1. Identify 4 components of correct nursing documentation?

Case Study - Mrs Anh Thuy

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 To 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 hourlyNeurological 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.

1. Clinical Handover is an important part of continuity of patient care and safety.Nurses use the tool ISBAR when giving clinical handover.
2. What information would you include when doing a verbal clinical handover for Mrs Thuy to your Registered Nurse? Please use the ISBAR format.