JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 214 Adult Health I
Adult Clinical Simulation
Focus: Ischemic Stroke
Give students a brief case scenario in which they have to determine that patient is having an ischemic stroke.
Student Interventions
Ensure Patent airway
 Call for Respiratory Care to intubate
 Remove Dentures
 Begin delivery of oxygen per ambu-bag
 Respiratory Care intubates but puts in right main stem
Sim Man Signs and Symptoms
No breath sounds
Pulse oximetry initially then increase after delivery of oxygen with ambu bag
76% then increase to normal
parameters
No lung sounds on left side.
Check oxygen sats(want to maintain >92%)
Establish IV access with Normal Saline
Check Blood pressure
Position head midline and elevate HOB 30 degrees if no symptoms of shock or injury
Check blood glucose
230/140
110 mg/dl
Tonic-clonic
Institute seizure precautions
Administer Dilatin(do not exceed 50 mg over 1 minute)
Neuro assessment
LOC
Glasgow
Motor and sensory function
Pupils
CT scan shows ischemic stroke
CT scan
Anticipate thrombolytic therapy-alteplase (tissue plasminogen activator t-PA)p. 1018
Blood tests for coagulation disorders
Hx of GI bleed
Stroke or head trauma within past 3 months
Major surgery within 14 days
Dyspnea and wheezes, fever,
changes in facial color, swelling
around the eyes
Begin to vomit bright red blood
Lab values wnl
Do not give
Doctor orders anticoagulant
(heparin or coumadin)or
antiplatelet drug (plavix) within 24
hours of tPA treatment
JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 214 Adult Health I
Stroke Learning Activity Exercise
Etiology and Pathophysiology
1. When does a stroke occur?
Risk Factors for Stroke
1. What are the modifiable risk factors for a stroke? Nonmodifiable?
2. True or False. Stroke only occurs in individuals over the age of 55.
3. What race is more at risk for stroke and why?
4. Name cardiac related risk factors. Which one is the most important to treat?
Transient Ischemic Attack (TIA)
1. What is a TIA?
2. Signs and Symptoms of a TIA depend on
________________________________________.
Types of Stroke
Ischemic stroke
1. What is an ischemic stroke?
2. What is a thrombotic stroke?
3. Diagram the pathophysiology of a thrombotic stroke.
4. What is an embolic stroke?
5. Diagram the pathophysiology of an embolic stroke.
Hemorrhagic stroke
1. Hemorrhagic strokes result from
_____________________________________________.
2. What is an intracerebral hemorrhage?
3. ________________ is the most important cause of intracerebral hemorrhage.
4. What is a subarachnoid hemorrhage?
5. Subarachnoid hemorrhage is commonly caused by a rupture of a
___________________.
6. What are the warning signs of a leaking aneurysm?
Clinical Manifestations
1. What is another term used to describe a stroke?
2. State the manifestations you will see with: (refer to p 1531, Fig 56-6)
Right-brain damage:
Left brain damage:
Communication
1. Define the following terms:
Aphasia
Dysphasia
Non-fluent dysphasia
Fluent dysphasia
Global aphasia
Receptive aphasia
Expressive aphasia
Dysarthria
2. When a client exhibits receptive aphasia, what area of the brain has been affected?
Diagnostic Studies
1. Why are diagnostic studies performed on a stroke client?
2. What is the primary diagnostic test used after a stroke? Why is it used?
3. What diagnostic test is used to determine the extent of brain injury?
4. Angiography is used to determine what?
Collaborative Care
Drug Therapy
1. What is the drug of choice for a client with a history of TIAs related to
arthrosclerosis?
2. What is the drug of choice for a client with a history of atrial fibrillation who has
had TIAs?
Surgery
1. Define carotid endarterectomy (CEA).
Emergency Management for Stroke Clients
Refer to Table 56-6 p. 1534
1. What is the first thing the nurse must do in emergent care of a stroke client?
2. Why is maintaining adequate oxygenation important?
3. Would you give the client supplemental O2 ? What would you want the client’s
O2 sats to be?
4.
5.
6.
7.
True or false. Low blood pressure is common immediately after a stroke.
Why should the client not be over-hydrated?
What IV fluids do you anticipate the doctor to prescribe? Why?
Increase ICP from cerebral edema usually peaks in _________ and may cause
_____________________.
8. What nursing interventions should be implemented in clients with increased ICP?
9. What medications are used to decrease cerebral edema?
Drug Therapy
1. What type of drug is tPA? Why is it used? When should it be administered?
2. In what circumstances can tPA NOT be administered?
3. Can antiplatelet medications be given after tPA treatment?
4. Give examples of the following medications:
a. Anticoagulants
b. Platelet inhibitors
5. When is oral warfarin replaced with heparin?
6. What lab value is used to measure and regulate warfarin (Coumadin)? Heparin?
7. The calcium channel blocker nimodipine (nimotop) is given when?
8. Should the nurse anticipate giving Dilantin? Why?
Nursing Assessment
1. What should your focused nursing assessment include?
2. What does the Glasgow Coma Scale determine?
3. Glasgow Coma Scale: What is the highest reading a patient can have? What
indicates coma?
4. Subjective data:
Objective data:
5. Identify the top 3 nursing diagnosis.
a.
b.
c.
6. What are the WARNING signs of a stroke?
7. Nursing interventions for a stroke client should the nurse include:
Respiratory:
Neurologic:
Cardiovascular:
Musculoskeletal:
Integumentary:
GI:
GU:
8. What should the nurse do before initiating oral feedings?