Watch Wolfgang's Story (can-sim.ca) and Answer head to toe assessment question and also the nursing care plan....
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Watch Wolfgang's Story (can-sim.ca) and Answer head to toe assessment question and also the nursing care plan.

http://www.can-sim.ca/games/sogi1e/story_html5.html




Head to toe assessment

General Survey:

1.Identify client (self-identifies, armband), isolation status/PPE

Ask how client feels. Observe environment, non-verbal cues, mobility, ROM.

Check IV; site inspection, correct solution/rate.

Check O2 admin, invasive lines/tubes, stomas, dressings


2.Vital signs and Pain:

Assess Temp, BP, Pulse, Resp.,

O2 Saturation, FiO2, Pain (ie. PQRST ), date/time last pain medication administered  


3.Neurological

Alert & oriented to person, place and time. Pupils equal bilaterally, round, reacting briskly to light and accommodation (PERRLA). Behavior and verbalization appropriate to situation. Moving all limbs spontaneously, symmetry of strength in all limbs.


4.Cardiovascular

Skin 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.Respiratory

Ant/Post diameter < transverse

Symmetric chest expansion, normal palpation, percussion

Ant/Post air entry normal and audible to all lobes, no wheezing, crackles or stridor.  


6.Gastrointestinal

Bowel 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.


7Genito-Urinary

Genitalia; no redness, edema, abnormal discharge

Able to void independently; urine clear, pale yellow, nil odour, normal output, no pain or burning on voiding.


8.Musculoskeletal

Full range of motion in all limbs. Nil weakness, paralysis, joint stiffness.


9.Psychosocial

No verbal or emotional concerns expressed by client and/or family





Nursing care plan


1.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 write down where you your information from.







Answer the following questions .

  1. Pathophysiology of Benign Prostatic Hyperplasia (BPH)
  2. Trans Urethral Prostate Resection (TURP) surgery procedure and post op guidelines
  3. Research acute complications of TURP surgery
  4. Review signs and symptoms of an enlarged prostate; identify populations that are high risk.
  5. Apply person and family centered care to the consent process; how can family be involved?

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