Vernon Russell documentation assignment PDF

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documentation assignment from virtual simulation course used during covid 19 online zoom lectures. Great content and can be helpful....

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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. Vernon Russel is a 55 year old, Native American who was admitted due to a stroke leaving him with mild hemiplegia. His vitals were within normal range with a temperature of 99 F, pulse 97 per min, respiration 12 bpm, BP 132/78, SP02 97%. His glucose levels were also within normal range at 91 mg/dl. I also assessed his skin and it was normal with no sweating or lesions/wounds. Due to his stroke, I performed a nurological assesstment, He is oriented x3, his pupils were 4 mm, eye movement was also normal. There was asymmetry when the patient smiled, and his left side is weaker then the right. 2. Identify and document the three primary nursing diagnoses related to Mr. Russell's current medical condition in order of priority. He was at risk for falls because of his left sided hemiplegia, risk of aspiration related to weakness of his muscles and had a communication barrier due to his nuerological status. 3. Document your call to the provider about Mr. Russell’s dysphagia using the situationbackground-assessment-recommendation (SBAR) format. Situation : Upon administering the ordered medication, patient began coughing and could not swallow the medication. Background : 55 year old native American male, admitted due to a stroke and mild left hemiplegia. History of hyoertension, artery disease, and diabetes. Assessment : nuerological assesstment performed, he has left sided weakness, vital signs witin normal range, glucose levels also normal. Recommendation : Keep patient in a high fowlers position, NPO status, administer medication through IV. Have airways viewed to figure out why patient cannot swallow.

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