provider
Labs: CBC, BMP, PT, and INR
Patient will be educated on risk and prevention of falls.
Educate on the importance of passive range of motion exercises to increase
mobility and circulation.
Physical therapy and Occupational therapy two times a day
Patient will be educated on how to manage symptoms or complications after
stroke
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Aspirin
CLASSIFICATION: NSAID
PROTOTYPE: Salicylates
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Mild- moderate pain adult: 350 -650 mg every 4 hours or 500 mg every 6 hours child: 10-15 mg/kg every 4-6 hours
PURPOSE FOR TAKING THIS MEDICATION
Nonsteroidal anti-inflammatory used to reduce fever and relieve mild to moderate pain from conditions such as
muscle aches, common cold, and headaches. It can also be use to reduce pain and swelling from conditions like
arthritis(Holland,2007).
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
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Take with food or milk to reduce GI symptoms
Do not give aspirin to children or teenagers with chickenpox or influenza like illness
Discontinue aspirin with onset of ringing or buzzing in the ears
Avoid alcohol when taking large doses of aspirin
Take as directed by provider
Avoid other medications containing aspirin due to danger of overdoes unless directed by provider
Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from
http://www.robholland.com/Nursing/Drug_Guide/
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Metformin
CLASSIFICATION: Antidiabetic agent
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adult: PO Start with 500 mg q.d. to t.i.d. or 850 mg q.d. to b.i.d. with meals, may increase by 500–850 mg/d every
1–3 wk (max: 2550 mg/d); or start with 500 mg sustained-release with p.m. meal, may increase by 500 mg/d at p.m.
meal qwk (max: 2000 mg/d)
PURPOSE FOR TAKING THIS MEDICATION
Treatment of type 2 diabetes mellitus in patients not controlled with diet alone. May be used with an oral
sulfonylurea (Holland,2007).
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
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Be aware that hypoglycemia is not a risk when drug is taken in recommended therapeutic doses unless
combined with other drugs which lower blood glucose.
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Report to physician immediately S&S of infection, which increase the risk of lactic acidosis (e.g.,
abdominal pains, nausea, and vomiting, anorexia).
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Do not breast feed while taking this drug without consulting physician.
Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from
http://www.robholland.com/Nursing/Drug_Guide/
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:Losartan
CLASSIFICATION: Antihypertensive: Cardiovascular agent
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adult: PO 25–50 mg in 1–2 divided doses (max: 100 mg/d); start with 25 mg/d if volume depleted (i.e., on
diuretics)
PURPOSE FOR TAKING THIS MEDICATION
Use to treat hypertension. Selectively blocks the binding of angiotensin II to the AT1 receptors found in many
tissues (e.g., vascular smooth muscle, adrenal glands). Antihypertensive effect results from blocking the
vasoconstricting and aldosterone-secreting effects of angiotensin II (Holland,2007).
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
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Notify physician of symptoms of hypotension (e.g., dizziness, fainting).
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Notify physician immediately of pregnancy.
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Do not breast feed while taking this drug.
Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from
http://www.robholland.com/Nursing/Drug_Guide/
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Nicotine Patch
CLASSIFICATION: Smoking deterrent
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Apply 1 transdermal patch 16 h/d by the following schedule: 15 mg/d x 4–12 wk, 10 mg/d x 2–4 wk, 5
mg/d x 2–4 wk
PURPOSE FOR TAKING THIS MEDICATION
In conjunction with a medically supervised behavior modification program, as a temporary and alternate
source of nicotine by the nicotine-dependent smoker who is withdrawing from cigarette smoking
(Holland,2007).
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
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Review carefully specific written instructions packaged with the chewing gum.
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Chew a piece of gum for approximately 30 min to get the full dose of nicotine.
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Chew only one piece of gum at a time. Chewing gum too rapidly can cause excessive buccal
absorption and lead to adverse effects: nausea, hiccups, throat irritation.
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Gradually decrease number of pieces of gum chewed in 24 h. Usually, a period of 3 mo is allowed
before tapering use of gum.
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Promptly discontinue use of transdermal patch and notify physician if a severe or persistent local or
generalized skin reaction occurs.
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Be aware that smoking while using the transdermal nicotine patch increases the risk of adverse
reactions.
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Do not breast feed while taking this drug without consulting physician.
Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from
http://www.robholland.com/Nursing/Drug_Guide/
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Chlorthalidone
CLASSIFICATION: Thiazide diuretic
PROTOTYPE: Hydrochlorothiazide
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Hypertension
Adult: PO 12.5–25 mg/d, may be increased to 100 mg/d if needed
Child: PO 2 mg/kg 3 times/wk
Edema
Adult: PO 50–100 mg/d, may be increased to 200 mg/d if needed
PURPOSE FOR TAKING THIS MEDICATION
Edema associated with CHF, renal decompensation, hepatic cirrhosis, corticosteroid and estrogen therapy; as
sole agent or with other antihypertensives to treat hypertension (Holland,2007).
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
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Maintain adequate potassium intake, monitor weight, and make a daily estimate of I&O ratio.
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Do not breast feed while taking this drug.
Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from
http://www.robholland.com/Nursing/Drug_Guide/
vSim Health Assessment Case 4: Vernon
Russell
Documentation Assignments
1. Document the Morse Fall Scale assessment you completed on Mr. Russell.
According to the Morse Fall Scale assessment, Mr. Russell is at a high risk for falls. He received a score of 50;
no history of falls (0), he has a secondary diagnosis because he has conditions that were present at the time of
diagnosis of a stroke (15), he needs the assistance of an ambulatory aide (15), he does not have an IV in (0), his
gait is weak (20), and his mental status is alert and oriented to place, person, and time (0). This amounts to a total
of 50 placing Mr. Russell at a high risk for falls.
2. Complete an SBAR report on Mr. Russell’s musculoskeletal assessment for the charge nurse.
S – Mr. Russell recently suffered a stroke which resulted in mild left hemiplegia. He was recently transferred to
the transitional care unit and has been scheduled for physical therapy and occupational therapy twice per day to
assess and build his strength.
B – Mr. Russell has a history of diabetes type 2, has hypertension and coronary artery disease. He rarely
exercises and has been smoking more than a pack a day.
A – ROM assessment revealed limited ROM in left extremities. Right extremities have full ROM. Hand grasps
are almost equal but left side is a bit weaker. Patient is alert and oriented, reports no pain. All skin intact without
bruising or lesions, no edema.
R – Continue to perform ROM exercises, reinforce deep breathing and coughing exercises, educate patient
about the importance of light to moderate activity each day. Discuss risk factors related to smoking and fall risks.
3. Document your focused assessment of Mr. Russell’s musculoskeletal system.
The musculoskeletal assessment involves testing the patients muscle strength and the range of motion in the
joints and legs to determine how the patient is progressing after being ill. Mr. Russel findings are as follows:
limited range of motion of the left shoulder to 160 degrees. Limited range of motion of the left elbow to 140
degrees. Full range of motion of the other joints in the arms. Normal sensation for touch and pain on patient’s
arms and hands. Active range of motion against gravity in the left arm. Active range of motion against full
resistance in the right arm. 3 out of 5 strength in the left arm and hand grasp, and 5 out of 5 in the right arm and
hand grasp. All skin free of lesions or scars; regular color and odor. Nails were smooth, clean, intact, with no
signs of cyanosis or clubbing. Active motion against gravity in the left leg and active motion against full
resistance in the right leg. Left hip flexion is limited to 80 degrees with full ROM in the other joints of the leg.
Active ROM against no resistance in left foot and active ROM against full resistance in the right foot.
References
Mayo Clinic. (2020, June 03). Stroke. Retrieved August 02, 2020, from https://www.mayoclinic.org/diseases-
conditions/stroke/symptoms-causes/syc-20350113
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of
clinical problems. St. Louis, MO: Elsevier.
vSim Health Assessment Case 4: Vernon Russell
Guided Reflection Questions
How did you feel throughout the simulation experience?
This experience helped me feel that I can identify fall risks as well as become comfortable with ROM exercises.
What do you think went well?
I felt that everything went well, I completed safety measures in the proper order, getting vital signs of patient and
then completing musculoskeletal assessment and reinforce education on the importance of range of motion and
mobility, and discuss fall risk with him.
Scenario Analysis Questions*
EBP
What priority assessment needs did you identify for Vernon Russell?
Mr. Russell had a stroke with a mild hemiplegia on the left side. This is has made him a fall risk. A neurologic
assessment and vital signs are important due to him having stroke. A musculoskeletal assessment and education on
the importance of range of motion and mobility and discuss fall risk with him.
EBP Describe findings that might concern you regarding Mr. Vernon’s safety, fall risk, and musculoskeletal
assessments.
Due to him having left sided weakness, performing activities of daily living are currently difficult to perform. Findings
of patient are limited range of motion of the left shoulder to 160 degrees. Limited range of motion of the left elbow to
140 degrees. Full range of motion of the other joints in the arms. Normal sensation for touch and pain on patient s arms
and hands. Active range of motion against gravity in the left arm. Active range of motion against full resistance in the
right arm. 3 out of 5 strength in the left arm and hand grasp, and 5 out of 5 in the right arm and hand grasp. All skin free
of lesions or scars; regular color and odor. Nails were smooth, clean, intact, with no signs of cyanosis or clubbing.
Active motion against gravity in the left leg and active motion against full resistance in the right leg. Left hip flexion is
limited to 80 degrees with full ROM in the other joints of the leg. Active ROM against no resistance in left foot and
active ROM against full resistance in the right foot.
S Utilizing the Morse Fall Scale, classify Vernon Russell’s fall risk.
Using the Morse fall scale assessment, Mr. Vernon is at high risk for falls being that he received a score of 50. He has
no history of falls (0), he has a secondary diagnosis because he has conditions that were present at the time of
diagnosis of a stroke (15). He needs assistance of an ambulatory aide (15). He does not have an IV (0), his gait is weak
(20), his mental status is alert and oriented to place person and time (0), giving him a total of 50.
T&C Based on Russell Vernon’s comment, “I have been walking by myself for 55 years. Why do I need someone
to help me now? I am not that bad off,” what other health care team member and/or support services should be
recommended?
I would tell Mr. Russell due his recent stroke causing him to have a mild left sided paralysis, it is best for him to have
someone assist him to walk to prevent any injury’s by falling. A Morse Fall Risk assessment was completed, and his
score was a total of 50. He has a high risk of falling, it is important that he gets physical and occupational therapy
twice a day to help him with his strength.
PCC What risk factors does Vernon Russell have (modifiable and nonmodifiable) that indicate the risk for
reoccurrence of a stroke?
Modifiable: Smoking, inactivity, hypertension, coronary artery disease, and diabetes mellitus
Nonmodifiable: age and ethnicity
PCC
What patient education should be initiated due to the identified modifiable risk factors?
Smoking cessation and increasing exercise.
Concluding Questions
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 put the knowledge and skills that I acquired to go forward; it will help me treat each patient properly. I would
make sure to prioritize assessments to ensure safety.
What opportunities for improvement should you address?
I need to remember not to forget to inspect the patients him when doing the musculoskeletal assessment.
References
Mayo Clinic. (2020, June 03). Stroke. Retrieved August 02, 2020, from https://www.mayoclinic.org/diseases-
conditions/stroke/symptoms-causes/syc-20350113
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of
clinical problems. St. Louis, MO: Elsevier.
Clinical Worksheet
Date: 08/02/2020
Initials: V.R
Age: 55
M/F: M
Code Status: N/A
Student Name: Aurora Vera
Diagnosis:
Right-Sided Stroke
Length of Stay: N/A
Allergies: no known
allergies
Assigned vSim: Vernon Russel
HCP:
N/A
Consults: N/A
Isolation: N/A
Fall Risk: high fall risk
IV Type: N/A
Location: N/A
Transfer: stand by
assist, patient can use
walker
Fluid/Rate: N/A
Critical Labs:
Hgb A1C: 7.1
CL: 96
Other Services:
- Physical therapist
- Occupational therapist
Consults Needed:
- Nutritionist
- Fall risk
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:
The patient was admitted to the hospital due to right sided stroke with a mild left hemiplegia.
Health History/Comorbities (that relate to this hospitalization):
Patient has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. Patient reports smoking a pack of cigarettes every day and does not
exercise.
Shift Goals/ Patient Education Needs:
1. Patient will be educated on the principles of range of motion and mobility, and discuss fall risk with him
2.Will perform vital sign and neurological assessment every shift
3.Will perform musculoskeletal assessment
4.Nurse will safely administer morning medications in a timely manner
Path to Discharge:
Patient shows no changes or declines in consciousness and mobility, patient was given education to prevent fall, nutrition and importance of exercise, patient was
given education on medications needed for discharge.
Path to Death or Injury:
Patient was not educated on preventative measures against fall ris, patient had incidences of falling , patient showed changes or decline in consciousness and
mobility and vital signs or neurological assessments were performed, patient had reoccurrence of stroke because no preventative measures or interventions taken
Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
Management of Care: What needs to be done for this Patient Today?
1.
Circulation problems
2.
Risk for falling
2. Nurse will educate patient on fall risks and preventions
3.
Risk for neurological decline (decline in level of consciousness or loss of motor
functions or senses)
3. Bedside blood glucose check twice a day before breakfast and at bedtime
1. Nurse will reinforce the principles of range of motion and mobility
4. Lab: CBC, BMP, PT, INR
What Assessments will focus on for this patient?
(How will I identify the above signs
&Symptoms?)
5. Vital signs and neuro assessment every shift
6. Will administer medications that are ordered for the patient
7. Physical and Occupational therapy twice a day
1.
Musculoskeletal Assessment
2.
Morse fall risk assessment
1. Nurse will reinforce the principles of range of motion and mobility
3.
Neurological Assessment
2. Nurse will perform musculoskeletal Assessment
Priorities for Managing the Patient’s Care Today
3. Nurse will educate patient on fall risk and discuss Morse fall risk assessment
List Complications may occur related to dx, procedure, comorbidities:
1.
Falling
2.
Urinary incontinence
3.
Dysphagia
4. Nurse will stay by patient’s bedside during mealtimes for any signs or symptoms of
aspiration after patient is cleared to eat
What aspects of the patient care can be Delegated and who can do it?
Nurse can delegate CNA to take patient’s vital signs
What nursing or medical interventions may prevent the above Alert or complications?
1.
Nurse will reinforce the principles of range of motion and mobility
2.
Nurse will keep call light near patient and instruct patient to call when needing help
to ambulate to the bathroom
3.
Nurse will educate and discuss fall risk
References
Mayo Clinic. (2020, June 03). Stroke. Retrieved August 02, 2020, from https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier.
Nursing
Diagnosis
Risk for
self-care
deficit
Nursing Interventions
Short term goal intervention
1. Assess abilities and level of deficit (0–4 scale) for performing
ADLs.
2. Maintain a supportive, firm attitude. Allow patient sufficient
time to accomplish tasks. Don’t rush the patient.
Long term goal intervention
1. Provide positive feedback for efforts and accomplishments.
2. Provide self-help devices: extensions with hooks for picking
things up from the floor, toilet risers, long-handled
brushes, drinking straw, leg bag for catheter, shower chair.
Encourage good grooming and makeup habits.
Rationale
Nursing Goals &
Expected Outcomes
Response to Intervention
1. Short term goalShort term GOAL evaluation
Patient will perform selfcare activities within Patient manage to perform self2. Patients need empathy and to know caregivers will be
level of own ability by care activities within his own
consistent in their assistance (Vera,2019).
end of the shift.
abilities by end of the shift.
2. Long term goal1. Enhances sense of self-worth, promotes independence, Patient will demonstrate
and encourages patient to continue endeavors (Vera,2019). techniques changes to Long term GOAL evaluation
meet self-care needs Patient shows knowledge of self2. To enable the patient to manage for self, enhancing
with them during shift
care care techniques at discharge
independence and self-esteem, reduce reliance on others
for meeting own needs, and enables the patient to be
form hospital.
more socially active. (Vera,2019).
1. Aids in planning for meeting individual needs.
(Vera,2019)
.
Risk for
ineffective
coping
Short term goal intervention
1. Identify meaning of the dysfunction and change to
patient. Note ability to understand events, provide
1. Independence is highly valued in American culture but is not as
significant in some cultures. Some patients accept and manage
altered function effectively with little adjustment, whereas others
may have considerable difficulty recognizing and adjust to
deficits. In order to provide meaningful support and appropriate
1. Short term goal1. Short term GOAL
Patient will verbalize
evaluation
awareness of own
coping abilities by end Patient can recognize what he is
realistic appraisal of the situation.
2. Identify previous methods of dealing with life
problems. Determine presence of support systems.
Long term goal intervention
problem-solving, healthcare providers need to understand the
meaning of the stroke/limitations to patient (Vera,2019).
2. Provides opportunity to use behaviors previously effective, build
on past successes, and mobilize resources. (Vera,2019).
1. To increase the patient’s sense of confidence and can help in
1. Provide psychological support and set realistic short- compliance to therapeutic regimen (Vera,2019).
term goals. Involve the patient’s SO in plan of care when
possible and explain his deficits and strengths.
2. Suggest possible adaptation to changes and understanding about
own role in future lifestyle (Vera,2019).
2. Support behaviors and efforts such as increased
interest/participation in rehabilitation activities.
References
Vera, Matt. (2019, April 12). Nursing Care Plans. Retrieved from https://nurseslabs.com/
of shift.
2. Long term goalPatient will verbalize
capable of doing and
understands what he cannot by
end of shift.
acceptance of self
after hip replacement
2. Long term GOAL
surgery by the time
evaluation
he is discharged
from hospital.
Patient demonstrates acceptance
of hip replacement at discharge.