SIM Concept Map
4
NSG 406 SIM Concept Map
Grace Rowley, Kaitlyn Schwab, Madison Tartaro
Overview
Overview
- Patient: E.A.
- Admitting Diagnosis: near syncope, dizziness
- Primary Diagnosis: ischemic stroke
- Health History: TIA, A fib, HTN, CAD, HLD
Pathophysiology and Risk Factors
Patho and Risk Factors
Pathophysiology
Pathophysiology
A blood clot in the brain that blocks blood flow and can lead to partial brain tissue death
Risk Factors
Family history, birth control, history of TIA, DM, HTN, high cholesterol, smoking, age
Nursing Diagnosis 1
- Impaired mobility related to ischemic stroke as evidence by patient experiencing right sided weakness
Nursing Diagnosis 1
Goal and Interventions
Expected Outcome
Goal: Pt. will recieve tPA fast enough to break up clot and regain mobility with physical therapy, rehab, and occupational therapy. See improvement in 3 months.
Interventions: provide safety (bed rails, mobility devices), assist with ROM exercises, fall precautions, provide comfort (assisting with repositioning, extra pillows)
Nursing Diagnosis 2
- Powerlessness related to rapid onset of stroke as evidenced by patient stating that they are unable to enjoy things they like such as ambulating at their own will and coffee with her NPO diet.
Goal and Interventions
Expected Outcome
Goal: Pt. will accept her condition and want to work toward the healing process with familial and medical support.
Interventions: Offer support groups for stroke survivors, educate on home aids and visits available to her, therapy is an option if she is interested, provide emotional support and therapeutic communication
Nursing Diagnosis 3
- Knowledge deficit related to treatment plan as evidenced by patient drinking coffee while on NPO status and asking questions about her treatment and care.
Goal and Interventions
Expected Outcome
Goal: Pt. will understand that an NPO diet is to help monitor her I and O's more strictly and allow patient to be ready for surgery or testing if necessary. Additionally, the pt. will understand her condition- expected before discharge.
Interventions: educate pt. on NPO diet, educate pt. on condition, educate pt. on how the tPA works
Medical Management
IV tPA (gold standard for dissolving clots causing an ischemic stroke), IV saline fluids, endovascular surgery, angioplasty, stent
Nursing Management
Nursing Mangement
Neuro checks, sensation/perception checks, motor control, swallowing ability, nutritional/hydration status, skin integrity, activity tolerance, bowel/bladder function (foley catheter)
Risk reduction
Risk Reduction
Nonmodifiable- advanced age (>55), gender (male), race (Black)
Modifiable- HTN, a-fib, HLD, obesity, smoking, DM, periodontol disease, heart disease
Clinical Manifestations
- trouble walking, unilateral weakness, slurred speech, paralysis or numbness of one side of face or body, blurred vision, pins and needles, difficulty swallowing