Just complete the template.
| 3/25 1700 | Nursing Note: Client arrived via EMS to unit. EMT stated client was limp, lethargic, and confused since they picked her up. Assessment completed. Client oriented x 1-self only. Slow to respond to questions, speech garbled, right-sided weakness present. |
| 3/25 1845 | Nursing Note: Received notification from MRI tech reporting indication of left-brain ischemic stroke. MD notified. Code stroke started. |
| VITAL SIGN TREND | ||||||
| Date | Temp | HR | RR | BP | SpO2 | O2 |
| 3/25 1700 | 97.3 oF | 115 | 12 | 150/70 | 94% | RA |
| NIH STROKE SCALE | |
| Date | 03/25 1715 |
| 1a. Level of Consciousness | |
| 1b. LOC Questions | |
| 1c. LOC Commands | |
| 2. Best Gaze | |
| 3. Visual | UN |
| 4. Facial Palsy | |
| 5. Motor Arm | UN |
| 6. Motor Leg | UN |
| 7. Limb Ataxia | |
| 8. Sensory | |
| 9. Best Language | |
| 10. Dysarthria | |
| 11. Extinction and Inattention | |
| BLOOD GLUCOSE LOG | ||
| Date | Result | Notes |
| 3/25 1705 | 96 mg/dL | Capillary blood glucose |
| PROVIDER PRESCRIPTIONS & NOTES | |
| 3/25 1720 | Prescriptions:
|
|
| Nursing Note: Client arrived via EMS to unit. EMT stated client was limp, lethargic, and confused since they picked her up. Assessment completed. Client oriented x 1-self only. Slow to respond to questions, speech garbled, right-sided weakness present. |
| 3/25 1845 | Nursing Note: Received notification from MRI tech reporting indication of left-brain ischemic stroke. MD notified. Code stroke started. |
| 4/1 1100 | Nursing Note: Client tolerating cardiac diet with thickened liquids. Using communication board effectively. Right-sided visual field obstruction causes difficulty with ambulation. Received prescription to discharge to TCU (transitional care unit). |
| 4/1 1130 | Client Education:
|
Name: Josephine Argent
Age: 65 years
Provider: R. Walter MD
Allergies: NKA
Code Status: Full Code
Admit Wt: 130 lbs (59.1 kg)
BMI: 23
