Documentation Assignments
1. Document the Morse Fall Scale assessment you completed on Mr. Russell.
The patient needs to continue with the range of motion exercise for the legs and arms. The patient needs to focus on
...
Documentation Assignments
1. Document the Morse Fall Scale assessment you completed on Mr. Russell.
The patient needs to continue with the range of motion exercise for the legs and arms. The patient needs to focus on the left side to improve strength. It is recommended for the patient to call for assistance if he needs to move from bed.
2. Complete an SBAR report on Mr. Russell’s musculoskeletal assessment for the charge nurse.
Situation:Vernon Russell is a 55-year-old Native American man who was admitted to the hospital with a stroke with mild left hemiplegia 2 weeks ago. He had a head computed tomography scan and received thrombolytic therapy in the emergency department. He has been stable and was transferred to a transitional care unit this afternoon. He has had physical therapy twice per day and is regaining some strength.
Background:He has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack per day for the past 35 years and does not exercise.
Assessment: I assessed the range of motion of the patient's arms. There was limited range of motion of the left shoulder and elbow, but full range of motion of the other joints in the arms. I assessed the strength of the patient's arms and hands. It was 3 out of 5 in the left arm and hand and 5 out of 5 in the right arm and hand. You assessed the strength of the patient's legs. It was 3 out of 5 in the left leg and 5 out of 5 in the right leg.
Recommendations: Nurses must assess a patient's risk for injury with a view toward maintaining independence and fostering self-esteem while providing a safe and predictable environment.
3. Document your focused assessment of Mr. Russell’s musculoskeletal system.
Patient's has muscle movement against gravity but no movement against resistance on the left side of body. His muscle movement on his left side is a 3 out of 5. Right side of body has normal movement 5 out of 5.
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