Kaitlyn Martin Vernon Russell Documentation Assignments

1. Document your initial neurologic assessment of Mr. Russell, with particular attention to indications of a possible stroke. He had mild left hemiplegia, asymmetry when he smiled, puffing cheek and tongue movement were normal. Gag reflex was intact. Hand grasps were close to equal but a little weaker on the left side due to the hemiplegia. There is normal sensation in his limbs and his face. 2. Identify and document the three primary nursing diagnoses related to Mr. Russell's current medical condition in order of priority.  Impaired swallowing related to stroke  Acute pain related to hemiplegia  Risk for falls related to the left sided weakness 3. Document your call to the provider about Mr. Russell’s dysphagia using the situationbackground-assessment-recommendation (SBAR) format.  Situation: Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had difficulty swallowing medication when given and aspirated on the medication.  Background:Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise. Before given medication swallowing study was normal.  Assessments: Neurological exam was done and stable. Swallow reflex and gag refex were intact prior to given medication. Patient education was provided on risk and prevention of aspiration.  Recommendations: NPO and remain in high fowlers to avoid aspiration