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Bow-Tie NCLEX Questions on NGN: Test Prep Guide

I'm. Good afternoon, everybody. Hello. Good afternoon, everybody. Good afternoon. Here in Europe. So good evening in the Philippines and welcome to another episode of Connetics College Lecture series. So my name is Emil Gomez, so you can call me Emil for short. And I represent IPASS online review. So thank you for joining me this evening. So as we go figure on dive into what we call the Next Generation NCLEX. So today or tonight we will be I will be doing a lecture series, lecture discussion about what we call the bowtie. So in this lecture, I'll be going to give you some tips and strategies that will help you further understand the dynamics of this question. If ever you will be able to encounter this particular question in the real NCLEX. So I believe some of you are having a questions, different questions about on the Internet. Some of you is like skeptics in terms of what should I really encounter during the actual entrance examination? And I'm telling you, worry no more because I pass in collaboration with Connetics nursing agency. We are doing a lecture series every third Monday of the month to ensure that we help our students not only on their journey toward in America, but rather preparing you holistically or the things that you really need to have or to gain as a knowledge for you to effectively manage your review during your entire preparation for the NCLEX. And what we are hoping right now is for you to pass your and let's at least first attempt. So without regard to let me introduce again myself, my name is Emil Gomez. I'm currently stationed or located here in Hamburg, Germany, so I am a cardiothoracic intensive care unit in one of the famous hospitals in a level one trauma hospitals in Hamburg, Germany. So back in the Philippines. So I was part of St Luke's Medical Global City as a clinical nurse, educator and nurse unit manager, and I was part of a various educational institutions like in the University of Makati. I became one of the faculty.

So also I was part of the review center of Radiologic Technologists back in the Philippines. So I decided to leverage further my nursing profession. So currently I am here in Germany. So in the next few months or hopefully this year, I'll be applying also to United States a peace also pray for me. So without further ado, let me discuss you my lecture. So what is the topic for this evening? So how to answer Angie and stand alone questions. So specifically, we will be dealing about bow tie or what we call the standalone one of the standalone questions in English. And so I'll be going to discuss with you some of the most important tips and strategies for you to effectively answer this particular standalone question. So as part of our learning objectives, you will be able to we will be discussing a quick overview of the energy and question types. So review of standalone questions, specifically we will going through on reading or lecturing about trend items and both items and discuss use scoring types for standalone questions, discuss tips on answering standalone questions and learn about stroke and disease conditions. So we will be applying I will be doing a certain lecture about of a particular condition. So after doing it, we will be applying it to a one question about AI. So, so that we will be able to analyze it. We gain something about the lecture and effectively utilize these information for us to manage.

Answering this bow tie so applied it's learned in answering standalone question example, which is particularly we will be dealing in bow tie. So as we all know, coming April one, 2023, I think a month from now we will be transitioning to what we call the next generation Internet, so to speak. So the basic reason why we have this endless transition from a normal NCLEX to what we call the next generation NCLEX the focus of this is basically to measure the clinical judgment ability. The clinical judgment, or what we call the cognitive thinking ability of the nurse in terms of how nurses effectively render nursing in the USA. So for the past couple of years, there are a lot of questions with regards to the re to the to the idea if the NTSB and or the end legs is really measuring the ability of the nurse if they can effective early use their what we call critical thinking the ability to effectively use this different cues information to effectively manage their patient. So as part of the training, as part of the research of the NTSB and they have this next generation in place that usually or aims to measure the clinical judgment or the cognitive thinking skills. So what are the things that we are expecting for this next generation? And so we have here a case study.

So basically we will have this 25% more questions, new questions NCLEX, which primarily focus on two types, which is case study base, and the other one is stand alone case. So in this 8 to 75 questions are still coming from the old one, and there will be an integration of the new format of the test, which will focus on the case study. And the other one, as we as we all know, is the stand alone, which I'm going to discuss the you in the next few slides. So information presented in tabs of medical records. So we we expect that there will be a what we call EMR. Okay. That will be presented as part of the the information. Once the question said so in the case study, we will be having six questions once in each set. So meaning that say there will be three case studies, in each case study there will be six question each that aims to measure the six cognitive skills in order. So what I did this six call this paired skills in order. So these are your recognize cues, analyzed use priority, citing hypothesis, generating solutions, taking actions and evaluating outcomes. So far, this is standalone questions. We will be dealing with single question that our goal is or our focus on what we called specific cognitive labels of the clinical judgment measurement model. So okay, so as we go along, what I guess clinical functions or six portions of clinical judgment, this is basically the nursing process, but rather but rather these are a figure breakdown into six critical steps which the nurse should utilize in, in each time they rendered nursing care. So we will start to start first on recognizing cues.

So what matters most with my patient? So what if what is really happening on my patient? So based on the information presented to you, you will have to analyze the cues. So what is what is the what does it mean? What are these cues mean? So after analyzing the accused, you need to prioritize the hypothesis. So where just where should I start? So after having this information, what should I do? So from this you need to generate solution going on. Moving on to step four, generate solution. What can I do about this? So after identifying the interventions possible interventions that you need to perform, you need to take action you will implement, then okay, be the action. And after implementing the action, you need also to evaluate the outcomes. So in evaluating the outcomes, you need to satisfy yourself. Did I help? Did this intervention help my patients? If not so, you need to like again, finding ways to to to address the problem of the patient or problems of division. So standalone question comprises 10% from that 25% new questions in the end end. So this is a single question based on information presented in an electronic medical record. So as I had mentioned, you will encounter definitely a real patient condition. So patient condition coming from the EMR or electronic medical records. So in standalone question, it has a stated diagnosis or implied diagnosis already. So you have to include the clinical information for a specific client. You need to to understand what are the clinical informations that is presented with the use of this EMR and provide components that required the entry level nurse to make one or more clinical decisions.

So aside from standalone questions, you will also be encountering some of these formats, such as traditional items which focus on multiple choice, the normal sidebar or yours. Select all that apply questions the ordered response fill in the blanks Graphics Exhibit two Extended multiple response Extended drag and drop will also be having close rationale The close rationale or table for a drop down type Your matrix grade for your multiple response are your multiple choice question your highlight or enhance hotspot, your index and table and the focus of my discussion for tonight, which is about a clinical judgment model, standalone question, which is we will be dealing more on both I and trend items, but the specifically bow tie. Okay, so what is this trend item types? So a trend item type is basically a any engine I can type that is mentioned to you a while ago. So you will be you will be presented with different tabs of information that is stranded over time. So what are the stats information that you have to see that you can see in this particular type of question, you'll be presented, for example, with vital signs, lab result, and also nurse's notes. So from these tabs you will have to gain informations about the condition of the patient.

So you will utilize these patterns in order for you to analyze the condition. What is the present condition? My, my, my the patient is experiencing now so that you will be able to effectively utilize this six critical judgment skills in order to find solution and in order also to address the problem of the patient. So all you have to do, if ever you'll encounter this type of question, you need to look at the tab information. You need to go on reading all the tabs information and recognize and analyze the trend. As we all know from these type of tests, engine and item type. So it is being trended, the information is trended over time. So I want you to read all the tabs carefully and analyze each tab for you to gain knowledge or information about what is the stem of the question or what is the the real problem all about. So what is going on? Why is this trend significant? So is there a significant change from, for example, it might patient has been in the back you or in both anesthesia care unit after underwent a particular surgery after an hour staying in the back, you these are the informations presented. So if there are significant changes that might be beneficial for me to anticipate whether there is what a problem with my patient. So you will be asked one question. So it focused on any or all of the cognitive level. It can be analyzed, it can be formulating hypotheses, it can be implementing, okay.

It can be any energy and type, whether the question is about your task is to highlight the condition that sense that the patient, for example, is experiencing this particular condition, your matrix or your question about multiple choice. So okay, so this example so this example shows you a trend. So as we as I have mentioned a while ago, you are presented with different tabs. So in this case you will have two tabs, your nurses nodes and your vital signs. So the question here is on the top, this is usually a basic statement that you will you will be receiving in the actual NCLEX exam. And the other part of the paper of this side, you will notice an arrow here. So an arrow here represent usually that trend in or what we call the lean in. So meaning to say the lead in. GIBBS the information about what is your past, what should I do or what is the question wanted you to answer? So before moving on here, so lead in on the right side, I want you to go over and read first these information on the times that this being present day. So from the word itself trending, you'll have to read everything. For example, the patient started at the operating unit at 8 a.m. and then at 1130 the patient is transferred to a post anesthesia care unit. And at 1200 the patient is now transferred to a surgical unit. So your task is to read every informations here, read everything from the pre operative unit, then followed at 1130 and 12 and analyze everything. Okay, so from the jump in on the right side.

So with the use of this lead in arrow on the right side, the question here is about the nurse is contributing to the client plan of care. Select the three potential nursing intervention the nurse should anticipate for the care of the client. So meaning to say from this, this this question you are asking to answer three anticipated nursing intervention. All of this information hence the word trending. Okay, so another so you'll be also presented with the vital signs you need to go over with and analyze this information from the pre operative, both anesthesia and surgical unit analyze the changes that occur from temperature, pulse rate are blood pressure and pulse oximetry and please do not rush, but rather analyze everything and see to it whether the information's or the values are somehow there are significant changes. Okay, because you are sitting here the trend question. So again, the question is presented on the right. That is the trend type of question. Now let me go ahead and discuss you this bow tie. So our discussion will focus on the bow tie. So you'll notice from the word itself, bow tie the task of the examinee for the bow tie is one to be able for you to understand or identify the potential condition your patient is experiencing. Your answer should be place. You will drag your answer and you will place it at the center. So after identification, identifying the potential condition, another task will be you need to analyze the condition. You need to make use of the cues to recognize the cues, analyze these information to be able for you to identify two actions to take. And you need to select those those actions below and you need to drag it here. So meaning to say without going deeper on what we call, how many correct answers should I expect to 2 to 2 to have, if I correctly answer the question in bow tie.

So definitely there are five questions, rather five answers to stool for action to take, one for potential condition and one and two for parameters to monitor. And mind you guys, the bow tie is the only trend on stand alone question and let's that measures the six clinical judgment model. So unlike with with the case study. Yes it asks the six clinical clinical judgment model, but the manner it was presented, it was being asked in the in the question is in progressing. So unlike with the bow tie, you need to do to perform first the first three steps, then identify the potential condition, then you need to identify the actions and parameter where the steps five and six in that clinical judgment model. Okay, So the bow tie, as I have said here, is a perfect visuals of the bow tie and bow tie item format as presented in the NTSB. Ed So you need to identify two actions to take one condition. Most likely my patient or your patient is experiencing and parameters to monitor. Okay, so now we will be doing an on approaches on how to effectively manage completing this bow tie. So remember guys in bow tie, you always think of the of what we call the the NCP. So as we all know during the clinical days, our clinical nursing school, we are tasked to make a nursing care plan. Basically the bow tie stems from this idea. So you need to identify the problems and you need to identify appropriate interventions in order for you to to, to address the situation. So with the use of this subjective cues, with the use of this objective, you utilize this information for you to make a nursing care plan, basically that is bow tie. So what they expect in bow tie, you will be encountering this in introductory sentence, introductory sentence, which just look at it on the upper left portion of the the the, the, the question so on. Right. So you will have a question encounter question on the right and also multiple pages.

As I mentioned, we had EMR. So the keys are presented on the lap. Okay. And this is what we call the bow tie now. So all you have to do first, what I guess steps to do, read the tabs. As I mentioned, it is very significant imperative. One should read the tabs all the tabs, read and open the tabs for you to do the gain information. Okay, then read this, then. So what is the the stem of the question? Okay. You'll be expected that there are five options at this position on the left side. Five options which is located on the right side and four options which is located which are located at the middle. So what are these? So we will be dealing with that for the next few slide. So your target is to drag and drop format. So as I mentioned, as soon as you, you, you selected an answer, you drag it and you drop it apart to a appropriate box until you complete the five major boxes there. So it is said to be you'll also get side points if ever you had to. You answer correctly. So all targets must be utilized for the examinees to move forward. So meaning to say if ever you don't have any idea about how to answer, you will sort out with like a guest because the computer will not allow you to move to the next question without ensuring that all the boxes are completed. So you will get five maximum points. And okay, another important thing to remember, it is a color coded, so don't worry, it is color coded so that you will not you will not be misled with all the options. But mind you, you cannot use the options on the lap to answer options, to answer questions on the right and so on. You cannot use options under right side to answer questions in the left side, so it doesn't work like that. So hence it is color coded to two. To give you an idea on where should you place directly your answer.

So a conditions most likely experiencing or your potential conditions is position at the center. Two actions to take on the lap and two parameters to monitor on the right. So the both eyes have one or more. Yep or tab so you can get nauseous. Notes History and Physical Assessment Laboratory results, vital signs and all admission notes, progress notes, medications, diagnosis, diagnostic results, or blue shift. Some of the question might you will get nurse's note plus vital signs or you may also have nurse's note plus medications. Nurses note, plus prognosis notes, plus medications. So the good thing about it, all of the informations are presented to you. All you have to do is to open all the tabs and read all the information for you to get the information. Because if you don't have the sufficient information, you cannot effectively answer the bow tie. That is how the this body runs. Okay, So remember, in order for you to move forward in this examination, all targets or response items must be filled with tokens. So what are these? So tokens are the place holder of the response. So for this example, I took it from your world nursing. So this is the bow tie. Okay, so options are located below. So actions to take here. As I mentioned, five, one, two, three, four. Usually they are five and four potential conditions and five parameters. All you have to do is to select two actions here. For example, I choose lose and restraint. I drag it and place it here on top. And I choose reorient the client a, drag it and choose it and place it here, drop it here.

And for a potential condition, let's say I intend to select neurovascular impairment. But the first thing to do is to identify first the potential condition for you to effectively analyze what actions are appropriate to do and also what actions or parameters that I need to to do. From this example, the target here are these five boxes and the tokens are here below. So you need to to get tokens in order for you to satisfy the target. So meaning to say they're asking you five questions before you can move on to the next question. So if ever you would not be able to do to answer each of the student, well, for example, yes, but worry no more. So it is easier to to to understand about bow tie. So that's why we're dealing we are discussing it today. And also if you apply in if you if you part of you will be part of the IPA's Online Review and Mentoring Academy. Definitely we are 101 ready. We are ready for this transition. So really, we holistically prepare our students by giving them a lot of drills and a lot of examples, and we make a continuous training for our students so that they will they will effectively answer or they will they will be ready for this energy and transition. Okay. How to score the bow tie. So the scoring for the bow tie is usually zero or one scoring. So meaning to say there are five possible points for each bow tie. One point a condition if you identify the right answer, if you are going to to identify two correct answers for actions and two points by parameters, you'll get five points. However, you will not receive any deduction if you endorse Incorrect answer.

Okay, You will not receive. I'm sorry for this wrong spelling here. You will not receive minus point if you selected a wrong answer because as I mentioned, this bow tie measures the sixth clinical judgment here. So it differs from the it differs from from other types of examination. Okay. So what there is sample problem. Okay. So let me just go on and give you a particular condition that is being asked. Okay. The usual quiz question that's being asked in class. So let's move on discussing this is stroke or what we call the cerebral vascular accident. So let's discuss this very short. And after this, we will apply the learning out of understand in this stroke in answering a specific bow tie. Okay, So let me go ahead. So what is this, a stroke or your city blue vascular accident? So I want you to think of the three important different terms. Important terms, oxygen reach, blood blockage or bleeding and death of the brain cells. So what happened during stroke? There will be a block within the any of the blood vessels that supply the brain with oxygen rich blood. Okay. So there are two reasons. It can be a block in there in the blood vessels or if might, there will be a bleeding that is happening. So because our perfusion is impeded and the brain being the most important tissues, that requires a constant supply of oxygen, rich blood, brain cells will start to die if ever will not be able to take action immediately to take action with regards to the patient, most especially if we if we determine that your patient or my patient or the patient is experiencing stroke or city or vascular accident.

So most of the time the most common type of CVA is skin mix job, which is which happens due to a clot. So meaning to say there is a block within the blood vessels that supplies the brain with oxygen rich blood. So the most common cause it might be an embolism. Embolism which causes like due to let's say the patient is a and with atrial fibrillation or atrial Fluor condition. So being to say for the longest time your patient is experiencing atrial fibrillation or atrial flutter, this predispose your patient of having ischemic attack. Hence the type of stroke is known as embolic stroke or in the other way around thrombosis. For example, your patient is a non hypertensive, so with hypertension your patient is suffering from atherosclerosis or hardening of the arteries because of too much or a high level density lipoprotein for example. Your patient is hyperlipidemia, for example, so your patient might encounter or might be having thrombotic stroke. Okay, so that might be a condition. So for you, hemorrhagic stroke, the bleeding in the brain due to a break in the blood vessels. So what are the costs? The costs might be aneurysms. The patient for a longest time has a uncontrolled hypertension all their age, aging or blood vessels, aging of the blood vessels. So remember, the brain cells are very sensitive. Within 5 minutes, the cells start to become damaged and become irreversible. So mean to say in dealing with stroke or cerebrovascular accident, time is of the essence. Time is very significant to the stroke or CBE patients. So let's go ahead passing through this brain function. So we also need to determine the different functions of the brain so that we can effectively understand the brain functions and what each of the part within the brain that controls some of the specific process within the body. So for example, here we have your plantar, so your pointer controls the thinking speaking memory movement, parietal the language and thoughts, your temperature hearing, learning and feelings occipital for our vision and also for color perception.

We have your brainstem which deals for your breathing heart rate and temperature, and your cerebellum, which focus on balance and coordination. So instead your it tend to attack one side of the body. So analyzing this idea will give us information about the clinical presentation of our patient. For example, on the right side, the right side controls the creative. Okay. The right side is what we called our create it side. So it controls our emotion, our soul being data, the problems, our reasoning, judgment, memory, and it controls the left side of the body. Okay, so what are the expected expected signs and symptoms if the patient has a problem or the application is the right side of the brain, the patient might be having a left side hemiplegia. So your patient has a confusion. Okay. For example, that is the reason why you need to to ask. For example, if the patient suspected of having you ask the patient, what is your name? Can you tell me where you are right now? Okay. Can you tell me your birthday example? Because here you are asking, you are analyzing, you are assessing the whether your patient has a contusion. Particularly you're asking about the daytime in the place. You need to see the orientation of the patient with these categories, date, time and place, and your patient cannot recognize faces or person's name. Your patient might lose depth of perception and trouble staying on topic when talking. Okay, so another thing your patient will be having unilateral neglect or your left side neglect. So your patient might this hemi hemi hemiplegia hemi a knops hemi a Natasha, which is for example, during eating, let's say you give a treat to the patient, then the food is placed in a plate, then you notice your patient like or only eating the other cup of the food. For example, let's say the right side or the left side.

So it determines that your patient is having a hemi an option. Okay, so on the left side, this is what we call the logical side. This controls our speaking ability to our right being, reading my skills in analyzing information and planning. So what are the expected if this is damage so your patient might be having hemiplegia okay, hemiplegia on their right, your patient will also exhibit trouble populating words and comprehending words. So in general, the medical term given is a fascia, so your patient will be having trouble understanding written text. Your patient might be having writing, difficulty writing or they will be having problems with using a bullpen or a pen and write. And whenever they write they can. You cannot understand the letters. It's really incomprehensible. Okay, That is what we call a graph here. And each is with seeing on the right side and also impaired math skills. Okay, So what are the risk factors for your cerebrovascular accident? So remember this pneumonia strokes happen. So if you notice this one, two, three, with this highlighted red on asterisks, here are the most common predisposing factors for a patient with stroke. So smoking your patient is with high blood pressure or hypertension patient with atherosclerosis or hyperlipidemia. And also another important predisposing factors is your rhythm changes. For example, your patient is having a atrial flutter or atrial fibrillation. So how how we know the patient has a rhythm changes. For example, if are presented with an EKG, there will be a what they call the absence a B wave and also your irregular rhythm. So figure your atrial fibrillation is divided into three based on the heart rate, it can be slow, moderate or rapid ventricular response, atrial fibrillation.

So these are the things that you need to do to also understand that this might be a predisposing factors for stroke. And one danger about if your patient is having atrial fibrillation is the idea that the heart is for bleeding when the heart is quivering and for bleeding so that formation of clot is possible or likely to happen. So that clot coming from the coming from the from the heart will go on make make troubles around the body. And for example, it plugs into a small capillary or a small, small artery within the brain and that block the perfusion within the brain because of what we call this thrombus for Michonne. Okay, so oral contraceptives key in it runs in the family excessive weight, seniority, descent. As you all know, hypertension, as I mentioned, atherosclerosis, physical activity, abuse, transient ischemic attacks and elevated blood sugars. Okay, This is also one important thing to remember in, in, in management of stroke, elevated blood sugar, especially during the point of contact to the hospital, for example, you need to check immediately the the the sugar because the sugar, the sugar, blood sugar is often remember this blood sugar is often elevated in acute stroke and higher admission glucose levels are associated with larger lesions, greater mortality and poorer functional outcome. So especially as all know, in stroke, in swimming, stroke, in particularly the most important more the treatment is the patient will, will, will receive Trombley Thrombolysis okay.

And if the patient is a non hypoglycemic or if the patient is a known diabete and which we do not control, does the elevation of the blood sugar remember it has believe that is associated with increased risk of hemorrhagic transformation of in pipe. So we need to see if the is presented in the hospital with skimming stroke and the blood blood sugar is not controlled well and the patient receives from the thrombolytic, for example or the TPA. If the blood sugar continues to rise and we do not institute measures to control the blood sugar, the likelihood of the infarct. Okay, this chemical ischemic stroke can transform into what we call he more tragic stroke. So here I am stressing out the role of sugar. Okay, So the National Institute of Health, Schultz Keel score or the NIH this is provided as information to effectively utilize, especially in the case of a patient who is suffering from stroke. So we normally use the fast ACC stands for this F for the phase A for the arm and leg. Esper is speech or B time. So what are you going to do with regards to the face? So there will be an even smile, facial droop or numbness. Okay, There will be a vision disturbance for the patient as the patient due to to raise his or her arm. So there will be a weakness, arm and legs. So there will be an e bends a an even smile is actually here on the face. Okay. The facial droop. This this vision disturbance is actually usually for the e here stands for the arm drip in the leg. So meaning to say if they ask you if you ask a patient to do to raise his or her arm, then you see that there is a and e been he or she cannot make a stable that his or her arm is raising, let's say, because of weakness.

That is why because the arm drape here, the s asked the patient to speak or repeat the sentence after you. Okay. If your patient is having trouble speaking, you're your patient is is having a slurred speech. Your patient is talking into inappropriate words and answers that are not the relevant to your question. Okay. So there would be a big question mark about about it. And definitely time is crucial. So you need to activate and call 911 right away. Okay. So there are other important stroke terms. So we have aphasia which is unable to speak, receptive a patient with is unable to comprehend speech, especially if your patient is a damaged with Wernicke's area. Broca's area result in expressive aphasia. So we also have mix of Asia, which is a combination of two or more aphasia and then global aphasia, which deals which happens when there will be a complete inability to understand speech or to produce it. Okay, another there might be a this idea you will be unable to hear speech clearly due to a weak muscles and hard to understand the patient's speech. Okay, it may be slurred, for example, approx. Sure, the patient can perform, can perform voluntarily movements linking, for example, moving arms to scratch an itch, and even through muscles. Okay, even though muscles function is normal, your patient might be experiencing a great fear or the loss of ability to write Alexa, which is the loss of ability to read.

Okay. Because the patient doesn't understand a recognized words, your patient might experience a nausea, which is he or she doesn't understand the sensation or recognize known objects or people your patient might experience. Also dysphagia, which is a issue of swallowing. Okay, with regard to dysphagia, I want you to to remember when the patient is suspected of stroke, please, as much as possible and be all immediately nothing for oral. Do not give anything by mouth unless there will be a comprehensive dysphagia screening tests. Because the problem with a patient with cerebrovascular accident is what they called aspiration. And that aspiration may lead to what we call aspiration pneumonia. So until such time that that the patient has been tested significantly with this dysphagia screening tests and if the patient has a problems with swallowing, please never give anything by mouth seeming to say your patient is expected to be to be inserted with A, A and B because the food, the medications will be delivered through the nasogastric tube, or if the patient has already an access that say your patient has a central venous line, your patient has a peripheral line, venous line already, so you have to give the medication to this access. So Hemi and Upshur, so a limited vision in the visual field or what we call the partial blindness and hemi paralysis, which is weakness on the side of the body. So what is the gold standard with identification of, of stroke? So the gold standard of which is your CT. Scan. So why is it c.t scan?

There are two options it's one can, can, can, can determine it with the use of CT scan or one can determine it with the use of MRI. So what is this MRI or city scan all about? So why is it that the city scan might be the the gold standard for identifying the stroke? Why? Because not all hospital has MRI. So you mean to say time is of the essence? So we need to send immediately the patient to to a radiologic department for him or her to have this test done right away. The CT scan. So remember that in city scan, we need we we need to perform the CT scan within 25 minutes of arrival to Stroke Center and within 45 minutes radiologists should read the CT scan. Okay. Should read the city scan. So if ever the plate is there already. So how are we going to identify where either my patient is having a a hemorrhagic stroke? Because knowing whether the type of stroke is hemorrhagic or ischemic, that could delineate the next intervention because the intervention or what we call thrombolysis is only applicable for a patient who is diagnosed with ischemic stroke. And that is a no no or what we call an intervention that cannot be done if the patient is diagnosed with hemorrhagic stroke for that matter.

Hence, see, this gun is a gold standard. So what do expect? So there will be a positive light ups. So what the what, what do we need by this? A positive light like ops which mean this gun here. Look at that. The plates here, this gun image with hyper dense okay areas of bleeding. So in this example, this is a hyper dense area of bleeding, making the patient ineligible for what we call TPA. Okay. So the other way around is your MRI. So the patient is lucky. So the Stroke Center has a CT scan or MRI is it's, let's say, up to the doctor what type of OB test he or she choose if CT scan an MRI is available. So again, without the MRI, the gold standard is CT scan. Okay. So a treatment for CV is everything. So TPA, the tissue PLASMINOGEN activator is the only is the only acceptable treatment for type of stroke, which is ischemic something to see if the patient you see more tragic stroke diagnosed with hemorrhagic stroke so mean to say TPA is not an option. So what is this TPA? So your TPA dissolves the blood within the blood vessels by activating the protein that causes fibrin analyzer. This so meaning the say in this plasminogen activator, it converts the plasminogen to blood plasma. And so your plasmid is your the major enzyme that breaks down the clot.

So as I mentioned, treatment is everything meaning to say there are there is what we call golden rule here. You can you can perform, you can administer only the TPA within 3 hours from the onset of stroke symptoms, 3 hours from the onset of stroke symptoms, meaning to say during the time that the nurse is gathering information, asking questions about the relatives, for example, the patients presented that because you cannot ask the patient, when did red when this symptom starts, because the patient, because of the presented idea already cannot articulate, can answer effectively your question. So you can ask the significant others, for example, the daughter of the patient, the husband or the wife of the patient or something significant, others that whom brought their patient to the emergency department, for example. So it can be given 3 to 4.5 hours after the onset. Yep. Criteria. SMITH So what are these criteria? So a key of the head reveal negative for hemorrhage the labs within normal limits glucose 6 to 100, for example INR. So what is this example? 0.92 0.92 to 1.8. That is that if you take level four INR. So being the see if the INR reveals that that is more than 3.5 seconds, meaning to say that this say prolonged bleeding. Okay, platelets, let's say your platelets as within 200000 to 400000. Okay microliter they should be these things might be within the normal limits. So the BP needs to be controlled. Okay. Your systolic blood pressure should be less than 185 systolic or millimeters.

Mercury, and your diastolic blood pressure should be less than 100. Then, however, there is what we call hyper permissive hypertension. So this permitted hypertension is something that we allow somehow the elevated pressure to occur to the patient, because of this pressure, it actually gives the opportunity to supply the tissue with oxygen rich blood because of the pressure. However, with this permissive hypertension, we need to see or we need to make sure that the systolic and diastolic we should follow with this. So to say, we can say that the patient is hypertensive. If the systolic blood pressure is hundred 80 or the diastolic pressure is 100, this is something that we want to make sure that the patient vital signs, specifically the blood pressure, should be with this level or what we call permissive hypertension. Okay. As I had mentioned a while ago, glucose control is important. Glucose control is important, especially if the patient receives Trumble Latex Thrombolytic. Why? Because uncontrolled hypoglycemia is the factor that causes this infarct. Systemic in part to jump in to what we called hemorrhagic type of stroke.

So we need to say your glucose control should always be checked as part of the point of care. Okay. And the patient is not receiving heparin or other types of anticoagulants. Remember during the time this is the one important thing to remember during the time that the patient is receiving a infusion for this TPA. Remember, we need to check the vital skew 15 minutes for the first one hour of infusion and then Q one after the infusion ends and usually the Glasgow Coma scale or the neurovascular checks should be done Q3 for the first one hour. Q Are you going 15 for the first one hour? Q 30 for the next hour and. Q One for the succeeding hours. That is the golden rule for now. Okay. So the nurse's priority to remember okay with your stroke is to monitor the bleeding. Okay? Because what, what's, what should the patient receive is definitely and by the system, ballistics. So the patient is predisposed definitely to the bleeding. So you need to ensure that you also check and monitor for the bleeding. As I mentioned, neuro check round the clock, vital signs, specifically your blood pressure, especially for your patient who has a uncontrolled hypertension. Again, for the labs. Okay. Priority is your glucose level. Definitely because of that particular rationale or the reasons why she had to do it to ensure that the blood glucose level is controlled preventing injury. You need to ensure that the patient must be in bed, rest, avoid unnecessary punctuation, avoid am injection.

So meaning to say if the patient is already diagnosed with stroke upon and for example receiving of thrombolytic, you should need to establish at the point of contact within the E.R. department. For example, your patients should be should have, let's say this access this the venous access already because once the patient receives already your thrombolysis, we need to ensure that as much as possible we minimize that the patient will be receiving, let's say, benefactors or you will withdraw blood, okay? Or you give medication to it. And because we really, really want to make sure that we minimize the chance that the patient having a bleeding and of course, immediate admission to the intensive care unit or a cardiac telemetry unit or the C VIP unit, then the patient should be monitored continuously and should be hooked to. Okay. To kind of monitor to determine the rhythm of the patient. And of course, you need to give the patient automatically oxygen, because what is the problem with the patient in a stroke? So the loss of perfusion, vital perfusion to the brain because of, for example, bleeding or because of what we call black within any of the arteries that supply oxygen, rich blood to the brain. Okay. So, yes, it is imperative that oxygen should be given to the patient. Okay. So you need to assess with the NIH the stroke scale. So these are the ranges. So it aims to assess the 11 areas, level of consciousness, gaze visual facial palsy, motor function and extremities, cranial nerves and monitor bowel and other functions. Okay, so communication is the key because in patients with stroke it doesn't mean that they have a deficit or mental problems.

The reason why they have deficit with communication, because of the implication of or because the applications in a particular area within the brain. So we need also to understand this. Wernicke's and Broca's area, because it gives us opportunity to effectively intervene, to effectively care for my patient. For example, in temporal lobe, this is where brain x area is located. So your patient will be having or will be solving problems related to receptive a patient. He or she will be unable to comprehend speech. They will be unable to comprehend speech. So this is this is what we call the Center for Language Comprehension. So meaning to see what interventions that they need to perform. So when you speak to the patient, you make use of the short phrases you use, gesture or point while giving a command. Be patient and not expect. The patient responds fast to you. And also you need to remove distractions. If the frontal area is the subject of the application. This is where the Broca's area is located. So the patient has a problem with the frontal area. This is the area where language is being produced. To express a patient might be the problem with our patient. So what are the interventions? So you have to give so much patient to your patient. Please give time and opportunity for your patient to express what he or she wanted to see. And please do not rush. Of course, be direct and simple when asking questions and give options so that your patient can select okay And also communicate with the use of dry erase board or what we called in Joint Commission International a communication board. Okay. You may also want to offer it to your patient so that the patient can understand what you are trying to see. Okay, So now let's apply what you have learned by incorporating this information.

So what call bow tie. Okay, Now, so what are the tips again and strategies in answering bow tie. So using this clinical judgment model, you need to anticipate the following and you need to use these steps in order for you to answer to bow tie. One, you need to recognize the cues, whether that is normal or abnormal. All you have to do is you need to read the information in the scenario and recognize which findings are relevant. That is your first step. Second step Make connections to determine what these relevant findings mean and what condition the client may be experiencing. This is something to do with analyzing use with the with these information's available, with these data, with these vital signs, with this and history of my patient with these clinical symptoms, the patient is activating. So you need to analyze these things information for you to understand what might your patient is experiencing or what might be the possible potential condition that your patient might be experiencing in the future. Hence, I'd like again to reiterate to you that the both are is the only standalone question that can measure simultaneously this six clinical judgment model because of these steps that I need. You to do to implement. So identify the client's immediate problem, and that is your priorities, housing priorities that prioritize rather hypotheses and identify your possible solutions. Then answered the bottom. As I've mentioned a while ago, in the left side, you need to do is to select the actions at the bottom.

You drop it and drop it on the left side. So you are asking to insert on the right side is the parameters, the match. Sure, you will be required to answer to two answers yes to give two answers or responses. Then you need to identify possible solution to address the client's needs or generate solution. Determine what is likely the cause of issue, the appropriate actions to take and parameters to monitor once action has been taken so that is your evaluate outcomes. Now let's go on giving you an important example. I think we are about to finish our discussion. This is actually an example taken directly from the NTSB and as part of the training for all of us. So I intend to use it for this for this reason so that our students can understand what both I the dynamics of both II. So as I had mentioned, a while ago, there will be a sentence here at the top. So you will you have to see on the right side of this slide, this is the bowtie, okay. The tokens and the targets, the bar. So these are again, the tokens and the side here, the targets.

So your target is to identify to action, identify one condition your patient is experiencing, identify parameter to, monitor to parameters to monitor. So this arrow here shows you the line in so meaning to say the lead in gives you the idea on what you should do. So what is the question here? So the nurse in the emergency department is caring for a 75 year old female playing. So there are three times that is being given to you, provided to you. You have your nurses nodes, your history and physical and your laboratory. So as I had mentioned a while ago, you need to go over read all this information's in this database to be able for you to have an idea. Okay, so let's go ahead, read the nurse's notes on 1215. Your client, the nurses in the emergency department is caring for a nine year old female again.