Diagnosis: Right-sided stroke (mild left hemiplegia)
Brief Summary :
Vernon Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday. The patient is nothing by mouth except medications. Chest-x-ray confirmed possible aspiration pneumonia on the right side.
· Losartan 50 mg PO BID
· Aspirin 81 mg PO daily
· Metformin 500 mg PO BID
· Chlorthalidone 25 mg PO daily
· Vital signs and neuro checks every 4 hours
· Activity: Up to chair, up to the bathroom with assistance
· Nothing by mouth except medications until swallow study completed tomorrow
· Speech therapist swallow study
· Fall risk assessment
· Labs: CBC, chemistry panel, and prothrombin time
· Bedside blood glucose twice a day
SBAR Report :
S: 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 video swallow study, which is scheduled for later this morning. He is scheduled for physical therapy later today.
B: 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.
A: 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 but impaired. He is oriented x2. Patient is slow to respond and noted to have some periods of slurred or delayed speech. I have already done a Morse Fall Risk assessment with a total high risk score of 60. Fall precautions implemented. Upon bedside RN swallow evaluation, the patient was noted to have frequent coughing when given a small sip of water. Chest x-ray done in the ED reveals that the patient has right-sided pneumonia, possibly due to aspiration.
R: You should do a vital signs assessment, perform a neurological assessment, and talk about safety with Mr. Russell. His morning medications are up and should be administered with caution. Maintain NPO status until video swallow performed. Patient was able to stand on side of bed with physical therapist, but weakness noted. Patient unable to take steps. Continue fall and aspiration precautions.
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