Head to Toe assessment Assignment

The nurse enters the room, performs hand hygiene, and observes the client, Peter Franks. What are your initial observations? After identifying self, identifying the client, providing privacy and explaining the assessment procedure......the nurse should ask the client a couple of questions before starting the assessment... What are those questions? The nurse proceeds to check vital signs. Discuss which vital signs are normal and which are outside of range. If there are any outside of range- discuss whether high and what the normal range for this patient should be.The results are as follows: Apical pulse 78 regular, Resp 14 and unlabored. The client denies any pain. Stated pain was a zero on the pain scale. Evaluate the vital signs to answer the question. Indicate on the image where the nurse should assess apical pulse by labeling the correct area with the words "Auscultate here" Mr. Franks denies having a cough. Respirations are shallow and unlabored at rest. The nurse auscultates the lung sounds and hears the following lung sounds. (Click on the play button by the instructions) What would the nurse call these lung sounds? normal lung sounds adventitious lung sounds clear lung sounds crackles wheezes The nurse proceeds to assess the abdomen. Bowel sounds are present and normoactive all four quadrants. the nurse palpates the abdomen and notes it is soft. No pain with palpation. The client states has a healthy appetite and eats 80-100% of all meals. Denies nausea, or difficulty urinating. Reports his last bowel movement was yesterday and denies any constipation and the bowel movement "was normal for me."Discuss three key points to remember when assessing bowel sounds. When assessing skin and extremities, what should the nurse assess? Describe in detail. The client has the following equipment. What should the nurse assess about this equipment? The nurse finishes the head to toe assessment, puts the bed in low position, places the call light within reach, and performs hand hygiene before leaving the room. Once leaving the room, the nurse documents the procedure.Document the head to toe assessment using a narrative documentation format below AND using the tips from the documentation unit. Refer to the data learned in the questions above to enter in your charting. If there is a value needed, but I did not give it to you... go ahead and make up the value. (such as information from the skin extremity assessment piece). Use today's date and sign off using your name. What piece of the assessment did the nurse forget to do? The nurse notices this after documenting, now what should the nurse do about it?