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ADPIE Document

Vernon Russell was admitted to the ED after being found confused with garbled speech and mild left sided weakness. His vital signs and neurological exam were performed. He has a history of hypertension, diabetes, and smoking which places him at higher risk for stroke. The nursing students checked his neurological status, vital signs, and recommended NPO due to difficulty swallowing with monitoring as a fall risk and involving physical therapy.

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Russell Flores
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52 views5 pages

ADPIE Document

Vernon Russell was admitted to the ED after being found confused with garbled speech and mild left sided weakness. His vital signs and neurological exam were performed. He has a history of hypertension, diabetes, and smoking which places him at higher risk for stroke. The nursing students checked his neurological status, vital signs, and recommended NPO due to difficulty swallowing with monitoring as a fall risk and involving physical therapy.

Uploaded by

Russell Flores
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Patient Chart

Chart for Vernon Russell

Student Name: Russell Flores and Natalie Hart


Patient Initials: VR
Clinical Date(s): 6/16/2022
Instructor: Shawna Wilkins
Vital Signs:
Temp 37
HR 94
RR 12
BP 134/80
O2 Sats 90
Pain 4 Quality Sharp Location Back
Neurological:
Orientation: Alert X Confused __ Unresponsive __ Person __ Place __ Time __
Facial full mobility_Smile symmetrical
Eyes: Pupils PERRLA
Speech Slurred
Arms strength mildly diminished on the left side
Morse Scale: 60
Bath/oral care/linen and gown change: completed
Hygiene performed: completed
Progress Notes:
Patient started to aspirate during oral care. LVN suctioned mouth, then put on a non
rebreather at10L
Name: Russell Flores
Natalie Hart
Date: June 17, 2020
Instructor: Tabitha Somers, Shawna Wilkins
Term: 1

S
Situation: I am Russ a nursing student at Carrington College.
I am calling about Mr. Vernon Russell.

Chief Concern: Patient was brought to the ED after his adult child found him at home
staring straight ahead, confused, with garbled speech and left, mild hemiplegia.
Vital signs are:

Time: 0000 BP: 155/90 HR:92 RR: 18 SpO2: 98 O2 Flow: RA Temp(oC): 36.9
Time: 0400 BP: 148/88 HR:88 RR: 16 SpO2: 97 O2 Flow: RA Temp(0C): 36.7

B
Background: The Patient has a history within 5 years of Hypertension, Type 2 Diabetes mellitus,
and coronary artery disease. He is a current smoker and drinks alcohol frequently.

Medications: Losartan hold for BP less than 110/65, Metformin, Chlorthalidone, Aspirin,
Acetaminophen, IB bag 0,9% sodium chloride, Alteplase bolus, Alteplase in 0.9 sodium chloride
running over 60 minutes. Has no current exercise.

A
Assessment: Mr. Russell has a right-sided stroke and a mild left hemiplegia and has a fall risk
assessment score of 60. Since he had a stroke, I would check his neurological assessment. He has
dysphasia and difficulty to swallow. His vitals WNL.

R
Recommendation: Mr. Russell should be requested by the provider to put him on an NPO order.
He should be monitored as a fall risk patient. Also, the patient should also be involved in any short
physical activities as the patient recovers. A speech therapist is required for his assessment on
swallowing. A Chest X-Ray is needed for his diminished lung sounds on the left and lower right
lobe.
Assessment Mr. Russell has a right-sided stroke and a mild left hemiplegia and has a fall risk
assessment score of 60. Since he had a stroke, I would check his neurological
assessment. His vitals WNL.
Vital signs are:

Time: BP: HR:9 RR: SpO2: O2 Flow: Temp(oC):


0000 155/90 2 18 98 RA 36.9
Time: BP: HR:8 RR: SpO2: O2 Flow: Temp(0C):
0400 148/88 8 16 97 RA 36.7
Nursing Diagnosis Patient was brought to the ED after his adult child found him at home staring
straight ahead, confused, with garbled speech and left, mild hemiplegia. He is a
fall risk patient. Has dysphasia and difficulty swallowing.

Planning Mr. Russell needs to continue short physical exercise and a provider’s order of
NBO because of his difficulty swallowing. Should be noted as a fall risk patient.

Implementation Mr. Russell should stop drinking and smoking. Continue physical training. To be
in a modified diet plan.

Evaluation As Mr. Russell continues treatment, will continue to monitor.

ADPIE

DEBRIEF QUESTIONS
1. How do you feel about the group’s simulation performance?
a. After performing the simulation we were grateful that we were able to have a
partner for our first final simulation.
2. What went well with the group’s scenario and why?
As a team we were able to think ahead and plan for our simulation. We went above and beyond
for recommendations for treatment and performed a thorough neurological exam that exceeded
expectations.
3. What would you do differently and why?
We should take a deep breath and remember to don’t forget the small things such as patient
privacy, rate of pain, and have confidence by what we know.
4. What was/were the patient’s key problem/s?
The patient’s key problems are mild left sided hemiplegia, right sided stroke, and diminished
lung sounds, as well as aspiration.
5. What nursing intervention/s was/were done and how did the patient respond?
We used a yankauer to remedy aspirations and non-rebreather at 10mL to raise his oxygen up.
6. What feedback would you like to give to your peers?
Don’t forget to take deep breathes and never doubt your capabilities. Make sure to have a plan
ahead of time.

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