Physical Assessment Neurologic Case study Paper

You will perform a history of a neurologic problem that your instructor has provided you or one that you have experienced and perform an assessment of the neurologic system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Title: Documentation of problem based assessment of the neurological system. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings. Course Competency: Apply assessment techniques for the neurological and respiratory systems. Instructions: Content: Use of three sections: o o o Subjective Objective Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them Physical Assessment Neurologic Case study Paper.

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Format: • Standard American English (correct grammar, punctuation, etc.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91 Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Competence Proficiency Mastery Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data. Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Objective (4 Pts) Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points:4 Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”. Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”Physical Assessment Neurologic Case study Paper.

Contains all objective information. May have signs of bias or explanation of findings. Points: 2 Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information Points: 3 Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information Points: 4 Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Points: 1 Points: 1.5 Points: 2 Points: 1 Actual or Potential Risk Factors (2 pts) data. Information is solely what “client” provided. Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Points: 0.5 Neurologic System Patient Case #1 (Stroke) Patient Case: Mr. Gardner, a 56-year-old native Alaskan male Admitted diagnosis: Cerebral Vascular Accident (Stroke) Medications: lisinopril Allergies: aspirin Substance use: cigarette use (1 pack per day for past 35 years) Status: Mr. Gardner is being admitted to an acute care neurologic unit via the emergency department (ED) following a stroke. When he arrived at the ED last night, he was unable to provide a detailed past medical history but stated he had a severe headache that had been present for “a few hours.” His medical chart reveals that he lives alone, and he has had no visitors at his bedside since admission Physical Assessment Neurologic Case study Paper.

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He does not remember the last time he took his blood pressure medication, lisinopril. Pain: 10/10 headache Past medical history: hypertension and dementia Physical Exam: Vital Signs: Oral Temp 36.8 C, HR 88 BPM, RR 22, and BP 168/92 mm Hg Inspection: Alert but confused and somewhat agitated. Oriented to name only. Speech is comprehensible but slurred. Can follow 1-step commands only – is easily distractable. Poor hygiene noted and is wearing multiple layers of mismatched clothing. CN II impaired, left visual field loss present. CN VII impaired, left lower facial droop present. CN XII impaired, left-sided tongue deviation noted. Palpation: Muscle tone slightly increased on left arm/leg. Muscle strength 2/5 left arm, 3/5 left leg. Left Babinski reflex present. Coordination in left arm/leg unable to assess due to weakness. Gait unable to assess – patient on complete bedrest. Diminished attention to objects/people on left side of bed. Difficult to assess sensation due to varying degrees of patient’s attention, diminished sensation appears to be present on left arm/leg. All other objective findings are within normal limits – please document the normal findings by describing what normal looks like Physical Assessment Neurologic Case study Paper