Aileen Diaz Week#3

Aileen Diaz Week#3 Vernon Russell Documentation Assignments 1. Document your initial neurologic assessment of Mr. Russell, with particular attention to indications of a possible stroke. Neurological assessment was done on patient Vernon Russel, his pupils were equal and reacted bilaterally to light. His smile is asymmetric due to his left side hemiplegia. His gag reflex and tongue movement were within normal limits. He had normal sensation on both sides of limbs although his hand grasp are almost equal but a little weaker on the left side. Patient is oriented x3. 2. Identify and document the three primary nursing diagnoses related to Mr. Russell's current medical condition in order of priority. - Risk of falls due to his left side hemiplegia weakness - Impaired swallowing related to stroke - Weakeness in left side due to hemiplegia. 3. Document your call to the provider about Mr. Russell’s dysphagia using the situation-background-assessment-recommendation (SBAR) format. Situation: Patient Vernon Russell is a 55 year old Native American male who was admitted last night due to a stroke and mild left side hemiplegia. I tried administering morning medications as stated in patient orders but patient is experiencing dysphagia, he started coughing and was unable to swallow medication. Background: Patient has a history of hypertension, coronary artery disease and diabetes mellitus type 2. He is also a smoker for the past 35 years and smokes over a pack of cigarettes per day and does not exercise. Assessment: His blood glucose was checked this morning. Vital signs are stable and patient slept through the night. He was able to get up to the restroom with the help of a walker to avoid a fall due to hemiplegia. Neurological assessment was performed, respiratory assessment. Patient was positioned in a high sitting position to avoid aspiration. From vSim for Nursing | Fundamentals. © Wolters Kluwer This study source was downloaded by from CourseH on :23:53 GMT -05:00 This study resource was shared via CourseH Recommendation: Vernon Russel should be monitored due to a high fall risk from his left side hemiplegia. He should also be monitored for dysphagia to avoid risk of aspiration. Patient will be on NPO until swallow test is performed. From vSim for Nursing | Fundamentals. © Wolters Kluwer This study source was downloaded by from CourseH on :23:53 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()