Vernon Russell Documentation Assignment PDF

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Vernon Russell Documentation Assignment for the point online clinical simulation...

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Vernon Russell Documentation Assignments 1. Document your initial neurologic assessment of Mr. Russell, with particular attention to indications of a possible stroke. Mr. Russel had mild left-sided hemiplegia resulting in unequal smiling during this part of the neurological assessment. A&Ox3. Puffing of cheeks and sticking his tongue out were fully intact. Pupils were 4 mm bilaterally. Extraocular movements were within normal limits. His gag reflex was intact but he showed difficulty swallowing his meds. There was weakness with left-sided movements but the movement was partially intact. Left-sided hand squeezes were milder than right-sided responses. Sensation on the upper and lower extremities was intact. 2. Identify and document the three primary nursing diagnoses related to Mr. Russell's current medical condition in order of priority. - Risk of aspiration related to impaired swallowing. - Risk of fall-related to left-sided weakness - Activity intolerance related to stroke as evidence by the use of a walker to use the restroom. 3. Document your call to the provider about Mr. Russell’s dysphagia using the situation-background-assessment-recommendation (SBAR) format. S- This patient was admitted with a stroke with mild left hemiplegia yesterday and is unable to swallow his oral medications.

B- He has CAD, diabetes mellitus 2, and hypertension. He smoked cigarettes for 35 years and does not exercise. A neurologic assessment was completed. He was asked about pain and did not report any. He was educated about risk of aspiration due to the stroke. Upon administering meds, the patient was unable to swallow. The patient is on nothing by mouth except for medications at this time. A swallow test has been scheduled. A- Neurologic assessment showed A&Ox3. Vitals were within normal limits. BP was 130/78 mm Hg. Puffing of cheeks and sticking his tongue out were fully intact. Extraocular movements were within normal limits. Pupils were 4 mm bilaterally. Pupils equal, round, reactive to light and accommodation. His gag reflex was intact but he showed difficulty swallowing his meds. There was weakness with left-sided movements but the movement was partially intact. Left-sided hand squeezes were milder than right-sided responses. Sensation on the upper and lower extremities was intact. He scored a 60 on the Morse fall risk assessment. From vSim for Nursing | Fundamentals. © Wolters Kluwer

R- The patient is unable to swallow medications so a different route should be considered. He is a fall risk and should call for help when ambulating, even when using his walker to use the bathroom. He should be positioned upright in semi-to-high fowler’s at all times considering his inability to swallow.

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