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Assessment Case 04 Vernon Russell DA Final
Situating the Practice of Nursing (NURS 102)
University of Pennsylvania
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vSim Health Assessment Case 4: Vernon Russell
Documentation Assignments
- Document the Morse Fall Scale assessment you completed on Mr. Russell.
History of Falling – No record of falling in the last 3 months 0 Secondary Diagnosis – history of hypertension, coronary artery disease, and diabetes mellitus type 2 15 Ambulatory Aid – Uses a walker 15 IV/Heparine Lock – No IV or Heparine Lock 0 Gait Transferring – Let sided weakness 10 Mental Status – Awake Alert and Oriented to Person, Place and Time 0 Total Score: 40
- Complete an SBAR report on Mr. Russell’s musculoskeletal assessment for the charge nurse.
S – Mr. Russell was admitted to the hospital due to a stroke with mild hemiplegia 2 weeks ago. Musculoskeletal assessment was performed to determine how he has been progressing since Mr. Russell became ill. B – Mr. Russell suffered a stroke with mild hemiplegia 2 weeks ago. He also has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. Has been smoking cigarettes a pack a day for 35 days and does not exercise. A – o There is no drooping of the eyelids, no inverted eyelids and no white sclera is visible above or below the iris. No discoloration, swelling, lesions, or discharge. Eyeballs are symmetrically aligned in sockets, without protruding or sinking. Sclera is white, conjunctiva is clear, moist and smooth. o Pupils are both round, 5mm in size, and react equal to light. o Glasgow Coma Scale: (Right) 15 (Left) 13 Eyes open spontaneously: 4 Has active motion against gravity in left arm and handgrasp: 3 Has active motion against full resistance in right arm and handgrasp: 5 Patient obeys verbal commands: 6 o Full Range of motion in the joints in the right arm o Limited Range of motion in the left arm Left shoulder range of motion 160° Left elbow range of motion 140° o Shoulders show no sign of asymmetry, swelling or discoloration. o Skin in both arms are warm, dry and mobile. texture and thickness are smooth and thin. Skin turgor is normal with no signs of edema.
From vSim for Nursing | Health Assessment. © Wolters Kluwer.
o Right hip has full range of motion o Left hip flexion is limited to 80° with knees flexed o Left hip flexion is limited to 40° with legs straight o Active range of motion against gravity in left leg o Active range of motion against full resistance in right leg o Skin in both legs are warm, dry and mobile. texture and thickness are smooth and thin. Skin turgor is normal with no signs of edema. o Hips and knees show no sign of asymmetry, swelling or discoloration. R – o Continue ROM exercises every shift. o Do a musculoskeletal assessment on Mr. Russell once a day. o Schedule appointments with physical therapy and occupational therapy o Provide emotional support o Assist with ambulation and be sure to provide walker when ambulation. o Provide information on support groups with peers who are recovering/recovered stroke o Educate patient on fall risks and ROM exercises
- Document your focused assessment of Mr. Russell’s musculoskeletal system.
o There is no drooping of the eyelids, no inverted eyelids and no white sclera is visible above or below the iris. No discoloration, swelling, lesions, or discharge. Eyeballs are symmetrically aligned in sockets, without protruding or sinking. Sclera is white, conjunctiva is clear, moist and smooth. o Pupils are both round, 5mm in size, and react equal to light. o Glasgow Coma Scale: (Right) 15 (Left) 13 Eyes open spontaneously: 4 Has active motion against gravity in left arm and handgrasp: 3 Has active motion against full resistance in right arm and handgrasp: 5 Patient obeys verbal commands: 6 o Full Range of motion in the joints in the right arm o Limited Range of motion in the left arm Left shoulder range of motion 160° Left elbow range of motion 140° o Shoulders show no sign of asymmetry, swelling or discoloration. o Skin in both arms are warm, dry and mobile. texture and thickness are smooth and thin. Skin turgor is normal with no signs of edema. o Right hip has full range of motion o Left hip flexion is limited to 80° with knees flexed o Left hip flexion is limited to 40° with legs straight From vSim for Nursing | Health Assessment. © Wolters Kluwer.
Assessment Case 04 Vernon Russell DA Final
Course: Situating the Practice of Nursing (NURS 102)
University: University of Pennsylvania
