.
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
Robert’s
deterioration (excluding vital signs).
For EACH nursing assessment, ensure your discussion
includes a description of the undertaking of each assessment in the context of
Robert’s
condition AND
clear rationale as to why these assessments would be priority
.
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