Mrs Anh Thuy is a 43 year old lady admitted following an incidence… 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·             Buddhist & 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 observationsBP 170/100PR 90 regularRR 24To 36.4SpO2 98% on room airBGL 7.4 mmolWeight 71 kgHeight 152 cm GCS (Glasgow coma scale) = 14Eyes open to speechOriented 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 forearmDischarge InformationMrs 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 11.        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……………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………. Health ScienceScienceNursing HLT 54115

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