Head-To-Toe Assessment

Head-to-Toe Assessment
Head-To-Toe Assessment
You have performed assessments of different parts of the body as part of your application assignments. For this assignment, perform a complete head-to-toe assessment. Your analysis should include the following:
Topical headings to delineate systems.
For any system for which you do not have equipment, explain how you would do the assessment.
Detailed review of each system with normal and abnormal findings and include normal laboratory findings for client age.
An analysis of age specific risk reduction health screen and immunizations.
Your expectation as normal findings and what might indicate abnormal findings in review of systems.
The differential diagnosis (disease) associated with possible abnormal findings.
A plan of care (include nursing diagnosis, interventions, evaluation).
Provide your answers in a 3- to 4-page Microsoft Word document.
Support your responses with examples.
Cite any sources in APA format.
Basics of Assessment from Head to Toe
Types of Evaluations
According to Zucchero, there are numerous types of assessments that can be undertaken.
A complete health assessment is a thorough examination that includes a detailed health history and a thorough head-to-toe physical examination.
For patients admitted to the hospital, or in community-based settings such as initial home visits, this type of assessment can be undertaken by registered nurses.
Complete assessments are also performed by advanced practice nurses, such as nurse practitioners, during annual physical examinations.
A problem-focused assessment is one that is conducted with specific care goals in mind.
A nurse who works in the ICU and a nurse who does maternal-child home visits, for example, have different patient populations and nursing care goals, according to her.
These examinations are usually focused on a single body system, such as the respiratory or cardiac systems.
While it is vital to assess the complete body, there is typically not enough time to do so.
Length of Evaluation
According to Ferere, the length of the exam is directly proportional to the patient’s overall health.
“Healthy patients with modest medical histories may be finished in under 30 minutes,” she explains.
“Many health offices require patients to fill out health history and pre-visit questionnaires before being seen for a comprehensive exam.
Reviewing these forms ahead of time can significantly reduce the amount of time required for the visit.”
How to Get Ready for the Exam
“Standard precautions (previously universal precautions) should always be used with each and every patient in a clinical setting to protect both the nurse and the patient,” Zucchero says.
“The major purpose of standard precautions is to prevent the exchange of blood and bodily fluids, which includes hand hygiene, the use of personal protective equipment, and the safe handling and cleaning of potentially contaminated equipment or surfaces,” according to the CDC.
Checklist of Required Equipment
According to Zucchero, the nurse may require specific equipment depending on the sort of examination performed.
The following is a list of essential equipment:
Thermometer Gloves
Cuff for measuring blood pressure
Watch sScale
Wall ruler for height
Penlight Stethoscope, tape measure
Additional equipment for more thorough inspections might include the following:
Otoscope
Ophthalmoscope
Hammer with a reflex
Depressor of the tongue
Sharp, sterile thing (like toothpick or pin)
Soft sterile item (like cotton ball)
Something olfactory for the patient (like an alcohol swab)
Starting an Evaluation
“It is critical to build a personal relationship of trust and respect between the patient and the nurse when commencing an assessment,” Zucchero explains.
She goes on to say that it’s crucial to monitor how the patient is doing throughout the examination and make sure they’re properly draped and comfortable.
“It’s also critical that an assessment is carried out in a systematic and efficient manner to avoid unwanted handling of the patient,” she added.
“The demands of the patient, the context of the examination, and the relationship with the examiner drive a head-to-toe assessment for new nursing graduates and nursing students,” Angela Haynes said.
“Knowledge about patient health needs, current health status, and patient goals for personal health outcomes, including health promotion and wellness counseling, is determined by this baseline examination,” she says.
What to Keep an Eye On
During an Evaluation
Zucchero emphasizes that being able to distinguish between normal and aberrant is a crucial ability.
Changes in normal respiration rate, which indicate respiratory distress, or a change in skin color, such as pallor, which may suggest anemia, or jaundice, which often signals liver problems, are examples of severe aberrant findings.
In general, the human body is symmetrical on all sides.
Make a note of any unexpected asymmetry when examining a patient.
There could be an underlying neurological or musculoskeletal issue if a patient is weaker on one side than the other, has a limited range of motion, or one side appears limper or otherwise different from the other side.
Developing a Relationship with the Patient
According to Zucchero, the nurse must always introduce oneself to the patient, double-check that they are with the correct patient, and explain what they will be doing.
Before beginning the physical aspect of the exam, Ferere recommends starting with a review of documentation and building a relationship.
It’s also a good moment to discuss the patient’s personal preferences for undressing for the exam, as well as lighting requirements, room temperature, and any pain or discomfort.
“For added comfort, the patient may wish to have another person in the room during the test.”
When possible, this should be permitted.
“For any invasive procedures, policies are normally in place to support the presence of a witness,” she says.
A constructively engaged patient visit may not be performed in the same order as a combative or confused patient, according to Ferere.
Engaging the patient early in the visit enhances the possibility that the patient will take greater responsibility for his or her health status and ongoing requirements.
Display Nursing Programs for Me
Pay close attention to the patient’s nonverbal cues.
According to Ferere, these indicators can include grimacing during ambulation, grunting during movement, or making touch with a body system.
“It could also be aversion to making eye contact or a hesitation to respond to questions,” she says.
“During the visit, the nurse must pay close attention to what the patient says and does not say.
During patient visits, nurses frequently serve as detectives, piecing together various facts, talks, and health histories.”
Sequence of Assessments from Head to Toe
According to Ferere, the sequence is determined by the examiner’s preference.
It usually starts with the least intrusive and progresses to the most invasive, giving the patient time to get used to the examiner.
It also increases the chances of the examiner forgetting a system throughout the exam.
“The first thing to remark during an examination is the patient’s overall appearance or general state,” Zucchero explains.
“Alertness, health/comfort/distress, and respiration rate are all factors to consider.”
This is done even before vital signs are taken.”
The Steps in a Head-to-Toe Evaluation
1. Overall Health Vital Signs
heartbeats per minute
Temperature and blood pressure
Pulse oximetry is a method of measuring the oxygen saturation in the blood.
The rate of respiration
Pain
2. Ears, Eyes, Nose, and Throat
Look at the color of your lips and how moist they are.
Examine your teeth and gums.
Examine the mucosa of the mouth and the palate.
Tongue Examine
Look at the uvula.
Look at your tonsils.
Examine the symmetry of your nose by palpating it.
Examine the septum and the insides of the nostrils.
Ensure that the nares are in good working order.
Examine the patient’s olfactory sensibility.
Sinuses palpate
Using a whisper test, assess the patient’s hearing.
Weber’s and Rinne’s tuning fork tests
Examine the inside of your ear
Examine the tympanic membrane and ear discharge.
Examine the conjunctive and sclera.
Examine your eyes for symmetry.
PERRLA
Snellen Chart is a tool that can be used to check your vision.
Examine the six cardinal gaze positions.
3. Examine lymph nodes in the neck
Examine and palpate the trachea and the neck.
Jugular Venous Distention should be checked.
Examine your neck’s range of motion.
Examine your shoulder shrug for resistance.
4. Respiratory Listen to the sounds of the lungs from the front and back.
Determine the extent of respiratory expansion.
Inquire about coughing.
Thorax palpate
5. Cardiac arrest
bilaterally palpate the carotid and temporal pulses
Pay attention to your heartbeat.
6. Examine your abdomen
Listen for bowel noises in four quadrants of the abdomen.
Check for discomfort or tenderness in each of the four quadrants of the abdomen.
Inquire about gastrointestinal or bladder issues.
7. Pulses Check the pulses in your arms, legs, and feet, including the Radial Femoral pulse.
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Extremes (nine)
Examine the range of motion and strength of the arms, legs, and ankles.
Examine the acute and dull sensations in your arms and legs.
Capillary refill on fingernails and toenails should be checked.
9. Examine the turgor of your skin.
Examine your skin for lesions, abrasions, and rashes.
Tenderness, lumps, and lesions should all be looked for.
Examine the patient to see if they are pale, clammy, dry, cold, hot, or flushed.
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Examine your gait and coordination.
Evaluate your reflexes
Examine your Glasgow Coma Scale score.