Question

Location: Neurological Unit 0800

SBAR report from the night nurse:

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 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.

Assessment: We have already checked his blood glucose level this morning. His vital signs have been stable and he slept well last night. 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. I have already done a Morse Fall Risk assessment with a total high risk score of 60.

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.

2 subjective data,

2 objective data

One nursing diagnosis

2 long term goals,

2 short term goals

4 interventions with rationales

4 evaluations of goals, 4 evaluations of intervention

Answer 1

NEUROLOICAL ASSESSMENT.

• Mental status- Oriented to surrounding
• Sensation and perception - have control on bowel and bladder movement
• Motor control - have some control
• Reflex- poor reflex

EDUCATION ON PREVENTION OF ASPIRATION

• Provide bed rest before eating atleast 30 min.
• Make the patient sit upright in the chair.
• adjust the rate of feeding and size of feeding.
• Plaicng the food in the mouth of the patient according to the deficit . Eg; if the right chin is weak keep it in the left side
• Minimize the use of sedatives before eating.
• Avoid distarction while eating
• Make sure denture fit correctly
• Avoid spicy food.

Subjective data;

1. patient says i have difficulty in swalloing
2. patient says i have pain in my chest

Objective data;

1. hemiplegia
2. Dysphagia

Nursing diagnosis;

- Impaired swalloing related neuromuscular impairement.

Goals; Short term-

• Patient will demonstrate feeding methods appropriate to individual situation with aspiration prevented.
• Patient will maintain desired body weight.

Long term-

• improved mobility
• maintaining skin integrity

INTERVENTION	RATIONALE
Offer solid foods and liquids at different times.	Prevents patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after patient has finished eating foods.
Maintain upright position for 45–60 min after eating.	Helps patient to reduces risk of regurgitation.
Encourage participation in exercise program	May increase release of endorphins in the brain, promoting a sense of general well-being and increasing appetite.
Administer IV fluids and/or tube feedings	Necessary for fluid replacement and nutrition if patient is unable to take anything orally.

Evaluation of goals-

• Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.
• Elevate affected arm to prevent edema and fibrosis.
• Prevent adduction of the affected shoulder with a pillow placed in the axilla.
• Provide counseling and support to family.

Evalutaion of inetrvention -

• patient is able swallow different types of food.
• Patients risk of regurgitation is decreased .
• patient have good appetite.