NR 340
NR 340 Week 6 Assignment: Clinical Simulation Prep Packet
NR 340 Week 6 Assignment.
NR 340 Week 6 NR 340 Week 6 Assignment: Clinical Simulation
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NR 340 Week 6 Assignment: Clinical Simulation Prep Packet
Directions: This assignment is to be completed independently (it is not a group assignment!) and turned in on your assigned clinical simulation day. Late submissions will not be accepted. The purpose of this assignment is to prepare you to complete the corresponding clinical simulation scenarios related to coronary artery disease and hypertensive crisis respectively. Resources to complete this assignment include the following:
A. Lewis Medical-Surgical Nursing, 9th edition. Prevention of osteoporosis (p. 1555) and hip replacement post-operative management (p.1526-1527).
B. Sole textbook Pulmonary Embolism (p. 423-425) and thrombolytic candidates (p. 382).
C. Stroke/TPA articles posted on shell
This assignment is worth 50 points.
Susan Weil Simulation Scenario
1. What is the nurse’s role in providing family centered care during and after a crisis? (1 point)
The nurse’s role in communication with family members and patients is to be involved during and after a crisis. The nurse should share information with family and patient that is clear and avoid using medical jargon, the nurse should also be truthful and show respect for the family and patients needs and listen to what information they have to provide. The nurse should also provide comfort and support to the family members, be aware of family strengths, and have respect for different methods of coping.
2. What pharmacological and non-pharmacological comfort measures can be used for a post-operative patient? (2 points)
Pharmacological: Opoids - morphine, dilaudid, fentanyl
Non-pharmacological: Guided imagery, relaxation or breathing techniques, active listening, re-positioning, and therapeutic touch, sedative music, limit noise and lighting, explanation of all procedures and interventions.
3. What vital nursing assessment data should be gathered on a patient post hip replacement surgery? (3 points)
Pain level (0-10), vital signs, check surgical site dressing for drainage and signs of infections, bowel sounds, lungs sounds and perfusion
4. Describe the major complications that can arise for patients who are post-operative hip injury/replacement? (3 points)
DVT, PE, stroke, infection, falls
5. Describe the pathophysiologic process of a pulmonary embolism. Include the typical origin site of a pulmonary embolism. (3 points)
There is a blockage in a blood vessel that forms a blood clot (thrombus). The thrombus dislodges from the blood vessel and travels through the blood until it becomes stuck in a blood vessel in the lungs and occludes blood flow. Pulmonary embolism happens most commonly due to mobilization of a clot from deep venous thrombosis in the lower leg.
6. What are 3 signs and symptoms associated with a pulmonary embolism? (2 points)
Shortness of breath (SOB), chest pain, coughing (possibly bloody)
7. What medical treatments can be used to treat a pulmonary embolism? (2 points)
Treatment includes anticoagulants (heparin), thrombolytics (tpa), or possibly surgery.
8. What immediate nursing interventions should the nurse perform for a patient who is experiencing a pulmonary embolism? (3 points)
Rapid Response
Bed Rest
Order for stat chest x-ray
Give supplemental oxygen
9. Describe the actions, indications, contraindications, adverse effects, dose range and method of administration for the following medications: (6 points)
Drug Actions Indications Contraindications Adverse effects Dose range Method of administration
Heparin
Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. In low doses, prevents the conversion of prothrombin to thrombin by its effects on factor Xa. Higher doses neutralize thrombin, prevention the conversion of fibrinogen to fibrin. Therapeutic effect: Prevention of thrombus formation. Prophylaxis and treatment of various thromboembolic disorders. Ex: PE, A fib Hypersensitivity, uncontrolled bleeding, severe thrombocytopenia
Bleeding, heparin-induced thrombocytopenia, pain at injection site, fever
IV: Intermittent bolus 10,000 units followed by 5,000-10,000 units q 4-6 hr. Continuous infusion 5,000 units (35-70 units/kg) followed by 20,000-40,000 units infused over 24 hrs. IV, Sub-Q
Cefazolin
Bind to the bacterial cell wall membrane, causing cell death. Therapeutic effects: bactericidal action against susceptible bacteria. Treatment of the following infections caused by susceptible organisms: skin, urinary, respiratory, intra-abdominal, bone, & septicemia. Hypersensitivity to cephalosporins, serious sensitivity to penicillins Seizures, pseudomembranous colitis, steven-johnson syndrome, anaphylaxis, serum sickness, diarrhea, nausea, vomiting, thrombocytopenia Powder for injection: 500 mg/vial, 1 g/vial, 10 g/vial, 20 g/vial, Premixed containers: 1 g/50 mL D5W, 2 g/50 mL D5W IV, IM
Enoxaparin Prevents conversion of fibrogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III; produces higher ratio of antifactor Xa to antifactor IIa Prevention of DVT and PE in hip and knee replacements Hypersensitivity to this drug, heparin, or pork; hemophilia, leukemia with bleeding, PUD, heparin-induced thrombocytopenia Fever, confusion, nausea, edema, hypochromic anemia, thrombocytopenia, bleeding, ecchymosis SubQ: 30 mg BID given 12-24 hr post-op for 7-10 days provided that hemostasis has been established Sub-Q
Valsartan
Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. Hypertension, alone or in combination Hypersensitivity, pregnancy, severe hepatic disease, bilateral renal artery stenosis Dizziness, insomnia, MI, dysrhythmias, hepatotoxicity, nephrotoxicity, cramps, cough PO: 80-160 mg q daily alone or in combination with other antihypertensives Oral
Triamterene
Acts on distal tubule and cortical thick ascending limb of loop of Henle by increasing excretion of water, sodium, chloride, and potassium Edema, HTN, diuresis, CHF, edema in corticosteroid, estrogen therapy Hypersensitivity to thiazides or sulfonamides, anuria, renal decomposition, hypomagnesemia Uremia, glucosuria, headache, dizziness, hepatitis, aplastic anemia, leukopenia, agranulocytosis, thrombocytopenia, neutropenia PO: 25-100 mg/day Oral
Acetaminophen/Hydrocodone
Inhibits the synthesis of prostaglandins that may serve as meditators of pain and fever, primarily in the CNS. Therapeutic effects: analgesia, antipyretic Treatment of: mild, moderate, or severe (with opioid analgesics), fever Pervious hypersensitivity, products containing alcohol, aspartame, severe hepatic impairment/active liver disease Hepatotoxicity, fatigue, insomnia, HTN, hypotension, headache, constipation, anxiety, increased agitation PO: 325-600 mg q 6 hr
IV: 1000 mg q 6 hr or 650 mg q 4 hr not to exceed 1000 mg/dose Oral, IV
Naomi Reed Simulation Scenario
10. Differentiate the pathophysiological processes and treatment options used in the 2 major types of stroke. (5 points)
Ischemic: Artery that is carrying oxygenated blood to the brain is occulded. The treatment for ischemic strokes is administration of tPA, if within the designated time frame, and anticoagulants not within 24hrs of stroke and antihypertensives. The two types of ischemic strokes include: thrombotic, when damaged cerebral arteries become blocked by the formation of a blood clot within the brain. Embolism, caused by a clot in an artery but that does not form in the brain but in another part of the body and travels to the brain.
Hemorrhagic: A weakened blood vessel in the brain breaks or a aneurysm within the brain bursts. Blood pours into the brain or around the brain causing swelling and increased pressure. Treatment includes administration of anticonvulsants, antihypertensives, and diuretics. Hemorrhagic strokes include: intracerebral, blood pools into the surrounding brain tissue from a leak of a vessel in the brain. Subarachnoid, bleeding around the brain into the tissue that covers the brain.
11. What is the National Institutes of Health Stroke Scale (NIHSS)? Briefly explain in 2-3 sentences what is assessed on the NIHSS and the scoring system. (2 points).
The NIHSS is a 15-item neurologic examination used when someone suffers from a stroke to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. A trained observer rates the patent’s ability to answer questions and perform activities.
12. Provide 3 nursing considerations for administration of tissue plasminogen activator (rTPA). What may result if administration of TPA is too fast or too slow? (3 points)
• Prior to tPA infusion, the patient’s systolic BP should be less than 185 mm Hg and the diastolic BP should be less than 110 mm Hg
• tPA is not compatible with other medications and requires a its own I.V. line
• tPA is dosed based on patient weight
13. List 5 contraindications for the administration of TPA. (2 points)
Serious head trauma
Subarachnoid hemorrhage
Recent stroke
Recent or history of intracranial surgery
Uncontrolled HTN, systolic greater than 185, diastolic greater than 110
Active internal bleeding
Intracranial aneurysm
14. Sample TPA calculation. 0.9 mg/kg over 60 minutes (not to exceed 90 mg) with 10% of the total dose administered as an initial IV bolus over one minute. Patient weighs 130 lbs. TPA comes in a premixed bag: 75mg in 75 ml. Calculate the infusion dose (in mg) and the bolus dose (in mg). (2 points).
Infusion dose: 47.9 mg
Bolus dose: 5.3 mg
15. How often are vital signs and neuro checks performed once TPA has been started? (2 points)
Assess and document vital signs, cardiac rhythm, neurological status, and for signs/symptoms of bleeding for the first 2 hours after initiating tPA administration, then every 30 minutes for 6 hours, then every hour for 16 hours and during tPA administration monitor BP every 15 minutes.
16. What nursing interventions need to be avoided once TPA administration has started? (2 points)
Do not administer heparin, aspirin, or warfarin sodium for 24 hours after tPA infusion due to increased risk for bleeding
Do not perform arterial or central venous lines, IM injections, NG tubes, or foley catheters for 24 hours post tPA administration unless procedure is life-saving
17. What are potential complications of TPA therapy the nurse will need to assess for? (2 points)
Uncontrolled bleeding is the most serious complication of tPA therapy. Internal and peripheral bleeding can occur in the brain, GI tract, GU tract, gums, retroperitoneum, inside the nose, at puncture and catheter sites, and under the skin causing ecchymosis
Other complications include seizures and neurotoxicity
18. What is the desired outcome of TPA? (2 points)
The desired outcome of administering tPA include:
Dissolve cerebral blood clot(s) thereby limiting cerebral ischemia and reducing the risk for cerebral infarction
Maintain blood flow to the brain
19. Describe the actions, indications, contraindications, adverse effects, dose range and method of administration for the following medications: (3 points)
Drug Actions Indications Contraindications Adverse effects Dose range Method of administration
Nicardipine
Inhibits the transport of calcium into myocardial and vascular smooth muscle cells. Therapeutic effects: systemic vasodilation resulting in decreased BP, coronary vasodilation resulting in decreased frequency and severity of attacks of angina. Management of HTN Hypersensitivity, sick sinus syndrome, 2nd or 3rd degree AV block, SBP < 90 mmHg, advanced aortic stenosis Arrhythmias, HF, peripheral edema, chest pain, bradycardia, palpations, dysuria, dermatitis, stevens-johnson syndrome PO: 20 mg 3 times daily, may increase q 3 days or 30 mg twice daily as sustained-release form
Oral, IV
Labetalol
Blocks stimulation of beta1 and beta2- androgenic receptor sites. Therapeutic effects: Decreases BP Management of HTN Uncompensated HF, pulmonary edema, cardiogenic shock, bradycardia or heart block Arrhythmias, bradycardia, CHF, pulmonary edema, orthostatic hypotension, fatigue, weakness, bronchospasm, wheezing PO: 100 mg twice daily initially, may be increased by 100 mg twice daily q 2-3 days as needed
IV: 20 mg initially, additional doses of 40-80 mg may be given q 10 mins as needed Oral, IV
Tissue Plasminogen Activator (TPA)
Convert plasminogen to plasmin, which is then able to degrade fiber present in clots. Therapeutic effects: Lysis of thrombi in coronary arteries, PE or DVT Acute MI, acute massive PE, acute ischemic stroke, acute DVT, acute arterial thrombi Active internal bleeding, history of CVA, recent intracranial or intraspinal injury/trauma, severe uncontrolled HTN Intracranial hemorrhage, epistaxis, GI bleeding, retroperitoneal bleeding, GU tact bleeding, anaphylaxis, hypotension Depends on indication
Ex: PE = IV 100 mg over 2 hr followed by heparin
Ischemic stroke = IV 0.9 mg/kg (not to exceed 90 mg) given as in infusion over 1 hr with 10% of the dose given as a bolus over the 1st min IV [Show Less]