Mrs Anh Thuy is a 43 year old lady admitted following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. A neighbour found her on the ground unable to move or speak.

She has been diagnosed as having an ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.

Family history –

·             Born to Vietnamese parents in Australia

·             Buddist & speaks Vietnamese & English

·             Lives with husband & 2 children, Grace 4 years old & Ty 13 years old. Also father who is a frail 82 year old.

Medical history –

·             Hypertension, Type 2 Diabetes, Asthma

·             Depression

·             Lactose intolerant

·             Hearing aid left ear

·             Bi-focal glasses (broken in fall)

·             Upper dental partial plate

·             Medication – Amlodipine, Metformin, Salbutomole.

Admission observations –

BP 170/100

PR 90 regular

RR 24

T^o 36.4

SpO₂ 98% on room air

BGL 7.4 mmol

Weight 71 kg

Height 152 cm

GCS (Glasgow coma scale) = 14

Eyes open to speech

Oriented to time, place and person (speech slurred, but able to be understood)

Right hemiparesis

PERL (Pupils equal reactive to light)

Issues/impacts of the CVA –

·             Pain on movement, mainly right hip & shoulder

·             Large haematoma right hip

·             5cm skin tear right elbow

·             Dysphasia

·             Dysphagia

·             Right sided facial droop

Doctor’s orders and interventions-

·             Rest in bed (RIB)

·             2nd hourly Neurological observations

·             Nil by mouth (NBM) until Speech Therapist review

·             Physiotherapist review

·             Full assistance with hygiene

·             IDC insitu

·             Intravenous Therapy via cannula in left forearm

Discharge Information –

Mrs Thuy will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy.  Community Services and the Discharge Planning team have been contacted.

PART 1

1.        Using the headings below explain how you would prepare for Mrs Thuy’s arrival to the ward.

a)        Preparation of room:

b)        List 4 piece of equipment required for a patient assessment:

c)        List four (4) types of forms and or risk assessment tools that will be required as part of Mrs Thuy’s admission:

2.        Identify 4 components of correct nursing documentation?

SOLUTION

PART 1

1. Preparation for Mrs. Thuy’s Arrival to the Ward:

a) Preparation of Room:

• Ensure the room is clean, well-lit, and adequately ventilated.
• Adjust the bed to a comfortable position and ensure all necessary equipment is available.
• Place call bell within the patient’s reach.
• Provide appropriate signage for patient identification and safety.

b) List of Equipment Required for Patient Assessment:

• Blood pressure monitor
• Thermometer
• Glucometer for blood glucose monitoring
• Pulse oximeter for oxygen saturation monitoring

c) List of Forms and Risk Assessment Tools:

• Admission assessment form
• Falls risk assessment tool
• Dysphagia screening tool
• Neurological assessment form

2. Components of Correct Nursing Documentation:
   • Accuracy: Documenting information accurately and objectively.
   • Timeliness: Documenting assessments, interventions, and observations promptly after they occur.
   • Completeness: Ensuring all relevant information is documented, including patient responses, vital signs, and interventions provided.
   • Legibility: Ensuring that handwriting is clear and legible, or using electronic documentation systems when available.