Scenario #2:
Ned Flanders is a 78-year old male who was admitted 2 days ago to room 10B under the service of Dr. Roster with a stroke. Mr. Flanders has been experiencing weakness to his left side, confusion, restlessness, and has become impulsive. After having a CT scan, it shows that Mr. Flanders has a right sided hemorrhagic stroke.
Being restless since admission Mr. Flanders now has an open area to his left lateral ankle from rubbing it against the mattress.
Mr. Flanders has a history of migraine headaches, and hypertension, he has no known allergies, and is a full code.
History Orders
• Migraines
• Htn
• NKA
• Full code
• Daily dressing to left lateral ankle. Cleanse with saline and apply dry dressing.
• Vital Signs q4h
• R.O.M q2h, while awake
• IV: Saline Lock
• Sitter 24 Hr
• Foley Catheter
•
You have just arrived for your day shift, the following is what you hear in report at 0730:
• Restless overnight, slept poorly.
• Started on medication to treat high blood pressure
• Re-positioned multiple times overnight
• Vitals at 0600 were T 36.6, pulse 82, resp 18 BP 190/90 O2 sat 88% R/A
Report is finished, and you are off to see Mr. Flanders…
1. Perform a Head-to-toe assessment. Include neuro/orientation, skin, respiratory, mobility, and safety.
2. What are your findings for IV assessment? Foley? Dressing? List what you would be assessing for each.
3. Please provide an initial shift assessment note.
4. Are you concerned with his set of vitals? What is normal/abnormal? What would you consider? What would you report?
5. What are signs and symptoms of a stroke?
6. Why would a sitter be ordered for Mr. Flanders? What would you do when you had to perform your assessments with the sitter present?
7. Mr. Flanders oxygen level remains around 88-92%%. What would you do? Please write an FDARP.
8. You are setting up Mr. Flander’s for breakfast, what considerations would you have?
9. Please write an FDARP on Safety.