BACHELOR OF SCIENCE IN NURSING:

INTENSIVE NURSING PRACTICUM

RLE LCP MODULE RLE LCP UNIT WEEK

CEREBRO VASCULAR ACCIDENT

 Read course and laboratory unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to course unit terminologies
for jargons
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks

At the end of this unit, the students are expected to:

1. Apply the nursing process in the care of groups of clients with cerebrovascular accident:
a. Assess the client’s total health condition and resources.
b. Formulate nursing diagnoses based on the given scenario.
c. Develop a plan of care for individuals with cerebrovascular accident.
d. Implement a plan of care applying the appropriate principles, guidelines, and steps in
administering care to client(s) with cerebrovascular accident (CVA)
e. Evaluate the outcomes(s) of care post CVA.
2. Demonstrate competencies of a beginning staff nurse, nurse leader, and researcher.
3. Promote personal and professional growth by showing independence in performing varied
tasks and responsibilities.
Virtual/Skills laboratory equipment and materials
To facilitate the practice of students’ nursing skills, the following rules must be implemented:
1. The use of the Nursing Skills laboratory equipment and materials appropriate of the given
case scenario are allowed.
2. Use resources from the required readings. (Cerebrovascular Accident)
3. Students must perform the tasks in the worksheet at a given period.
Key Areas of
Competency
Responsibility
1. Safe and Demonstrates knowledge
Quality Nursing about the clients’ health status
Care and set priorities in nursing
care based on clients’ needs
Provides sound decision
making in the care of
individual/ family considering
their beliefs and Values
Promotes safety, comfort, and
privacy
Administers medications and
other health therapeutics
safely (accurately and
correctly)
2. Management Organizes workload to
of Resources facilitate client care.
Utilizes resources to support
client care by ensuring proper
functioning of equipment
3. Health Develops health education
Education plan based on assessed
learning needs
4. Legal Adheres to practices in
Responsibility accordance with the nursing
law, institutional policies and
protocols, and other relevant
legislation.
Expected Performance and Criteria
Identifies the client’s health status in
determining the need for immediate care for
CVA
Gathers and analyzes data relevant to the
client’s health condition perform the correct
management for CVA
Maintains a safe environment and performs
cardiac catheterization procedures and
protocols safely ensuring privacy in all aspects
of care.
Conforms to the 10Rs of medication
administration and health therapeutics
Identifies nursing tasks and performs them
based on priorities.
Finishes tasks on time.
Observes appropriate protocols and
institutional policies.
Ensures availability, completeness, and
functionality of equipment and nurse’s
paraphernalia relevant to the management of
CVA
Implements applicable age-appropriate health
education activities to the client based on
needs assessment
Acts and performs nursing tasks related to
CVA management in accordance with
established norms of conduct expected of a
nurse and an OLFU student as well as with the
other relevant legislation.
 Key Areas of
Competency Expected Performance and Criteria
Responsibility
5. Ethico-moral Adheres to Code of Ethics of Maintain the privacy and confidentiality of
responsibility Nurses and respect rights of client’s information.
the client and other individuals
Accepts responsibility and accountability on
involved in the care of the the decisions made relating to the client’s
client. care.
6. Personal and Project a professional image Performs nursing tasks according to
Professional of the nurse professional standards.
Development Demonstrates good manners and right
conduct at all times.
Observes proper grooming and hygiene.
Adapts to changes willingly by being open to
new strategies or approaches relevant to the
management of CVA.
7. Quality Identifies and reports Identifies and reports inadequacies and
Improvement variances and recommends problem(s) encountered in the provision of
appropriate solutions. care in clients with CVA
Recommends practical and appropriate
solutions.
8. Research Enhances competency level in Specifies researchable problems related to
the utilization of different CVA care and modalities.
forms of data gathering and Gather, analyze, and interpret relevant data.
principles of assessment and
nursing care.
Analyzes and interprets data, Utilizes findings in research in the provision of
disseminate findings and CVA-related measures and client care.
apply recommend actions.
9. Records Maintains accurate and Records outcome of client care.
Management updated documentation of Submits legible, accurate and updated
client care observing legal documentation and/or information regarding
imperatives in documentation the client care.
and record keeping.
10. Communicatio Identifies verbal and non- Interprets and validates client’s body language
n verbal cues and facial expressions
Uses appropriate information Utilizes appropriate means and/or channels of
technology to facilitate communication to support the delivery of care
communication. to clients with myocardial infarction
11. Collaboration Collaborates plan of care with Respects the role of other members of the
and Teamwork the other health care team health care team in administering care to the
members. client with CVA.
Refers the client to the appropriate allied
health team partners.

The Mock OSCE scenario part is made up of three stations: Ongoing Assessment, Implementing Care and
Ongoing Care. The instructions and available resources are provided for each station, along with the specific
timing.
SCENARIO:

A 63y/o male, diabetic and hypertensive was admitted to the emergency room
because of weakness on the right face, arm and leg. His speech is slurred and
looked confused. The doctor’s initial working diagnosis is Acute Ischemic
Cerebrovascular Accident. Initial vital signs are as follows: BP 190/100, HR 105/min
RR 23/min. The patient is awake but confused and appears sleepy. The patient can
move the fingers but not able to raise the right arm and leg if was asked to. The
patient was placed on bed rest with HOB at 30◦. Oxygen supplementation is
initiated at 2-3L/min via nasal cannula. Continuous pulse ox monitoring to keep
SpO2 >95%. Neuro Checks every 30 minutes was ordered. Instituted Falls Risk Precautions. NPO diet
temporarily was prescribed. PNSS IVF was started at KVO rate. Diagnostic tests were ordered immediately-
Cranial CT scan with no contrast, CXR, CBC, Urinalysis, FBS, HBA1c, Lipid profile, PT, PTT, Kidney function test and
Liver function tests.

History:

Patient is a taxi driver, known diabetic and hypertensive for more than 10 years with poor compliance with
medications, he smokes 6 sticks of cigarettes per day and drinks alcohol occasionally. He has a strong family
history of DM and hypertension.

***You will be asked to complete the following activities to provide high quality, individualized care for the
patient.

STATION TASKS RESOURCES

Ongoing Assessment  You will collect, organize and  Assessment overview and
– 15 minutes document information about the documentation which you will
patient. be asked to complete

 Observations chart

Implementing Care  You will perform necessary  An overview of appropriate

–15minutes nursing care to this client with
CVA.
Ongoing Care  You will document the care that
– 15 minutes has been provided using an
FDAR tool – (Focus, Data,
Assessment and
Recommendation) so that this is
communicated with other
healthcare professionals.
principles, guidelines, and
steps in administering care
to client(s) with (CVA)
 An overview and Ongoing Care
letter for the person you have
been caring for
Station 1: Ongoing Assessment

TASKS: Assume that it is 9:00am. You have been asked to assess the patient. Complete the
assessment data to provide high quality, individualized care for the patient.
OBSERVATIONS CHART
Patient Profile:

Subjective Data:

TIME Objective Data:

TIME Critical Points to check:

Accomplished by: _________________________________________

Verified by: _______________________________________________

REMARKS:
Adapted from PreMIS (https://ncems.org)

Station 2: Implementing Care

TASKS: Perform necessary nursing care to this client with CVA.

Patient Care Report Narratives

Time: F:

Date: D:

A:

R:
 Accomplished by: _________________________________________

Verified by: _______________________________________________

REMARKS:

CV
CVA – check list
Skill Tested YES NO
1. The student identifies priority needs
2. Assesses client in the emergency room
a. Checks for chief complaint
b. Checks for vital signs
c. Check for orders to be carried out initially
3. Demonstrates / performs correct neurologic assessment
a. Mental Status Exam
b. Cranial nerve examination
c. Assessment of the Level of consciousness
d. Assessment of reflexes
e. Assessment of Motor Function
4. Anticipates diagnostic tests and possible outcome
5. Demonstrate monitoring for complications in the ICU
6. Anticipate drugs to be given and their mechanisms of action
7. Identify possible complications of CVA
8. Student formulates nursing care plan for client with CVA
9. Student anticipate expected outcome of the client in the scenario
Station 3: Ongoing Care
TASKS: Complete each section in full.

Confirmed Diagnosis:

Date of Appointment
Situation

Background

Assessment

Recommendations

Identified areas of self-care

Identified potential areas for health promotion:

Other members of the multidisciplinary team who need to be aware of the ongoing care needs for
this patient

Accomplished by: _________________________________________

Verified by: _______________________________________________

REMARKS:
Discussion Questions
The student should be able to answer the following questions:
1. What will be your focus physical assessment on this client before you start your nursing
care?
2. What do you anticipate as possible results of the tests? Identify tests and possible
outcome and why?
3. Make a pathophysiology chart and show how the client manifests the following clinical
manifestations
4. Formulate a comprehensive nursing care plan for this patient?
5. Supposed a tissue plasminogen activator (Alteplase) is being ordered to be given, what
is the nursing considerations when this drug is administered?
6. Priority Decision: What are the priority therapeutic and nursing interventions to prevent
complications?
7. Teamwork and Collaboration: What care can be delegated to a Nursing assistant?
8. What are the common complications of CVA?
9. Priority Decision: Based on the assessment data presented, what are the priority nursing
diagnoses? Are there any collaborative problems?
10. Formulate nursing care plan to this client.

Hinkle, J. and Cheever, K. (2018). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing,
14th ed. USA: Wolters Kluwer

Ignatavicius, D. and Workman, L. Medical-Surgical Nursing, 9th Edition

Mc Cance (2012) Pathophysiology, Eighth edition, Elsevier