You are a registered nurse working on an orthopaedic ward. You have just accepted a client admission from the emergency department. The client is Julia Chan.
In this admission process you will need to complete a systematic assessment (combination of head to toe assessment and body systems) approach in your admission of Julia. Please follow this as a guide:
1. CNS e.g. GCS, alert & orientated, neurological assessment, drug & alcohol use, drug /alcohol testing 2. Respiratory: e.g. risk of complications, respiratory assessment,? need for oxygen 3. CVS: e.g. cardiovascular assessment, neurovascular assessment, risk and complications, haemostasis 4. Renal: e.g. metabolism of drugs, continence, interpret blood/urine results, history 5. GIT/liver: e.g. nutritional/fluid status, NBM? Pre surgery, abdominal assessment 6. Integument: e.g. appearance, including skin breaks, mobility, wounds 7. Musculoskeletal: e.g. Range of motion, musculoskeletal assessment, mobility, trauma, injury 8. Endocrine: e.g. glycaemic status, ?use of oral contraceptive pill 9. Immune: e.g. risk of infection, allergy status 10. Reproductive: e.g. (female: menstrual disorders, cancer, endometriosis), STIs, (male: prostatitis, cancer, testicular torsion, phimosis). 11. Medication use: e.g. medical history, drug interactions, medications she has received pre op (e.g analgesia) 12. Psychosocial: e.g. cultural issues, language, and family status
Activity 1: Neurological assessment
In pairs, practice taking your partner’s neurological observations and document your findings on a neuro chart.
Why are we doing a neurological assessment for Julia?
Activity 2: Cranial nerve assessment and discussion with facilitator
You note in the admission entry from the doctor that they assessed Julia’s cranial nerves.
List the cranial nerves.
Give a brief description of how you would assess the olfactory and facial cranial nerves?
Why do you think it…