Nursing Head To Toe Assessment

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Student 1- You are the client. You are alone in your hospital room due to a stroke leaving you with right sided weakness. You attempt to get out the bed to go to the restroom when you fall upon attempting to stand. The call light is out of reach and you are unable to call for help due to global aphasia. You have soiled yourself and are to remain in the floor until the nurse arrives. Feel free to ad lib responses to nurse’s questions upon her arrival.
Student 2- You are the registered nurse. You come into the patient’s room and find the patient on the floor, soiled. You press the call light for the CNA to come and assist you, followed by conducting a head to toe assessment. You ask the patient how he ended up in the floor and if he is having any pain. You get the patient in the bed, change his soiled clothing/linen, and gesture for the aid to meet you in the hall. In the hall you ask the CNA if she was able to check on the patient during her hourly rounds. After listening to the CNA’s response, you state it …show more content…
You come to patient’s room and note he is in the floor and soiled. You assist the RN with getting the patient cleaned up and put back in bed. Upon being asked if you were able to complete your hourly rounds; you admit you were unable to complete the task because you were helping with a patient that was not assigned to you. You note you should have relayed to the nurse you would be in another room for an extensive time period and asked for the RN to look in on the patient’s for her. You are then called to the nurse manager’s office to recount the scenario.
Student 4- You are the nurse manager. The nurse and CNA have come to your office to recount the scenario and fill out an incident report. You review with the staff the importance of time management, policies and procedures to ensure patient safety, and effective communication. After the review you give the CNA a verbal warning and proceed to check on the

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