Vernon Russell DA - vsim PDF

Preview

Summary

vsim...

Description

Vernon Russell Documentation Assignments 1. Document your initial neurologic assessment of Mr. Russell, with particular attention to indications of a possible stroke. Patient is A&Ox3, and has an asymmetrical smile. Gag reflex is intact. Hand grasp is weak in the left side (right 5/5, left is 4/5). Patient has equal sensation in all limbs and face.

2. Identify and document the three primary nursing diagnoses related to Mr. Russell's current medical condition in order of priority. Risk for Aspiration related to impaired to swallowing. Risk for Fall related to left side hemiplegia. Risk for Injury related to impaired physical mobility. 3. Document your call to the provider about Mr. Russell’s dysphagia using the situationbackground-assessment-recommendation (SBAR) format. Situation - Native American, 55 yr. old male, who recently suffered a stroke. Client choked on his medication, and had to spit it out because he could not swallow it. Backgrond – Patient has drooping on left side of face and his grasp is weaker than the right side due to stroke. Patient has history of hypertension, coronary artery disease, type 2 diabetes, and smokes 1 pack of cigarettes a day.

From vSim for Nursing | Fundamentals. © Wolters Kluwer

Assessment - Vital signs are stable but continues to have left hemiplegia. Patient can move tongue and puff up his cheeks in a normal range. Patient’s gag reflex is intact. Pupils are equal, round, and reactive to light and accommodation. Patient is A&Ox3. Left side still weaker than right side ( R - 5/5 – L 4/5). Recommendation- Keep monitoring vital signs and neurological status. Provide education on: Risk of Aspiration, revention of aspiration, Risk of Fall, and prevention of fall. All (PO) by mouth medication is suspended until speech therapy evaluation is completed.

From vSim for Nursing | Fundamentals. © Wolters Kluwer...