Head To Toe Assessment

Hi Terry. Nice initial post and I enjoyed reading it. I learned to gather my data accurately and perform the head-to-toe assessment thoroughly. The data that we gather during assessment should be factual and complete to provide diagnostic reasoning, decisions, and proper treatments for patients (Jarvis, 2012). I definitely agree with you, the Shadow Health Assessment with Ms. Tina Jones was also my biggest moment from this course. She was surely challenging, but I would say it was worth it. The comprehensive assessment was difficult and I spent hours in order for me to complete the assignment. I enjoyed doing the assessments of each system. I learned the importance of documenting accurately, clearly, and concisely. In addition to that, the

The head to toe physical assessment is the first step of the nursing process and is a systemic approach of collecting objective (physical) and subjective (mental) data on the patient that will help the nurse formulate nursing diagnoses and plan patient care. It is also used to confirm or question data that was stated in the pt. previous history stated in the charts and to evaluate the effectiveness of the nursing interventions that were carried out on the patient. The main focus of the head-to-toe assessment is to focus on what the patient is currently presenting with; the patient's responses to actual or potential problems.

M.C. is a 4 week old Caucasian male and was assessed on 2/3/2015. M.C. was awake and crying in his mother’s arms. He appeared to be well-nourished, well developed and in distress. M.C.’s mother stated his full name and date of birth, which matched his ID band. His mother was sitting in the hospital bed holding him in her arms and attempting to comfort him. His father was laying on the couch in the room. A complete head to toe assessment was not done during this time but the following results were obtained based on a focused assessment. M.C. was on contact-droplet isolation. M.C. had a temperature of 37.2C, his blood pressure was 33/47 with a MAP of 68 taken on his left leg. His respirations were 40 breaths per minute with an oxygen saturation of 100%. His pulse was 178 beats per minute. M.C. was on room air and had a PIV located in his left hand. There was no presence of tubes or drains. Pain was not assessed at this time however, M.C. was fussy and crying. The anterior and posterior fontanels were inspected. The anterior fontanel was soft and flat. M.C.’s lung sounds were clear to auscultation. His mother reported that he had some nasal congestion but had no

Moving further into the physical assessment I’d inspect the integumentary system for indications of cyanosis, or pallor, I’d also not mucosa membranes, and nail beds including capillary refill. I’d auscultate all lung lobes for adventitious sounds, percuss to determine if there the appropriate resonance or an abnormal finding that would warrant further assessment. Palpating for crepitus, tactile fremitus, or tenderness also aid in identifying underlying lung complications. Noting if the patient has sputum production is also helpful in identifying the cause of dyspnea, it is important to inspect produced sputum and possibly collect for further lab testing (Ignatavicius & Workman,

The primary assessment of this patient is the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. According to the ABCDE approach, it is crucial to check the airway first to see if the airway is patent. Then, check the patient’s breathing. Determining the respiratory rate, inspecting movement of the chest wall, measuring pulse oximeter and using the stethoscope to auscultate the lung sounds are the possible way to check if the breathing of the patient is sufficient (Thim et al., 2012). Next, check the circulation. Skin changes, such as check the colour and sweating, relate to the circulatory problems. Also, heart auscultation, blood pressure measuring and electrocardiography monitoring should be involved in this procedure (Thim et al., 2012). When measure the blood pressure, using the AVPU score (A for ‘alert’, V for ‘reacting to vocal stimuli’, P for ‘reacting to pain’, U for ‘unconscious’) to assess the consciousness, which is for the disability part. Moreover,

I enjoyed reading your post. I agree that when conducting a comprehensive assessment, it depends on what area of the hospital you work in. I work in the PACU, assessing a patient is much different than when I worked in the ICU. When I worked in the ICU, I would gather the necessary information from the ED and conduct my initial assessment based on prior documentation. I would do a complete head to toe assessment and physical assessment. For example, assessing a patient’s skin completely for pressure ulcers was mandatory. Working in the PACU, our patient usually receives a telephone interview prior to their surgery, which entails obtaining medical and surgical history, medication, support systems, allergies, living arrangements, etc.

Our initial evaluation includes assessment of vital signs, assessment of the cardio-pulmonary status including work of breathing, breath sounds, perfusion, and pulses for circulatory assessment (Jevon, 2012, p. 193).  Assessment of consciousness, using the paediatric Glasgow Coma Scale (GCS) (ANZCOR, 2016), Level of consciousness using Alert, Verbal, Pain, Unresponsive scale (AVPU) (Jevon, 2012, p.194). Neurological observations, EDOES and CEWT to determine deterioration (PMH, 2013).

Considering the issues mentioned in criteria 1, the examinations might be Physical Examination, laboratory tests, ECG, CVP, x ray, CT, US.

Before the head-to-toe examination, a health history was obtained from the patient, in which a detailed

Thinking back to when I have done a health history I have luckily had good experiences. As a nurse I do not have much to compare to but I have had a dew admissions where I have obtained a health history. For one I can remember the patient was not verbal. He was in his 60’s and had multiple CVA’s. His 87 mother took care of him, along with his medications, doctors’ office and any car he needed. She had great family support with her other children so this made it a lot easier for her. At first when I received report from the ED that the patients mother would be providing the health history and medication history I was worried but I was wrong. The patient’s mother knew, off the top of her head, exactly what medication her son was on. To

to the motor and neurological development. A therapist will use several standardized test depending on

I agreed with you how we an as nurses help the different culture people. I can understand we can make a best care plane if we know the patient culture and beliefs. Otherwise patient and family member could not understand the way of our education. You told as nurses need to do head to toe assessment with personalized care plan. But here is my thinking before assessment we need to judge the patient if he ready or not , Because some different culture people doesn't like if anybody touch them . Before any assessment as nurses we need to check the cultural background and then discuss with the patient and family members about the assessment. And all health worker needs to know about the patient culture and language

Detailed evaluation of feet is mandatory. Assessment of digital pulses, temperature and appearance of feet, and quality and integrity of feet should be made. The coronary band should be checked for the presence of edema, sinking areas, or tender areas. The shape and position of the sole should be assessed for any abnormalities. All of these should be summed up and assessed to come up with the best podiatry program.

A physical examination such as a head to toe assessment helps in identifying clues to poor nutrition status. George had no significant abnormalities of major body systems. Hair was well distributed , skin was intact with no lamp. Lung and heart sounds were normal. Abdominal Inspection, auscultation, palpation,and percussion were normal . Respiratory rate was 15 whereas his pulse rate was 92 . Blood pressure was 130/84mm Hg.

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that