Skills Lab Virtual Scenario-
Head to Toe Assessment with Follow Up You have just conducted ahead-to-toe assessment on your patient. The assessment showedabnormal objective and subjective findings, both requiring nursingdocumentation & actions. During the assessment you noted thefollowing: Objective data: Patient is AAOx1, pleasant andcooperative with new onset of confusion.
PEARLA. Patient has hearing aid & wears reading glasses butis unable to locate them. Respirations are irregular, labored.Breath sounds clear to RUL & LUL but wheezes noted to LUL andcrackles to LLL with nonproductive cough.
Patient is on room air, no oxygen. Skin is pale, warm, dry andintact; has 2 Stage 4 pressure ulcers to R&L buttocks, (R)buttock wound measures 4x5x1 but has no drainage or odor and woundbed is bed, (L)buttock wound measures 6×6 with eschar with nodrainage or odor; no other areas of bruising or open areas.
Radial and Pedal pulses are palpable on R&L. NormalCapillary refills. NonJugular Vein Distention, Denies CalfTenderness, Heart rate & rhythm regular. RUE double lumen PICC,dsg intact, patent. Edema noted to BLE. Abdomen is soft and round.Bowel sounds present x 4 quarters. Patient is incontinent of bowel& bladder.
Urine is dark yellow & has sediment; complaints ofdiscomfort on urination. Patient is on a diabetic diet. Patientambulates with assistance via wheelchair.
Vital Signs: T 100.8, HR 101, BP 96/78, RR 24, Sats- were notobtained by nurse aide
Subjective data: Complains of generalized aching pain rating8/10.
1) Based on these findings you will need to document head to toeassessment using the appropriate documentation form (nursingdocumentation form) and include objective and subjectivefindings.
2) What findings would be considered abnormal, if any?
which would be the GREATEST priority to address? What OBJECTIVEDATA supports this?
What do you anticipate would be the MD orders for theappropriate nursing intervention(s)?
What would be the 2nd priority to address? What OBJECTIVE DATAsupports this?
What do you anticipate would be the MD orders for theappropriate nursing intervention(s)?
