You check on Robert to undertake routine post CVA assessments and note the following:

Altered conscious state, GCS 10

Temperature: 35.1 and cool on palpation

Pulse: 65 bpm and irregular

Blood Pressure: 196 / 120 mmHg

Respiration: 14 bpm

SpO2: 96% on room air

Pain scale using Baker Wong pain scale indicates no pain.


Question 2: Discuss TWO specific nursing assessments that should be PRIORITY for


deterioration (excluding vital signs).

For EACH nursing assessment, ensure your discussion

includes a description of the undertaking of each assessment in the context of


condition AND

clear rationale as to why these assessments would be priority