Patient Introduction Location: Transitional care unit Time:
Patient Introduction Location: Transitional care unit Time: 2000 SBAR report from the charge nurse: Situation: Vernon Russell is a 55-year-old male who was admitted to the hospital with a stroke with mild left hemiplegia 2 weeks ago. He had a head CT scan and received thrombolytic therapy in the ED. An MRI confirmed the stroke. He has been stable and was transferred to our transitional care unit this afternoon. He has had physical therapy twice a day and is regaining some strength. Background: Vernon Russell has a history of hypertension, coronary artery disease, and diabetes type 2. He has smoked over a pack per day for the past 35 years and does not exercise. Assessment: Vernon Russell’s vital signs are stable, and he can ambulate with his walker and the help of one person. His neurological checks are stable, and he continues to have mild left hemiplegia. His hand grasps are almost equal but a little weaker on the left side. His pupils are equal and react to light. His swallow reflex is intact. He is oriented to person, place, time, and event. I have completed a Morse Fall Scale, and the patient had a score of 40. I have not had a chance to discuss this result with the patient yet. Recommendation: Vernon Russell just had a neurologic examination, but the nurse on the previous shift was interrupted before she could do the musculoskeletal part, so please complete the musculoskeletal assessment. Also, please assist him in performing range-of-motion (ROM) exercises, and assess his understanding of, and reinforce the principles of, ROM. Please also educate him about fall and safety precautions related to his Morse Fall Scale score. Health Assessment Weber, J.R., and Kelly, J.H. (2022). Health Assessment in Nursing, 7th Edition. Assessing Musculoskeletal System, Chapter 24, pp. 534-572 Diseases and Conditions Expert Clinical Content from Lippincott Advisor Coronary artery disease Diabetes mellitus (type 2) Hypertension Stroke Drugs Expert Clinical Content from Lippincott Advisor Aspirin Losartan potassium Metformin hydrochloride Problem-Based Care Plans Expert Clinical Content from Lippincott Advisor Fall risk Signs and Symptoms Expert Clinical Content from Lippincott Advisor Muscle weakness Procedures Expert Clinical Content from Lippincott Procedures Fall prevention Passive range-of-motion exercises Progressive mobilization 1. Document range-of-motion exercises performed and Vernon Russell’s response to the activity. 2. Document your focused assessment of Vernon Russell’s musculoskeletal system in an SBAR format. 3. Document patient education provided to Vernon Russell regarding the following aspects of his rehabilitation plan: fall prevention, safety precautions, and mobility/exercise. SCIENCE HEALTH
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