An_Easy_Guide_to_Head_to_Toe_Assessment_Vrtis_12_2008_Website

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Unformatted text preview: ________________________________________ Route: _____ Last dose: ____________ NSAIDS/ Adjuvants: __________________________________________________ Route: _____ Last dose: ____________ PCA: N/A Morphine Dilaudid Fentanyl via IV Epidural, dressing: D&I _____________ Continuous dose: ________ / hr Demand dose: _____ every _____ minutes Max doses per hour: _____ (Assess pain every 2 to 4 hours, evaluate the # of attempts vs the # of demand doses received to determine if dose is sufficient) Does the client have concerns about overusing medications/ addiction? No Yes, _____________________________ IV Assessment Type of line: Peripheral, site __________ Triple lumen CVL PICC Tunneled CVL Implanted port (check CXR for catheter tip placement before using all new central venous and PICC lines) Insertion site: WNL Redness Tenderness/ pain Warmth Swelling Drainage (IV needs to be DC’d if s/s of infection, thrombophlebitis or pain is present. Change PIV, notify MD of PIV and CVL concerns ) IV fluids: N/A, heplock IV fluids: _________________ @ _____ mls/ hr Continuous over ___ hrs IV pump Dial-a-flo Gravity TPN/ PPN: N/A TPN PPN @ _____ mls/ hr Continuous over ____ hrs per ________ pump Blood sugars: q 6 hrs q 8 hrs other: _______ Blood sugars ranges: WNL High with coverage needed PCA: N/A Morphine Dilaudid Fentanyl via IV Epidural, dressing: D&I _____________ Continuous dose: ________ / hr Demand dose: _____ every _____ minutes Max doses per hour: _____ (Assess pain every 2 to 4 hours, evaluate the # of attempts vs the # of demand doses received to determine if dose is suffici ent) Hot spots over cast? Cast intact: Drainage: No Yes None Cast/ Extremity Assessment Yes, describe: No, describe: Yes, describe: Extremity check Color: Temperature: Sensation: Pain increasing? Swelling increasing? WNL Warm WNL No No Pale Cool Loss of sensation Yes, describe: Yes, describe: TYPES OF APHASIA: Dysarthria – patient has problems with speech due to muscular control. Expressive aphasia (Broca’s) – patient understands, can respond w/ great difficulty in short abbreviated, phrases. Aware and frustrated. Often frontal lobe damage. Receptive aphasia (Wernicke’s) – patient cannot understand spoken and sometimes written words, speaks fluently, long sentences that do not make sense. Patient may not be aware of deficits. Often secondary to L temporal lobe damage. Global or mixed aphasia – patient has difficulty in understanding and speaking/ communicating. Often secondary to extensive damage of the language areas of the brain. ASSESSMENT FOLLOW UP: Notify the physician of all abnormal findings!! Use the nursing process to: o Analyze subjective and objective findings. o Make a nursing diagnosis. o Plan and implement appropriate interventions. o Evaluate the effectiveness of the plan and revise as needed. An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com Putting it All Together As you walk into the room asses...
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This note was uploaded on 03/26/2013 for the course NURSING 1201 taught by Professor Smith during the Spring '12 term at Glendale Community College.

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