Question Use this video link that I provided to answer the head to toe… Use this video link that I provided to answer the head to toe assessment and nursing care plan.Video link: http://www.can-sim.ca/games/sogi1e/story_html5.html General Head to Toe AssessmentGeneral Survey:1.Identify client (self-identifies, armband), isolation status/PPEAsk how client feels. Observe environment, non-verbal cues, mobility, ROM. Check IV; site inspection, correct solution/rate. Check O2 admin, invasive lines/tubes, stomas, dressings2. Vital signs and Pain:Assess Temp, BP, Pulse, Resp., O2 Saturation, FiO2, Pain (ie. PQRST ), date/time last pain medication administered 3.NeurologicalAlert & oriented to person, place and time. Pupils equal bilaterally, round, reacting briskly to light and accommodation (PERRLA). Behaviour and verbalization appropriate to situation. Moving all limbs spontaneously, symmetry of strength in all limbs.4.CardiovascularSkin warm, dry, no bruises, rash, lesions, pruritis. No hair loss. No evidence of cyanosis. No peripheral edema. Cap refill < 2 sec. Peripheral pulses (radial, dorsalis pedis) palpable, regular, normal quality. BP, Apical pulse (rate, rhythm, amplitude), heart sounds.5.RespiratoryAnt/Post diameter < transverseSymmetric chest expansion, normal palpation, percussionAnt/Post air entry normal and audible to all lobes, no wheezing, crackles or stridor. 6.GastrointestinalBowel sounds present, normal x 4 quadrants. Abd non-distended, soft, non-tender. Absence of nausea/vomiting. No recent weight gain/loss. Normal appetite, bowel patterns.7.Genito-UrinaryGenitalia; no redness, edema, abnormal dischargeAble to void independently; urine clear, pale yellow, nil odour, normal output, no pain or burning on voiding.8.MusculoskeletalFull range of motion in all limbs. Nil weakness, paralysis, joint stiffness.9.PsychosocialNo verbal or emotional concerns expressed by client and/or familyNursing care plan1.Assessment Data/ Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis)2.Client Outcomes (SMART: specific, measurable, achievable, realistic and time specific)3.Nursing Interventions (Nursing initiated actions based on the medical plan of care and client outcomes)4.Rationale/Evidence Based (Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology. and show where you got the information. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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