Below is a summary of Maya’s electronic health record during her four hours in the emergency room. As her ED physician, you are responsible for examining Maya and ordering tests. These tests will help diagnose her condition. Answer the following questions and be prepared to discuss the responses with the rest of Maya’s healthcare team.

1. Review Maya’s VPE: You assess Maya’s condition and review her vitals listed in her EHR. Maya’s blood pressure and pulse rate are high, and you are concerned that Maya is having a stroke. You immediately begin performing the National Institute of Health’s Stroke Scale (NIHSS). Maya’s results show her score as a 24, which indicates that she has suffered a severe stroke.

After reviewing her NIHSS score in VPE, which areas are of high concern?


A. LOC question: Month and age.

B. LOC question: Open and close eyes

C. Gaze

D. Visual field

D. Facial palsy



2. Internet Research: There are three types of strokes. Your first task is to determine what type of stroke Maya is having.
   Match the name of the stroke with the correct description.

   ____ Ischemic	A. A weakened blood vessel ruptures.
   ____ Hemorrhagic	B. A temporary clot.
   ____ Transient Ischemic Attack	C. An obstruction within a blood vessel.



Of the three types of strokes, which is the most common type of stroke?

A. Transient Ischemic Attack (TIA)

B. Hemorrhagic stroke

C. Ischemic stroke

D. Both B and C



3. Internet Research: You write orders for an immediate CT Angiography of Maya’s brain.
What information can be obtained from a CT Angiography that may be helpful in determining Maya’s diagnosis?

A. Determine if there is insufficient blood flow to the heart.

B. Determine if there is blockage of the brain’s blood vessels.

C. Determine if there is blockage of the carotid arteries.



4. Review Maya’s ED EHR: What do the results of Maya’s CT Angiography indicate?

   A. Slurred, unrecognizable speech.

   B. Loss of mobility in both right arm and leg.

   C. Diffused region of hypodensity, left ventricle.

   D. All the above

   
   
5. Internet Research: You determine Maya is having an ischemic stroke. Which is the BEST treatment for her?

   A. Cardiovascular procedure

   B. Surgical treatment

   C. tPA injection

   D. Both A and B



View Maya’s EHR – ED Chart   Virtual Physical Exam
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National Institute of Health’s Stroke Scale (NIHSS): A standardized tool used by physicians and other health care professionals to measure the level of impairment caused by a stroke.

(MD, PhD Jose Vega. “How Is the NIH Stroke Scale Used for The Evaluation of Stroke?” Verywell. N.p., n.d. Web. 12 May 2017.)
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Ischemic stroke: (is-skem-ik) The most common kind of stroke, which is caused by an interruption in the blood flow to the brain. (“Stroke.” Mayo Clinic. N.p., n.d. Web 15 Sept. 2014.)

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 healthcare 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


Internet Research: What are normal results / ranges of the following vital signs?

Temperature _______	Respiration _______
Pulse / Heart rate ______	Blood pressure ______



2. Review Maya’s VPE: You prepare Maya for a CT Angiography. Fill in the blanks below describing what the tests results provide the physician. Use the following word bank (bleeding, brain injuries, fluid, ischemic, location, skull fractures, swelling, tumors) to answer the question below.

The CT Angiography can detect if _________ or ________ has occurred. And it can identify __________ or __________. It also looks at the structures of the brain for __________ , __________ or __________ strokes. The physician can also tell the __________ of the stroke.


3. Internet Research: The ED physician believes that Maya is suffering from an ischemic stroke. Which would be the quickest treatment for her?

A. Remove the blood clot that is blocking the blood vessel to the brain.

B. Use tPA to dissolve the blood clot to improve the blood flow.

C. Use surgery treatment to stop the bleeding within the brain.

D. Both B and C



4. 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 healthcare team. What can you legally tell Maya’s daughter about her health since Maya is unable to grant permission?

A. No information can be shared with Maya’s daughter.

B. Using professional judgment, you can only confirm that Maya is in the hospital.

C. Using professional judgment, you can discuss information about Maya concerning her care.

Below is a summary of Maya’s EHR activity during her four hours in the ED. As a technologist, you are responsible for obtaining and providing test results. This will assist the physician in diagnosing Maya’s condition. Answer the following questions and be prepared to discuss the responses with the rest of Maya’s healthcare team.

1. Internet Research: Maya’s results must be obtained quickly. The physician orders a CT Angiography. Which of the following statements are TRUE (T) and which are FALSE (F).

   ______ Detects enlarged blood vessels in the brain

   ______ Evaluate a tumor formed by blood vessels

   ______ Test to find abnormal vessels in the brain

   ______ To find blood clots formed in your leg and traveled to the stomach




2. Review Maya’s VPE: The physician has ordered several laboratory tests. Among the tests are: coagulation, lipid panel, complete blood count (CBC) and basic metabolic panel (BMP). Match the test with the statement about how the test could help determine if a stroke has occurred?

   ______ Coagulation	A. A high WBC and ow platelet value indicates a possible infection.
   ______ Lipid panel	B. High glucose levels could be a factor in her stroke. High potassium levels show an imbalance inside her body.
   ______ Complete blood count	C. Elevated levels of PT, PTT and INR suggest that her blood is not clotting as it should.
   ______ Basic metabolic panel	D. High level of total cholesterol and triglycerides can cause plaque to build up in arteries which can cause an ischemic stroke.




3. Review Maya’s ED EHR: Of the following list of test results, note which are abnormally high (H) and which results are abnormally low (L) as indicated in red or blue? (Use “H” for high and “L” for low.)

______ SBP/DBP	______ Trigylcerides
______ SP02%	______ White blood count (WBC)
______ NIH stroke scale	______ Platlets
______ Coagulation	______ Glucose
______ C-reactive protein	______ Potassium
______ Total cholesterol

Below is a summary of Maya’s EHR activity during her four hours in the ED. As a pharmacist, you are responsible for making sure that Maya receives her medications. You are also responsible for reviewing possible side effects Maya might have with her medications. Answer the following questions and be prepared to discuss the responses with the rest of Maya’s healthcare team.

1. Review Maya’s ED EHR: You are responsible for ensuring that the medications prescribed by Maya’s physician do not interfere with her current medications or allergies. What is Maya allergic to?

   A. Altace

   B. Lipitor

   C. Toprol-XL

   D. Codeine


Internet Research: What would happen if Maya was given the drug she is allergic to?

A. Her drug reaction could go away with time so there would be no issue.

B. She could have a life-threatening reaction to the medicine.

C. Her body would react, within hours, developin a rash, hives, wheezing, etc.

D. Both B and C




2. Internet Research: Maya’s ED EHR indicates that she was taking Altace (Ramipril), Zaroxolyn (Metolazone) and Toprol-XL (Lopressor) prior to admittance. Match each medication with the type and treatment use (there are 10 types).

   ______ Altace	A. Beta blocker used to reduce heart rate.
   ______ Zaroxolyn	B. ACE inhibitor used to relax blood vessels and treat high blood pressure.
   ______ Toprol-XL	C. Diuretic used to treat salt and water retention.



3. Review Maya’s VPE: The physician orders a tissue plasminogen activator (tPA).
   
   True or False: tPA is used to dissolve the blood clot that can cause an ischemic stroke.

Below is a summary of Maya’s electronic health record (EHR) activity during the four hours she is in the ED. As a medical and health services manager, you are responsible for making sure that Maya receives excellent care. You will also figure Maya’s bills, consisting of her tests, procedures, room charges, supplies and medications. Using her EHRs, Virtual Physical Exam (VPE) and Internet research, fill out the billing statements and be prepared to share this information with the rest of Maya’s healthcare team.

• MHSM – Bill (which includes both an ED and Inpatient statement)
• MHSM – Bill Reference
• Maya’s EHR – ED Chart (link below)
• Virtual Physical Exam (link below)
• Maya’s EHR – Inpatient Chart

1. Use the blank copy of Maya’s ED and Inpatient bills and the Bill Reference to calculate her costs. In her EHRs, look for the number of times a test is administered, number of days a cost is incurred or the units per day a medication is administered. You may need to do additional Internet research. Some helpful sites are www.healthcarebluebook.com, www.fairhealthconsumer.org and www.pharmacychecker.com

Below is a summary of Maya’s EHR activity during her four hours in the ED. As a health coach, your job is to recommend changes to decrease the need for future emergency care or hospitalization. You will also provide the resources she needs to understand her diagnosis and what may have caused her condition. Answer the questions and be prepared to discuss the responses with the rest of Maya’s healthcare team.

1. Internet Research: As a health coach, you want everyone to know the warning signs of a stroke. From the list below, designate which are the 4 signs of a major stroke (M) and which are other (O) possible symptoms of a stroke.

______ “pins and needles” sensation	______ face drooping
______ blurred vision	______ arm weakness
______ severe headache	______ paralysis
______ speech difficulty	______ time to call 9-1-1




2. Review Maya’s VPE: As Maya is being cared for in the ED, you begin to plan for her recovery. You review her National Institute of Health Stroke Scale (NIHSS) in VPE and notice several issues that are of concern. Select all of the areas that are of high concern.

   A. LOC question: Month and age

   B. LOC question: Open and close eyes

   C. Gaze

   D. Visual field

   E. Facial palsy


Internet Research: From the list below, select all of the following issues Maya might need for rehabilitation after she leaves the hospital. (Consider the issues from the question above that were high concern areas when she entered the hospital.)

A. Stroke rehabilitation facility or in-home care

B. Speaking and communicating

C. Thinking and memory

D. Bladder and bowel problems

E. Swallowing and eating




3. Review Maya’s ED EHR and story: In reviewing Maya’s EHR and medical history, you discover several areas she can improve to decrease her risk of having another stroke. From the list below, select all of the issues she can immediately change.

A. Decrease her salt intake

B. Lower her blood pressure

C. Decrease her total calorie intake

D. Choose better options for snacking

E. Lower her cholesterol levels

F. Begin a walking / exercise program