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Delaware Technical Community College

Nursing Department
Ischemic Stroke with Increased ICP
This simulation is based on a female diagnosed with ischemic CVA. This information
was covered briefly in the first level or LPN portion of the program, and then reemphasized again in this course. Lecture is intended to review and then further
advance your knowledge of CVA and its management. The purpose of this sim is to
put theory into practice in a controlled lab setting. Students will work in groups of 3
or 4 and be assigned different roles Charge, primary or staff nurse. Students will
be asked to Assess, provide timely interventions, prioritize, educate and evaluate.
You will be assessing the Vital Sim manikin and provide such interventions as
administering medications (including rTPA (activase)) and oxygen, inserting a foley
catheter and possibly starting an IV. You will also call a primary provider for orders
and be responsible to carry out the orders appropriately. The goal is to work as a
team to deliver safe nursing care for a CVA patient in a Med-Surg setting in an
organized fashion with a focus on prioritizing care.
Assessment:
Students will participate in a debriefing session immediately following each
simulation. Students will have both fellow student and instructor feedback. Each
debriefing is followed by the next simulation so students can utilize observed skills
as a guide for improving performance.
The Simulation experience is a pass/recycle grade for clinical it is part of the
clinical/lab component of the course grade. Students who provide unsafe care, are
unprepared, not involved or who do not take this experience with the professional
demeanor required will be in jeopardy of recycling this experience and then the
course.
Julie Wilson is a 48 y.o. female admitted today with a diagnosis of rule out ischemic
stroke. PMH includes: HTN, Diabetes-type II, hypercholesterolemia, ppd smoker.
She has an allergy to iodine. The patient was brought to the ER by her husband
after she collapsed at home this morning. Initially, she was slightly confused. Pt is
complaining of severe right temporal lobe headache and blurred vision. Husband
stated that she has been complaining of severe headaches and blurred vision that
came and went several times this past week. CT completed in the ER was
negative for intracranial bleeding. She presented to the ER in the time frame
appropriate for fibrolytic therapy and the physician has ordered rTPA. The ER did not
have time to give the bolus or the infusion. They brought the medication with them
when they dropped off the patient. It needs to be given in the next 20 minutes.
Last set of vital signs taken in the ER: T 99, P 102, R 22, BP 174/104, SpO2 92% on
RA
ER neuro results: Eyes open spontaneous, confused verbal response, obeys
commands, severe weakness in right arm and right leg, pupils 4 mm bilaterally. NIH
stroke scale was completed in the ER.

Group 1
(1)
(2)
(3)

Group 2

Group 3

Group 4

Roles/Responsibilities
1.

Charge nurse-look at orders, call doctor, help with patient care as able

2.

Primary nurse-assessment, assist with procedures, delegate tasks

3.

Nurse-IV and medication administration, help as needed