Vernon Russell
Documentation Assignments
1. Document your initial neurological assessment of Mr. Russell, with particular attention
to indications of a possible stroke.
Answer:
A 55 years old, Native American male was admitted with a stroke and with mild left
Hemiplegia. His Vital signs were normal, pulse was regular 97 per min, temperature 99 F,
Oxygen concentration 97%, blood pressure was 132/78, his respiration were regular 12
respiration per minute, his glucose level was in normal range -91 mg/dl and skin
assessment is normal, no wounds or lesions and patient is not sweating.
After preforming neurological assessment, pupil diameter was 4 mm, eye moment was
normal. Asymmetry noticed when patient smiles, and after strength test, his left side is
weaker than the right 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.
Answer:
Risk of Aspiration related to weakness of the muscles due to deterioration of the
neurological system.
Risk of fall related to left side Hemiplegia.
Lack of communication related to neurological deterioration.
3. Document your call to the provider about Mr. Russell’s dysphagia using the
situation- background-assessment-recommendation (SBAR) format.
Situation: patient started coughing and unable to swallow the medication. Patient has no
pain.
Background: 55 years old male, admitted with a stock and mild left Hemiplegia.
Past history of hypertension, coronary artery disease and diabetes myelitis type 2.
Assessment: preformed neurological assessment, respiratory assessment, check vital
signs, aspiration assessment.
Resolution: education patient about swallowing, keep patient in high rise position to
Documentation Assignments
1. Document your initial neurological assessment of Mr. Russell, with particular attention
to indications of a possible stroke.
Answer:
A 55 years old, Native American male was admitted with a stroke and with mild left
Hemiplegia. His Vital signs were normal, pulse was regular 97 per min, temperature 99 F,
Oxygen concentration 97%, blood pressure was 132/78, his respiration were regular 12
respiration per minute, his glucose level was in normal range -91 mg/dl and skin
assessment is normal, no wounds or lesions and patient is not sweating.
After preforming neurological assessment, pupil diameter was 4 mm, eye moment was
normal. Asymmetry noticed when patient smiles, and after strength test, his left side is
weaker than the right 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.
Answer:
Risk of Aspiration related to weakness of the muscles due to deterioration of the
neurological system.
Risk of fall related to left side Hemiplegia.
Lack of communication related to neurological deterioration.
3. Document your call to the provider about Mr. Russell’s dysphagia using the
situation- background-assessment-recommendation (SBAR) format.
Situation: patient started coughing and unable to swallow the medication. Patient has no
pain.
Background: 55 years old male, admitted with a stock and mild left Hemiplegia.
Past history of hypertension, coronary artery disease and diabetes myelitis type 2.
Assessment: preformed neurological assessment, respiratory assessment, check vital
signs, aspiration assessment.
Resolution: education patient about swallowing, keep patient in high rise position to
