Below is a summary of Maya’s EHR activity during her four hours in the ED. As a nurse you are responsible for obtaining and monitoring her vital signs. Answer the following questions and be prepared to discuss the responses with the rest of Maya’s health care team.

  1. Review Maya’s ED EHR: As an ED nurse, you are responsible for collecting Maya’s vital signs (heart rate, blood pressure, temperature and respiration/breathing rate). Select all of Maya’s vitals that are abnormal and are a cause for concern.
    A. Temperature
    B. Blood pressure (SBP/DBP)
    C. Peripheral Pulse rate (bpm)
    D. SpO2 (oxygen level)
    D. Respiratory rate

  2. Internet Research: What are normal results / ranges for these vital signs?
    Temperature _______       Respiration _______
    Pulse / Heart rate ______       Blood pressure ______

  3. Review Maya’s VPE: You prepare Maya for a CT scan and angiography. Fill in the blanks below concerning what these tests are and what the results tell the physician. Use the following word bank (Ischemic, Location, Hemorrhagic, Stroke) to answer the question below.

  4. Both the CT scan and angiography can determine if a _________ has occurred. If there is hemorrhaging in the brain it would be considered an __________ stroke. If there is a blockage in the brain it is considered an __________ stroke. The physician can also tell the __________ of the stroke.

  5. Internet Research: The ED physician believes that Maya is suffering from an ischemic stroke. Which would be the quickest treatment for her?
  6. A. Remove the blood clot that is blocking the blood vessel to the brain.
    B. Use tPA to dissove the blood clot to improve the blood flow.
    C. Use surgery treatment to stop the bleeding within the brain.
    D. Both B and C

  7. Internet Research: You greet Maya’s daughter when she arrives. As a nurse you are required by law to follow HIPPA – which only allows for certain information to be shared by the health care team. What can you legally tell Maya’s daughter about her health since Maya is unable to grant permission?
  8. A. No information can be shared with Maya’s daughter.
    B. Using professional judgement, you can only confirm that Maya is in the hospital.
    C. Using professional judgement, you can discuss information about Maya concerning her care.

View Maya’s EHR – ED Chart   Virtual Physical Exam