Vernon Russell
Documentation Assignments
1. Document your initial neurologic assessment of Mr. Russell, with particular attention to
indications of a possible stroke.
2. Identify and document the three primary nursing diagnoses related to Mr. Russell's
a current medical condition in order of...
Vernon Russell
Documentation Assignments
1. Document your initial neurologic assessment of Mr. Russell, with particular attention to
indications of a possible stroke.
Pupils reacted to light bilaterally, 4mm and round. Muscle strength in arms is almost
normal with the left side being a little weaker. Puffing of his cheeks and smile are normal.
Slight drooping on left side of face.
2. Identify and document the three primary nursing diagnoses related to Mr. Russell's
current medical condition in order of priority.
Muscle weakness related to possible stroke, Dysphagia related to possible stroke,
Aspiration related to difficulty swallowing
3. Document your call to the provider about Mr. Russell’s dysphagia using the situation-
background-assessment-recommendation (SBAR) format.
S- (situation) Mr. Russell has difficulty swallowing with aspiration
B- (background) History of hypertension, coronary artery disease, and diabetes type 2,
smoking.
A- (assessment) Vitals are all within normal limits (respirations at 12 breaths per minute,
Pulse 95bpm, temp. is 99F, BP is 134/80. Neurological assessment was mostly
normal. Pupils reacted to light bilaterally, 4mm and round. Muscle strength in arms is
almost normal with the left side being a little weaker. Puffing of his cheeks and smile
are normal. Slight drooping on left side of face.
R- (recommendation) Get swallow study. Aspiration precautions
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