Head To Toe Assessment For This Assignment Perform A Complet ✓ Solved
Head To Toe Assessmentfor This Assignment Perform A Complete Head To
Perform a complete head-to-toe assessment on someone of your choice or a hypothetical person who has at least two systems issues. Document your assessment using the provided template, adding additional lines as necessary. The paper should be 4-5 pages in length, formatted in APA style, excluding the title and references pages. Discuss each of the following criteria: the system being assessed; a detailed review of each system with normal and abnormal findings, including assessment methods for systems without equipment; normal laboratory findings for the client’s age; an analysis of age-specific risk reduction health screening and immunizations; two differential diagnoses related to abnormal findings; a plan of care with two priority nursing diagnoses, interventions, and evaluation; pharmacological treatments for identified health issues; and client- and age-appropriate evidence-based strategies for health promotion. Include a separate references page citing all sources in APA format.
Sample Paper For Above instruction
Introduction
Performing a comprehensive head-to-toe assessment is fundamental in nursing practice, allowing healthcare providers to gather essential information about a patient's overall health status. This assessment guides diagnosis, plan of care, and intervention strategies. This paper details a complete assessment of a hypothetical 65-year-old male patient experiencing hypertension and mild COPD, highlighting normal and abnormal findings, relevant laboratory data, age-specific screening practices, differential diagnoses, and care planning.
System Being Assessed
The primary systems evaluated include the cardiovascular, respiratory, neurological, gastrointestinal, musculoskeletal, and integumentary systems. The patient’s presenting issues involve elevated blood pressure and breathing difficulties, indicating potential cardio-respiratory system concerns.
Detailed Review and Findings
Cardiovascular System
Normal findings include a regular heartbeat, normal heart sounds (S1 and S2), and no edema. Abnormal findings discovered are elevated blood pressure readings (140/90 mmHg) and a grade II systolic ejection murmur auscultated at the aortic area. Assessment involved palpation of carotid pulses, auscultation, and checking for peripheral edema.
Respiratory System
Normal findings encompass a respiratory rate of 16 breaths per minute with symmetric chest expansion and clear breath sounds. Abnormal findings include mild wheezing heard during auscultation and a history of shortness of breath on exertion. The assessment included inspection, palpation, percussion, and auscultation.
Neurological System
Normal findings involved alertness, oriented x3 (person, place, time), and normal reflexes. Abnormal findings included reports of occasional dizziness and slight memory lapses, which warrant further investigation.
Gastrointestinal System
Normal assessment showed soft, non-tender abdomen with normoactive bowel sounds. No abnormal findings were noted, but assessment would include inspection, auscultation, palpation, and percussion. For systems lacking equipment, palpation and visual inspection suffice.
Musculoskeletal System
Normal findings included full range of motion and no joint swelling or deformities. Abnormal findings included decreased muscle strength (4/5) on the right side and mild kyphosis.
Integumentary System
Normal findings include intact skin with no lesions or ulcers. Abnormal findings involve dry, mottled skin consistent with dehydration or poor circulation.
Normal Laboratory Findings for Patient's Age
Laboratory results expected in a 65-year-old male include lipid panel showing controlled LDL and HDL levels, fasting blood glucose within normal limits, and stable renal function tests (creatinine and BUN). Routine CBC may show mild anemia common in this age group.
Age-specific Risk Reduction and Screenings
Screenings for this age include blood pressure monitoring, cholesterol screening, colonoscopy every 10 years, and annual mammograms (if applicable). Immunizations should include influenza, pneumococcal, and shingles vaccines, as recommended by current guidelines to reduce infection risk.
Two Differential Diagnoses
1. Hypertension secondary to arterial stiffness and lifestyle factors.
2. Chronic obstructive pulmonary disease (COPD) exacerbation possibly related to smoking history.
Plan of Care
Priority nursing diagnoses include:
- Ineffective tissue perfusion related to hypertension.
- Ineffective airway clearance related to COPD.
Interventions for hypertension include antihypertensive medication adherence, dietary modifications (DASH diet), and regular blood pressure monitoring. For COPD, interventions involve smoking cessation counseling, bronchodilator therapy, and oxygen therapy if needed. The evaluation involves monitoring blood pressure control and respiratory status improvements.
Pharmacological Treatments
Medications such as ACE inhibitors or thiazide diuretics can be used for hypertension management. Bronchodilators (e.g., albuterol) and inhaled corticosteroids are prescribed for COPD.
Evidence-based Strategies for Health Promotion
Patient education focusing on medication adherence, nutritional counseling, smoking cessation, regular exercise, and vaccination are crucial. Incorporating motivational interviewing techniques promotes better health behaviors, and community resources can support lifestyle changes.
Conclusion
A thorough head-to-toe assessment provides a comprehensive overview of the patient's health, facilitating early detection of issues and personalized care planning. Addressing abnormal findings through targeted interventions can improve health outcomes, especially in older adults with chronic conditions.
References
- American Heart Association. (2022). Guidelines for the management of hypertension. Circulation, 145(5), e387–e388.
- GOLD Scientific Committee. (2023). Global strategy for the diagnosis, management, and prevention of COPD. GOLD Reports.
- Jarvis, C. (2019). Physical examination and health assessment (8th ed.). Elsevier.
- McPhee, S. J., & Detmer, D. E. (2019). Current diagnosis & treatment: Family medicine (6th ed.). McGraw-Hill.
- National Institute on Aging. (2023). Healthy aging: Strategies and recommendations. NIA Publications.
- O'Hara, M. (2021). Laboratory values in the older adult. Journal of Geriatric Nursing, 42, 14-20.
- U.S. Preventive Services Task Force. (2022). Recommendations for screening and immunizations. USPSTF Reports.
- World Health Organization. (2023). Ageing and health. WHO Publications.
- Williams, B., Mancia, G., et al. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal, 39(33), 3021-3104.
- Yoon, S. Y., et al. (2020). Chronic obstructive pulmonary disease: Epidemiology, management, and prevention. The Lancet Respiratory Medicine, 8(1), 24-36.