Help on how to document a neuro note (CARE PLAN DUE NEXT WEDNESDAY)

athena55, BSN, RN · Mar 30, 2009

I am having a hard time with how to document my neuro assessment. Half of the assessment we have to make up to go along with our scenario. Pt 83 y/o female with left sided hemiplegia and right facial droop. t 97.5 , P 80, R 20 reular, deep, B/P 140/80, Pox 95% on 2L N/C. She has a hx of HTN, NIDDM, AFib, chronic renal insufficiency, chronic anemia, alzheimers and anxiety. I was told the other information needs to be completed by me and must fit the dx. There is decreased circulation to the affected side with CVA therefore I said the pulse was weaker in the affected leg. As well as the pedal pulse on affected side. PERRLA WNL L eye and pupil reaction sluggish R eye. AROM on R side and PROM L side. Am I really far off with how this pt would look and HOW do I organize this information in my note?? please help. Thank you

Hello!

i am not quite sure what you are requesting or need: Your assignment is to make up an assessment based on the above scenario....?

Well, why don't you start from head to toe using a format like this and "plug" in your information:

Neuro: What is this patients Glasgow Coma Scale? Pt awake, orientated to person (is patient also orientated to place, time, events?) Follows simple/complex verbal commands - or doesn't. Is she responsive to you? Pupils equal and reactive or sluggish or non-reactive. Is there consensual reaction present. Is she able to see you, is she tracking you? Or does she have problems with her field of vision? Homonymous hemianopia? Does this patient have corneals, gag, swallow? Is patient able to verbalize and if so, is it appropriate meaning: is her speech recognizable, does she have expressive or receptive aphasia? If she has recognizable speech and is not aphasic, give or tell her 3 differernt words (table, clock, dog)

Ask her to open her mouth, close her eyes, can she smile, show her teeth, can she raise and lower her upper extremities and lower extremities....Any weakness or absent movement noted? How is her muscle tonus, can she squeeze your hands and is it equal in both her hands? Is this patient spastic or flaccid (her extremities)? Ask her if she can remember and tell you the three words you told her before (table, clock, dog) When talking to you does she fabricate?

Pulmonary: Is there symmetrical chest expansion? Upon auscultation of her breath sounds you hear....? Does she have any dyspnea, or DUE (dyspnea upon exertion), SOB; do you notice any increase in her work of breathing? If she is able to speak, can she finish a sentence without being SOB? Does she complain of orthopnea? Does she have clubbing of her fingers? Any peripheral or central cyanosis? Is she on oxygen and if so, how is she receiving it (nasal cannula, simple face mask, 100% NRBR - Non ReBreather) Is she tachypnic? s you mentioned above, what is her oxygen saturation (trends)?

Cardiovascular: What does the monitor show? Is she regular rhythm? How has her BP been? Can you palpate all her pulses? (temporal, facial, subclavian, carotid, brachial, radial, femoral, popliteal (these can be hard to palpate), posterior tibial, dorsalis pedis) If you can't can you hear them with a doppler? how does her pulses feel? Bounding? Thready? Irregular? Auscultate her heart sounds (if you have done so in the past, if not skip this part) where do you feel her PMI?

How is her skin color? "Normal" for her ethnicity? Has she been afebrile? Complaining of any type of chest pain or discomfort? If she does complain of chest pain/discomfort, does it feel better if she assumes a certain position?

GI/GU: Has she had ENT or Speech and Hearing evaluate her for a swallow test yet? Has she complained about dysphagia? Observe, auscultate, percuss and palpate her abdomen (in that order): document what you hear in all four quadrants: bowel sounds absent, hypo or hyperactive? Is she passing gas/flatus? When was her last stool and its color/consistency? When she is semi-flat and you observe her abdomen do you see any pulsation (her "heartbeat" or pulse in her belly?) Do you notice any unusual markings or veins on her belly? Is she voiding or does she have a foley? What is the color of her urine? Is it clear? Cloudy? How much urine is she making per hour? Any complaints of burning when she urinates (if she doesn't have a foley)? Does her urine have a odor?

Skin/Integ: How does her skin look? Is there tenting? Mottling? Ecchymotic areas? Skin tears? Does she feel warm, cold?

Does she have an even distribution of hair on her arms and legs? Is she at risk for skin breakdown? What was her last albumin and total protein? Is she able to eat, and if no is she receiving tube feeds or TPN?

What was her last finger stick? Does she have insulin coverage or on a drip? What was her last Hgb/Hct? Her last Cr Cl, or her BUN/Cr ratio?

Boy, good luck on your assignment! I probably was of no help to you.....

Krissy12386 · Mar 30, 2009

Thank you. Yes from this information, I have to make up the rest of my assessments for this pt. Then form a narrative nurses note to accompany my careplan. I am having a some trouble on how my note should flow. I gave this pt a GCS of 12. Now do I put that in my note? This is what I have so far...

Pt awake, lethargic. Oriented to person and place. T 97.5. P 80 radial, irregular +3 on R side +2 on L. R 20 reg., deep. B/P 140/80, RA, sitting. Pox 95% on 2L N/C. Breath sounds diminished RLL (3 sec L side. Pedal pulses palable. L sided hemiparalysis. R side AROM. Responds to commands. L pupil reacts brisk to light, R eye sluggish. 3 mm in size. Gag reflex intact.......... (that is all I have right now. Am I far off? Did I organize this information quickly? Is this what I would see if I had a pt w/stroke. How should I continue my note? THANK YOU SOOOO MUCH for responding so quickly.

athena55, BSN, RN · Mar 30, 2009

Thank you. Yes from this information, I have to make up the rest of my assessments for this pt. Then form a narrative nurses note to accompany my careplan. I am having a some trouble on how my note should flow. I gave this pt a GCS of 12. Now do I put that in my note? This is what I have so far...
Pt awake, lethargic. Oriented to person and place. T 97.5. P 80 radial, irregular +3 on R side +2 on L. R 20 reg., deep. B/P 140/80, RA, sitting. Pox 95% on 2L N/C. Breath sounds diminished RLL (3 sec L side. Pedal pulses palable. L sided hemiparalysis. R side AROM. Responds to commands. L pupil reacts brisk to light, R eye sluggish. 3 mm in size. Gag reflex intact.......... (that is all I have right now. Am I far off? Did I organize this information quickly? Is this what I would see if I had a pt w/stroke. How should I continue my note? THANK YOU SOOOO MUCH for responding so quickly.

Krissy:

So far, so good:up:

Yeah I would also state if the patient has purposeful movements on her unaffected side....Is her vision altered?

Does she have the ability to chew and swallow? (would make her at increased risk for aspiration) Can you back up your documentation that her pulse is +3 on right and +2 on left (i.e., if your professor asked you can you give a definition as to which each means? Just like with the GCS if you patient has a total of 12....)

Does the patient have any productive sputum? And, what do you hear in the other lung fields?

Also, I know in the real world oftentimes we don't either have the time or the space to write out a great narrative note, but in your note when you write of her being orientated to person and place, give example (patient able to correctly state her first and last name, can give her birth date as a patient identifier - don't use SSN anymore, and states she is in suchnsuch hospital)

Maybe not so much in a written format, but once you graduate and start to give report you will have the time to fill in the above "stuff" which can be so important to the oncoming nurse.

So YEAH, pretty much what you would see.....What caused the stroke? What kind of treatment did she receive once she was came into the ED? I am just curious if the hospital you are at adheres to the Stoke Guidelines

Also make sure you put in how verbal she is, or isn't....Cuz this will affect your patient teaching.

Good work, kiddo!

Let me know if I can be of further help but it looks like you won't need any!:wink2:

I will think of you this Wednesday!

As an aside, what year are you in?

athena

Krissy12386 · Mar 31, 2009

Thank you. I am scheduled to graduate this May.