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Scenario: Casey Corriveau: Care of a Client Experiencing an Ischemic Stroke
Student Pre-Simulation Guide
PURPOSE:
The purpose of this document is to provide an overview of the simulation-based activity aligned with the course and guide your preparation activities. This document will review the required foundational concepts related to pathophysiology, management of the disease process, and the clinical skills that learners will be expected to apply during the scenario. SCENARIO OVERVIEW: Casey Corriveau is a 68-year-old client admitted to the Medical Telemetry Unit for 24-hour observation with a diagnosis of Syncopal episodes. During admission client develops signs and symptoms of a stroke. Client has a history of Type 2 diabetes. The scenario takes place at 0730 with nurse to nurse change of shift report.
SCENARIO RUN TIME: 45 minutes
MAPPING OF LEARNING OBJECTIVES:
Didactic Course Objectives MET UNMET
1. Implement safe and effective nursing care to adults and older adults
experiencing complex health alterations to achieve desired patient, systems, and population outcomes.
2. Defend the choice of nursing therapeutics based on the best available
evidence to achieve patient, systems, and population outcomes.
3. Revise the plan of care based on biopsychosocial assessment data to
achieve desired patient and population outcomes.
4. Prioritize nursing actions across patients based on aggregate
biopsychosocial assessment data.
5. Lead the development of the interprofessional plan of care. ☒^ ☐
6. Defend decisions from a cost-effectiveness perspective. ☒^ ☐
Lab Course Objectives MET UNMET
1. Provide safe, effective evidence-based care to a group of adult and
older adult patients to achieve desired patient, systems, and population outcomes.
2. Administer prescribed therapeutics safely, effectively, and cost
effectively.
3. Transition patients safely to other levels of care to achieve quality and
cost system and population outcomes.
4. Gather and report nursing sensitive patient and population data to ☒^ ☐
improve outcomes.
5. Manage self in a manner that promotes patient safety and quality of
care.
6. Establish a therapeutic relationship with patients. ☒^ ☐
Scenario Learning Objectives
- Evaluate the client’s neurological status using the National Institutes of Health (NIH) Stroke Scale.
- Anticipate diagnostic orders and therapies that will be included in the plan of care for a client displaying signs and symptoms of cerebrovascular ischemia.
- Prioritize interventions in the plan of care for client with a cerebrovascular infarction.
- Calculate correct dosage and safely administer tPA according to the Six Rights.
- Evaluate effectiveness of interventions and modify the plan of care as appropriate.
- Analyze assessment and diagnostic lab data and report pertinent findings to the healthcare provider using SBAR.
- Demonstrate therapeutic communication techniques to establish client rapport and reduce anxiety.
- Prepare client for transfer to a different level of care and provide nurse to nurse handoff report using SBAR. LEARNER ROLES DURING THE SIMULATION-BASED ACTIVITY The facilitator of the simulation-based activity will ensure that each learner is assigned to a specific nursing role. While each of the roles represent a component of the responsibilities of a nurse providing client care, it is important that learners function as a nursing team to successfully complete the simulation-based activity. This may require delegation and/or learners to assume responsibilities aligned with other roles. The learner roles for this scenario are as follows: Charge Nurse The charge nurse is the team leader, ensuring the client receives safe, organized, high-quality care. The learner fulfilling this role may delegate duties to members of the nursing team as appropriate. The charge nurse will be the primary point person for communicating with members of the interdisciplinary team to coordinate client care. This role requires the learner to keep members of the nursing team updated with changes in client status, healthcare provider updates, and new information learned throughout the scenario. Additionally, this role will support the primary nurse with the implementation of orders as needed. Primary Nurse The primary nurse is fundamentally responsible for maintaining effective communication with the client and/or family member(s). The learner fulfilling this role will obtain the client’s health history, perform initial comprehensive or focused physical assessments and follow-up reassessments, and implement non- medication interventions included in the plan of care. The primary nurse will purposefully observe the client for any changes in status. Additionally, the primary nurse will provide all clients and family members with education, with the exception of medication administration.
4. Complete an ATI Medication Active Learning Template for recombinant alteplase (rt-PA)
alteplase Expected pharmacological action converts plasminogen to the proteolytic enzyme plasmin, which lyses fibrin as well as fibrinogen. Therapeutic use to dissolve blood clots that have formed in the blood vessels Complications bleeding, angioedema, anaphylaxis, and fever Contraindications/Precautions Intracranial hemorrhage. Subarachnoid hemorrhage. Internal bleeding. Stroke within the last three months. Intracranial or intraspinal surgery within the last three months. Serious head trauma within the last three months. Intracranial neoplasms, arteriovenous malformations, or aneurysms. Interactions aspirin or ibuprofen (Motrin, Advil) shortly after you have received alteplase Evaluation of medication effectiveness within 4.5 hours after the stroke started Medication administration intravenously Nursing interventions Perform neurologic assessment every 15 minutes during the 1- hour infusion. Check for major and/or minor bleeding. Monitor blood pressure every 15 minutes during the 1-hour infusion. Monitor for signs of intracranial hemorrhage (ICH) Monitor for signs of orolingual angioedema. Client Education allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue signs and symptoms of bleeding such as bloody or black, tarry stools; red or dark-brown urine; spitting up blood or brown material that looks like coffee grounds; red spots on the skin; unusual bruising or bleeding from the eye, gums, or nose signs and symptoms of a stroke such as changes in vision; confusion; trouble speaking or understanding; severe headaches; sudden numbness or weakness of the face, arm, or leg; trouble walking; dizziness; loss of balance or coordination slow or fast heart rate
5. Based on the below order, calculate the dose to be administered. Show your work.
Tissue Plasminogen Activator 0.9mg/kg IV. Give 10% of dose as initial IV bolus over
1 minute then infuse remaining dose over 60 minutes. Patients weight is 48 kg.
0.7mL
6. Review and practice the National Institute of Health (NIH) Stroke Scale
Document located at
https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf)
Training video at https://www.google.com/search?
sxsrf=AJOqlzUd3SfAe28gFKl_4L60ef5uGeauCg:1679581809243&q=NIH+stroke+scal
e&tbm=vid&sa=X&ved=2ahUKEwjYq_HoofL9AhX8EUQIHRxMALcQ0pQJegQIDBA
B&biw=1920&bih=995&dpr=1#fpstate=ive&vld=cid:a230b873,vid:b_RgpYUfi8Q
References
Scenario: John Kearns: Care of a Client with Acute Coronary Syndrome
Student Pre-Simulation Guide
PURPOSE:
The purpose of this document is to provide an overview of the simulation-based activity aligned with the course and guide your preparation activities. This document will review the required foundational concepts related to pathophysiology, management of the disease process, and the clinical skills that learners will be expected to apply during the scenario.
interdisciplinary team.
- Provide developmentally appropriate education on rational for interventions and the need to transfer client to a higher level of care.
- Provide nurse to nurse handoff report using SBAR to transition client do a different level of care. LEARNER ROLES DURING THE SIMULATION-BASED ACTIVITY The facilitator of the simulation-based activity will ensure that each learner is assigned to a specific nursing role. While each of the roles represent a component of the responsibilities of a nurse providing client care, it is important that learners function as a nursing team to successfully complete the simulation-based activity. This may require delegation and/or learners to assume responsibilities aligned with other roles. The learner roles for this scenario are as follows: Charge Nurse The charge nurse is the team leader, ensuring the client receives safe, organized, high-quality care. The learner fulfilling this role may delegate duties to members of the nursing team as appropriate. The charge nurse will be the primary point person for communicating with members of the interdisciplinary team to coordinate client care. This role requires the learner to keep members of the nursing team updated with changes in client status, healthcare provider updates, and new information learned throughout the scenario. Additionally, this role will support the primary nurse with the implementation of orders as needed. Primary Nurse The primary nurse is fundamentally responsible for maintaining effective communication with the client and/or family member(s). The learner fulfilling this role will obtain the client’s health history, perform initial comprehensive or focused physical assessments and follow-up reassessments, and implement non- medication interventions included in the plan of care. The primary nurse will purposefully observe the client for any changes in status. Additionally, the primary nurse will provide all clients and family members with education, with the exception of medication administration. Medication Nurse The medication nurse is accountable for performing all aspects of medication administration and documentation. The learner fulfilling this role will ensure all medications are administered according to the Rights of Medication Administration and clarify related orders with the healthcare provider_._ The medication nurse will provide client education on the actions, expected effects, required monitoring, and adverse reactions for each medication administered during the simulation-based activity. Additionally, the medication nurse must be prepared to provide observational findings, including but not limited to changes in client status or psychosocial needs, and make recommendations for nursing interventions. Documentation Nurse The documentation nurse is responsible for recording all assessments, interventions, and client outcomes during the simulation-based activity, with the exception of medication administration. The learner fulfilling this role will validate all data entered into the electronic health record with team members. The
documentation nurse should also be prepared to provide observational findings, including but not limited to changes in client status or psychosocial needs, and make recommendations for nursing interventions. PRE-SIMULATION ASSIGNMENT Directions: Complete the following pre-simulation assignment using the course textbook or other refereed resources. Answers to questions must be written using APA format with a reference page. The completed document is to be uploaded into the Canvas dropbox by the instructor assigned due date.
1. Describe the pathophysiology of Acute Coronary Syndrome (ACS).
Decreased blood flow to part of heart musculature which is usually secondary to plaque
rupture and formation of thrombus
2. Identify risk factors for Acute Coronary Syndrome.
Smoking, hypertension, diabetes, hyperlipidemia, male sex, physical inactivity, family
obesity, and poor nutritional practices. cocaine abuse can also lead to vasospasm.
3. Describe the clinical manifestations of ACS.
Chest pain
4. Compare and contrast the pathophysiology and clinical manifestations of Stable
Angina, Unstable Angina, Non-ST elevation (NSTEMI) and ST elevation (STEMI),
and Cardiogenic Shock in the table below.
With stable angina, chest pain or other symptoms only occur with a certain amount of
activity or stress. The pain does not occur more often or gets worse over time. Unstable
angina is chest pain that is sudden and often gets worse over a short period of time.
NSTEMI stands for non-ST segment elevation myocardial infarction, which is a type of
heart attack. Compared to the more common type of heart attack known as STEMI, an
NSTEMI is typically less damaging to your heart.
The pathophysiology of cardiogenic shock involves a vicious spiral circle: ischemia
causes myocardial dysfunction, which in turn aggravates myocardial ischemia.
Myocardial stunning and/or hibernating myocardium can enhance myocardial
dysfunction, thus, worsening the cardiogenic shock.
Disorder Pathophysiology Clinical Manifestations Stable Angina reduced blood flow to the heart muscle chest pain that occurs behind the breastbone or slightly to the left of it Unstable Angina results when the blood flow is impeded to the myocardium Chest pain that you may also feel in the shoulder, arm, jaw, neck, back, or other area
Smoking Cessation.
7. Complete the table below for medications used in the management of Acute
Coronary Syndrome and cardiogenic shock.
Medication Route Indications Adverse Effect Nursing Implications Amiodarone IV treatment of recurrent hemodynamically unstable ventricular tachycardia and recurrent ventricular fibrillation constipation. loss of appetite. headache. decreased sex drive. difficulty falling asleep or staying asleep. flushing. changes in ability to taste and smell. changes in amount of saliva. monitor the EKG continuously during IV amiodarone infusion and initiation of PO therapy. Aspirin PO Angina pectoris. Angina pectoris prophylaxis. Ankylosing spondylitis. Cardiovascular risk reduction. Colorectal cancer. Fever. Ischemic stroke. Ischemic stroke: Prophylaxis. Abdominal or stomach pain, cramping, or burning. black, tarry stools. bloody or cloudy urine. change in consciousness. chest pain or discomfort. confusion. constipation. convulsions, severe or continuing. Use the lowest effective dose of aspirin for the shortest period of time. Administer aspirin after meals or with food or an antacid. ... Advise the patient not to crush or chew enteric- coated aspirin tablets. Advise patient not to take antacids within 1 – 2 hr of enteric-coated aspirin tablets. Dopamine IV correction of hemodynamic imbalances present in the shock syndrome due to myocardial infarction, trauma, endotoxic septicemia, open- heart surgery, lightheadedness, chest pain, fast, slow, or pounding heartbeats, shortness of breath, cold feeling, numbness, blue-colored Correct hypovolemia with fluid resuscitation before initiating dopamine infusion. Monitor blood pressure, pulse, and peripheral pulses every 15 minutes.
renal failure, and chronic cardiac decompensation as in congestive failure appearance in your hands or feet, and. darkening or skin changes in your hands or feet. Monitor hourly urine output. Cardiac monitor should be used on patients receiving dopamine infusion. Heparin IV prevention and treatment of thrombotic events such as deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as atrial fibrillation (AF) Abdominal or stomach pain or swelling. back pain or backaches. bleeding from the gums when brushing teeth. blood in the urine. constipation. coughing up blood. dizziness. headaches, severe or continuing. Heparin can increase the risk of bleeding, especially in patients with a history of bleeding disorders, ulcers, or recent surgery. It is important to monitor patients for signs of bleeding and adjust the dose of heparin as needed. Metoprolol PO treatment of angina, heart failure, myocardial infarction, atrial fibrillation, atrial flutter and hypertension. Headaches. Make sure you rest and drink plenty of fluids. ... Feeling tired, dizzy or weak. If metoprolol makes you feel dizzy or weak, stop what you're doing, and sit or lie down until you feel better. ... Cold hands or feet. ... Feeling sick (nausea) ... Stomach pain. monitoring the patient's vital signs, such as blood pressure, heart rate, and respiratory rate. Morphine IV musculoskeletal pain, abdominal pain, chest pain, arthritis, and even headaches when patients fail to respond to first and second-line agitation, hallucinations (seeing things or hearing voices that do not exist), fever, sweating, confusion, fast heartbeat, Reassess pain after administration of morphine. Monitor for respiratory depression and hypotension
Scenario: Kai Sugamoto: Care of a Client with Diabetic Ketoacidosis
Student Pre-Simulation Guide
PURPOSE:
The purpose of this document is to provide an overview of the simulation-based activity aligned with the course and guide your preparation activities. This document will review the required foundational concepts related to pathophysiology, management of the disease process, and the clinical skills that learners will be expected to apply during the scenario. SCENARIO OVERVIEW: Kai Sugamoto is a 40-year-old male directly admitted to the medical-surgical unit from the healthcare provider’s office with a diagnosis of diabetic ketoacidosis. The client was diagnosed with type 1 diabetes mellitus 1 year ago. The scenario takes place at 0900 with nurse to nurse handoff report.
SCENARIO RUN TIME: 45 minutes
MAPPING OF LEARNING OBJECTIVES:
Didactic Course Objectives MET UNMET
- Implement safe and effective nursing care to adults and older adults experiencing complex health alterations to achieve desired patient, systems, and population outcomes.
- Defend the choice of nursing therapeutics based on the best available evidence to achieve patient systems, and population outcomes.
- Revise the plan of care based on biopsychosocial assessment data to achieve desired patient and population outcomes.
- Prioritize nursing actions across patients based on aggregate biopsychosocial assessment data.
- Lead the development of the interprofessional plan of care. ☒ ☐
- Defend decisions from a cost-effectiveness perspective. ☒ ☐
Lab Course Objectives MET UNMET
- Provide safe, effective evidence-based care to a group of adult and older adult patients to achieve desired patient, systems, and population outcomes.
- Administer prescribed therapeutics safely, effectively, and cost effectively.
- Transition patients safely to other levels of care to achieve quality and cost system and population outcomes.
- Gather and report nursing sensitive patient and population data to ☒ ☐
improve outcomes.
- Manage self in a manner that promotes patient safety and quality of care.
- Establish a therapeutic relationship with patients. ☒ ☐
Scenario Learning Objectives
- Correlate assessment findings and diagnostic lab data with the pathophysiology of the disease process.
- Prioritize nursing interventions in the plan of care for a client with DKA.
- Evaluate the effectiveness of interventions for DKA and modify the plan of care as appropriate.
- Correctly calculate intravenous insulin dosage and safely administer medication according to the Six Rights.
- Interpret diagnostic lab data and report abnormal findings to the healthcare provider in a timely manner using SBAR.
- Utilize the electronic health record to accurately document assessments, interventions, and evaluations.
- Provide developmentally appropriate client education on the rationale for interventions performed as part of the plan of care. LEARNER ROLES DURING THE SIMULATION-BASED ACTIVITY The facilitator of the simulation-based activity will ensure that each learner is assigned to a specific nursing role. While each of the roles represent a component of the responsibilities of a nurse providing client care, it is important that learners function as a nursing team to successfully complete the simulation-based activity. This may require delegation and/or learners to assume responsibilities aligned with other roles. The learner roles for this scenario are as follows: Charge Nurse The charge nurse is the team leader, ensuring the client receives safe, organized, high-quality care. The learner fulfilling this role may delegate duties to members of the nursing team as appropriate. The charge nurse will be the primary point person for communicating with members of the interdisciplinary team to coordinate client care. This role requires the learner to keep members of the nursing team updated with changes in client status, healthcare provider updates, and new information learned throughout the scenario. Additionally, this role will support the primary nurse with the implementation of orders as needed. Primary Nurse The primary nurse is fundamentally responsible for maintaining effective communication with the client and/or family member(s). The learner fulfilling this role will obtain the client’s health history, perform initial comprehensive or focused physical assessments and follow-up reassessments, and implement non- medication interventions included in the plan of care. The primary nurse will purposefully observe the client for any changes in status. Additionally, the primary nurse will provide all clients and family members with education, with the exception of medication administration. Medication Nurse
3. Compare and contrast the clinical manifestations of Diabetic Ketoacidosis (DKA)
and Hyperglycemic Hyperosmolar State (HHS) by completing the table below.
DKA: nausea, vomiting, and abdominal pain. Other symptoms include increased thirst
and urination. Kussmaul breathing (labored deep breathing) and fruity odor are specific
signs present on examination of a patient with diabetic ketoacidosis. HHS: Increased
thirst and urination (at the beginning of the syndrome)
Feeling weak.
Nausea.
Weight loss.
Dry mouth, dry tongue.
Fever.
Seizures.
Confusion.
DKA HHS
Occurrence most common among people with type 1 diabetes arises from a complication of diabetes mellitus Onset can develop within 24 hours can take days or weeks to develop
Laboratory Work : Blood glucose levels Arterial pH Levels Serum Bicarb Levels Urine or serum ketones Effective serum osmolality Anion Gap Blood glucose test. Ketone testing (through a urine or blood test). Arterial blood gas. Basic metabolic panel. Blood pressure check. Osmolality blood test. electrolytes with calculated anion gap, plasma glucose, blood urea nitrogen (BUN), creatinine, serum and urine ketones, osmolality, and arterial blood gas. Manifestations Fast, deep breathing. Dry skin and mouth. Flushed face. Fruity-smelling breath. Headache. Muscle stiffness or aches. Being very tired. Nausea and vomiting extreme thirst, frequent urination and confusion.
4. Identify priority assessments for a client with DKA.
Monitor vitals.
Check blood sugars and treat with insulin as ordered.
Start two large-bore IVs.
Administer fluids as recommended.
Check electrolytes as potassium levels will drop with insulin treatment.
Check renal function.
Assess mental status.
Look for signs of infection
5. Describe priority interventions for a client with DKA.
After initial stabilization of circulation, airway, and breathing as a priority, specific
treatment of DKA requires correction of hyperglycemia with intravenous insulin, frequent
monitoring, and replacement of electrolytes, mainly potassium, correction of
hypovolemia with intravenous fluids, and correction of acidosis.
6. Identify patient education priorities for a client with DKA.
in 0.9 Normal Saline (N5NS) Dextrose 5% in 0.45% Normal Saline (D 1/2 NS) Dextrose 5% in Lactated Ringer's (D5LR)
8. Complete the table below for medications used in the management of DKA.
Medication Route Indications Side Effect Nursing Implications Regular Insulin IV For the treatment type 2 diabetes mellitus. ... For the treatment of gestational diabetes or pre- existing type 1 or 2 diabetes mellitus during pregnancy (pregestational diabetes). ... For the treatment of diabetic ketoacidosis (DKA). redness, swelling, and itching at the injection site. changes in the feel of your skin, skin thickening (fat build-up), or a little depression in the skin (fat breakdown) weight gain. constipation. Gently rotate the vial containing the agent and avoid vigorous shaking to ensure uniform suspension of insulin. Rotate injection sites to avoid damage to muscles and to prevent subcutaneous atrophy. Monitor response carefully to avoid adverse effects. Potassium IV potassium deficiency or hypokalemia, a condition in which serum potassium level falls below a critical range. stomach upset, nausea, diarrhea, vomiting, or intestinal gas Arrange for serial serum potassium levels before and during therapy. Administer liquid form to any patient with delayed GI emptying.
Administer oral drug after meals or with food and a full glass of water to decrease GI upset. Sodium Bicarbonate IV Severe renal disease. Uncontrolled diabetes. Severe primary lactic acidosis[1] [2][3] Circulatory insufficiency due to shock. Severe dehydration. Extracorporeal circulation of blood. Cardiac arrest. Drug toxicities. Severe headaches. Loss of appetite. Nausea or vomiting. Irritability. Weakness. Urge to urinate more frequently. Slowed breathing. Swelling in the feet or legs long-term use of oral preparation with milk or calcium can cause milk-alkali syndrome: Anorexia, nausea, vomiting, headache, mental confusion, hypercalcemia, hypophosphatemia, soft tissue calcification, renal and ureteral calculi, renal insufficiency, metabolic alkalosis.
References
Bsn, M. V., RN. (2023). Pharmacology Nursing Mnemonics & Tips. Nurseslabs.
https://nurseslabs.com/pharmacology-nursing-mnemonics-tips/
