Asha Roberts`FundamentalsVernon RussellDocumentation Assignments1. Document your initial neurologic assessment of Mr. Russell, with particular attention to indications of a possible stroke.●During initial neuro-assessment the patient continued to have normal tongue movement,puffing of cheeks and gag reflexes. Also patient has mild left side hemiplegia. Patient’s hand grasp is weaker on left side than right.2. Identify and document the three primary nursing diagnoses related to Mr. Russell's current medical condition in order of priority.●Stroke/Coronary artery DiseaseAspirin 81 mg orally●Type 2 Diabetes Normal Saline 100 mg (Intravenous)Metformin 500mg twice a day orally●HypertensionLosaratan 50 mg twice a day orallyChlorthalidone 25 mg orally.3. Document your call to the provider about Mr. Russell’s dysphagia using the situation-background-assessment-recommendation (SBAR) format.Situation- I am calling in regards to patient Vernon Russell age 55. Presenting complaint is issues swallowing medication.
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- Fall '19
- Vernon Russell