Head to Toe Assessment Information.
There is no obvious airway obstruction. There is normal elasticity of the skin. Her skin is cool and she is very sweaty.
She is breathing at 22 breaths per minute. The chest is moving equally.
Leopold maneuvers were performed. The fetus is in longitudinal lie in vertex presentation.
Vital signs:
Heart Rate: 114 beats
SPO2: 87
Radial pulse: 115
Blood Pressure: 168/100
Temperature: 90 degree
Skin: There is normal elasticity of the skin. Her skin is cool and she is very sweaty.
Pain scale: 4 on a scale of 0-10
Pain Location : Right Cross her forehead. Does not want anything for pain.
Neurological Assessment: The patient is conscious. The muscle strength and sensation are normal, but the deep tendon reflexes are Hyperactive graded to +4. The patient shows signs of clonus.
Cardiovascular: The IV site has no redness, swelling, infiltration, bleeding, or drainage. The dressing is dry and intact.
Infusion of 125ml Lactated ringer.
Carotid pulse 115 beats per min.
GI: The bladder contains 130ml of urine.
Uterus and fetus assessment: Fetal heart rate of 156 beats per min.
This is some information on my client I will send more if needed and examples.
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