Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemi

Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He was brought in by ambulance from his home. His son Jonathan is a college student came home and found him down on the ground. He had a head CT and received thrombolytic therapy in the ED. He is nothing by mouth except for medications until the speech therapist has completed a bedside evaluation, which is scheduled for later this morning. He is scheduled for physical therapy later today.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. Surgical history: CABG x2. He is a widowed. Assessment: We have already checked his blood glucose level this morning. His vital signs have been stable and he slept well last night. VS: 118/69, HR 76, RR 18, 95% RA, 98.6F. He was able to get up to go to the bathroom with the use of a walker. 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. Swallow reflex is intact. He is oriented x3 agitated at times usually with him self not being able to do what he wanted to do. He constantly asking the doctor to go outside and smoke. I have already done a Morse Fall Risk assessment with a total high risk score of 60. His NIH stroke scale is 6. Recommendation: You should do a vital signs assessment, perform a neurological assessment, and talk about safety with Mr. Russell. You should also provide patient education on risk and prevention of aspiration. His morning medications are up and should be administered. Orders: Vital signs and neuro checks every 4 hours, NIH assessment q shift. Activity: Up to chair, up to the bathroom with assistance as tolerated Nothing by mouth except medications until swallow study completed tomorrow Speech therapist swallow study Fall risk assessment Labs: CBC, chem panel, and prothrombin time Bedside blood glucose twice a day Head CT: no intercranial bleed seen, acute ischemic effect correlate with a thrombotic stroke. Nursing Application Assessment: Management of care?( providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel) Safety and infection control?(protect clients and health care personnel from health and environmental hazards)  Basic care and comfort?  Health Science Science Nursing NURS 137 Share QuestionEmailCopy link Comments (0)

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