Week 7 Assessment Scenario SBAR and Link PDF

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Download Week 7 Assessment Scenario SBAR and Link PDF

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Patient Hx: Age: 56 History of Present Illness: Currently admitted to your floor s/p tPA for right MCA ischemic stroke x 3 days ago. Put on call light complaining of 8/10 headache. You note that the patient’s left grip is much weaker than baseline when he tries to hand you his water pitcher. Past Medical History:    

Diverticulosis x 4 years Occasional lower back pain (controlled with OTC NSAIDs) Tension headaches Atrial fibrillation

Medications:    

Metoprolol succinate 25mg BID Xarelto 20 mg QD Pantoprazole 20 mg QD LR@TKO--> Left AC PIV

When completing the scenario think of the following questions to help guide your actions:      

What is your next action(s)? Why? What would you assess? Why? What are your thoughts on what is happening? What do you think got the patient to this point? Are there any labs or diagnostic tests you would recommend? Are the medications appropriate? Would you add anything?

SBAR Situation: Patient arrived at unit post tPA for MCV right side ischemic stroke. Patient has left side grip weakness far below baseline. Patient reports 8/10 headache. Background: Patient’s hemiparesis likely result from right side ischemic stroke, but patient is experiencing weakness below established baseline, with onset of 8/10 headache, and patient medication Hx of Xarelto and OTC NSAIDs increases risk for hemorrhagic conversion. Patient’s IV set to TKO. Assessment: Concerned about the patient’s hydration status, medication history, and onset of headache. Assessed patient’s pain to determine if this is a tension headache, patient has hx of, or if this is hemorrhagic conversion of ischemic stroke. Patient’s labs would need to be checked, specifically electrolytes, H&H, Platelet count and differential WBC. Patient should also have trough level checked for Xarelto.

Recommendation: Recommend a CT to check for hemorrhagic bleed in the brain. Recommend drawing labs for H&H, Platelets. Recommend patient stay on stroke precautions. Recommend a sitter 1:1 until patient’s risk status can be downgraded, or risk of hemorrhagic conversion can be mitigated. Recommend Q15 neuro assessments to track hemiparesis as treatments progress. Reflect: I feel like there was no way I was going to be able to get all of that out in three minutes. Maybe as I progress through my nursing career, I’ll be able to weed out the really unimportant stuff. If I had to pick something to do differently, I would try to not include as much information as possible into my presentations. I know that in trying to be as detailed in my descriptions as possible, I tend to get bogged down in the minutiae. As for what I learned, learning that hemorrhagic conversion of ischemic stroke exists is scary. Ischemic stroke by itself is awful, but knowing that based on treatment and medication history, an already awful event can turn deadly, especially due to one of the treatments, in this case tPA. Video Link https://youtu.be/d1IxpNIIAOA...