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Case Study: Athena Washington was diagnosed with acute right cerebellar infarct and right vertebral artery dissection
Week 4 iHuman Nurse Notes Template
Complete each item below:
- Write an SBAR note (Situation, Background, Assessment, Recommendations) to summarize Ms. Washington’s current assessment and health status. This SBAR note will be reviewed by the emergency department physician caring for Ms. Washington. Hint: Since Ms. Washington is in need of emergent care, a brief review of your focused assessment is appropriate with a focus on the priority findings. Recommendations should relate to the next steps in care. To develop your note, type the appropriate information after each letter below.
Mrs. Athena Washington, a 48-year-old stroke patient, was admitted to the emergency department due to stroke-like symptoms and complaints of a recurring headache.
The supporting background information is that she is hypertensive and experiences right-sided weakness, nausea, and slurred speech. The patient took Tylenol 500 mg for the headache before going to bed. She has hypercholesterolemia and is unable to control her hypertension. She currently takes hypertensive and cholesterol-lowering medication.
The patient presents with sluggish speech and right-sided weakness. Her last vital signs were: BP of 182/103, HR 111, RR 24 bpm, pulse oximetry 97%, temperature 98.5 %
CN assessment for right-sided weakness: check vital signs every 10 minutes, reassess for aspiration risk, and assess lung for fluid overload.
Referrals: speech therapist for further assessment, occasion therapy, blood pressure-lowering medication, assistance with daily activities, and fall prevention. The family should be taught ways to prevent falls and symptoms of a stroke.
- Identify two other healthcare team professionals with whom you would collaborate when caring for Ms. Washington.
- Neurologist to direct and help assay for stroke-intensive care
- Physical therapist to evaluate the patient and design an individualized rehabilitation program for the patient’s right-sided weakness.
- In a one-paragraph response, what findings in your iHuman assessment led you to select these two providers?
The iHuman assessment revealed that the client is suffering from hypertension that predisposes her to stroke; this aspect is exacerbated by the fact that she does not adhere to her medication to lower blood pressure. As a result, a neurologist is a crucial member of the care team who will direct and help assay for the client’s symptom deprivation in case of any need for hospitalization in the intensive care unit. The assessment findings also reveal that the client has right-sided weakness and numbness, which means she cannot perform light tasks such as drinking water. A physical therapist will provide appropriate treatment to restore the patient’s right-sided functioning for performing simple tasks related to movement and walking.
- In a one-paragraph response, describe the role each of the two identified healthcare professionals would have in providing Ms. Washington with individualized, patient-centered care. Cite your resources in your paragraphs and list your reference(s) after your response.
A neurologist will help identify and confirm a stroke diagnosis to tailor and provide the right treatment approach. They will also order X-rays and CT scans to show how blood is flowing and check the nerves for any sign of malfunctioning that could be impeding proper functioning in the patient’s right side. The neurologist will also be crucial in appropriately administering intravenous medications such as clot-busting tissue plasminogen while coordinating the care team to ensure patient-centered quality care (Kanner, 2020). The physical therapist will design and tailor the most appropriate neurorehabilitation care based on the patient’s condition (Terry & Kayes, 2020). They will ensure the patient relearns simple motor activities to restore the right side to full functionality.