Head To Toe Assessment Paper

By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)

Comprehensive assessments is the most valuable piece which allows Nurse Practitioners to know about the health risks, strengths and needs of their patients. Furthermore, the comprehensive assessment strengths the relationship between the Nurse Practitioners and their patients. From clinician-patients relationship, it helps a complete assessment to answer patients questions which in the long run help to achieve measurable goals and provide quality outcomes to the patients. Nurse Practitioners use comprehensive assessment approach to analyze, interpret, implement and follow up care to ensure their patients receive appropriate care and prevent inappropriate diagnosis. Comprehensive assessment is where the patients are encourage to

It can sometimes be too late. I have learned over some years by watching those that mean a lot to me let their lives become of nothing because they do not worry about their physical appearance or the foods that they eat, and even though you can give them all the advice to try and persuade them they are determined to do what they feel and what they want to do.

The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient 's complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

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.

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

This essay sets out to discuss the importance of comprehensive and accurate assessment on a registered nurses’ ability to make excellent clinical decisions. It will examine what factors can change a nurses’ capability to be aware of, and act on abnormal assessment findings. As well as assessment being part of the nursing process that is used in every day nursing, it is also a critical part of patient safety (Higgins, 2008). Assessment findings are used to determine what needs to be done for the patient next. Early warning scoring systems currently exist to aid in the early detection of patient deterioration (Goldhill, 2005). The rationale for the use of these systems is that early recognition of deterioration in the vital signs of a

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

Goodman and Snyder (2013) states that according to the Guide to Physical Therapy Practice, “the Systems Review is defined as a “brief or limited exam of the anatomic and physiologic status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems” (p.20). The System Review is completed as the examination and assesses communication and cognitive ability, affect, language and learning style (Goodman & Snyder, 2013). The Review of Systems (ROS) looks at the history and clinical presentation for conditions that may point to systemic disease and is completed after conducting an interview and assessment of pain. (Goodman & Snyder, 2013). The systems review looks at the “whole person” while the ROS looks at possible symptoms of systemic disease (Goodman & Snyder, 2013). In other words, the System Review briefly exams the health status of a system. The ROS looks for a cluster of symptoms and signs that may point to a systemic disease. The Systems Review is more in line with what a physician would check in a basic exam. In the ROS, the therapist may uncover information that a patient has forgotten or does not think is important (Goodman & Snyder, 2013). The Systems Review checks for specific information during an examination. The ROS is a way for a therapist to determine if a cluster of signs should initiate a referral to a physician for further analysis (Goodman & Snyder, 2013). Therapists do not identify a specific disease in an ROS; however after classifying the clusters may determine a problem outside the scope of practice. (Goodman & Snyder, 2013). The physician may begin with a Systems Review when the patient is referred back with the addition of the cluster signs found in the Review of

Assessment is a key component of the nursing practice. It is required when planning and providing patient care. Nurses assess plans and then implement and evaluate nursing care in collaboration with a multidisciplinary health care team to achieve goals and health outcomes for the patient. The focused assessment is the detailed nursing assessment of body systems relating to the presenting problem or current concern of the patient.

The second area is for the nurse to fill in. do they have a secondary diagnosis?

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

Introduction: A long-term degenerative neurological condition (LTDNC) is a term used to describe diseases that affect the nervous system leading to its degeneration. Conditions such as Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis etc. are all categorized by impairment in brain, nerve and spinal cord pathway cells (Canadian Institute for Health Information, 2007). Due to such disruptions, the nerve signals between the brain and the body are affected which result in problems with walking, controlling movement, balance, full or partial paralysis, breathing and talking problems, occurrence of seizures, lack of bladder and bowel control at later stages, and even problems with the heart (Canadian Institute for Health Information, 2007). In 2011, the Canadian Institute for Health Information reported that Canada has one of the highest incidences of multiple sclerosis (MS) in the world, where approximately 93,500 individuals are currently affected. Despite the prevalence of the disease, there is still much that remains unknown. According to the 2012 statistics from the ALS Society of Canada, the number of new diagnoses per year is

Nursing is a complicated profession requiring a broad knowledge base, discipline, and a deep desire to understand and interpret scientific data with a goal of obtaining the best possible patient outcomes. This can be very difficult to achieve, requiring the nurse to process a variety of information, prioritize, and problem solve at a critical level (Wilkinson, Treas, Barnett, Smith, 2016). The nursing process is a scientific approach, utilized by nurses to systematically improve patient care by following five steps: assessment, diagnosis, planning, implementation, and evaluation (Wilkinson et al., 2016). A good nurse is someone who understands these phases, continues to build on them, and uses the information to create the best possible, individualized, healthcare plan for the patient. It is a mastery of art to find a way to include all of these concepts with so many diverse medical diagnoses. Having a structural way, such as the nursing process, paves a strong foundation for the nurse to maintain a patient centered approach to implement exceptional nursing care (Goncalves, Spiri, Ortolan, 2017).