The Head to Toe Assessment

2229 Words Jan 11th, 2014 9 Pages
The Head to Toe Assessment
Principles of Assessment for RN’s

Edward is a 45 year old male who is present today for his Annual Physical Examination. He is asymptomatic and has no complaints.
Subjective:
History: The patient has a history of Chicken Pox at 5 years old. He has been a smoker for 25 years and currently smokes 2 packs a day. He consumes alcohol daily 2-4 glasses of wine. He reports of history of depression and anxiety 3 years ago after separating from his wife. His is not currently on any medications. He also has a history of a positive TB skin test with no active disease. The patient spent 15 years in the military traveling overseas. He had right rotator cuff surgery 10 years ago.
Objective: Head to toe Assessment:
…show more content…
If I had an ophthalmoscope I would use it to inspect the Ocular fundus: red reflex, disc, vessels and retinal background which could give a preview to diseases such as Glaucoma. There is some yellowing of the sclera
The extra ocular muscles which are stimulated by cranial nerves III,IV and VI and allow for voluntary movement of the eye was tested by holding a pencil up and having Edward follow the movement of the pencil with his eyes. Cranial or eye muscle damage was not evident since he was able to move the eye downward and inward straight and rotary movement (Jarvis, 2012). The external eye structures are intact with no lesions; there is no drainage from the lacrimal gland.
Ears
There is no mass, lesions scaling, discharge or tenderness on palpation of the Pinna. The tympanic membrane would be inspected with an otoscope, if I had one. I would expect the normal membrane to be gray, with no discharge. Whispers were heard bilaterally with no difficulty.
Nose
No external lesions noted, although he does have some facial acne. Cranial nerve VII seems to be intact since the cheeks, lips and eyebrows are symmetric bilaterally. Nares are patent as evidenced by good air passage on both sides when the other side is closed. The internal mucosa is pink with no lesions or tenderness. There is no tenderness in the maxillary sinuses.
Mouth and Throat
The mucosa and gingivae are pink, no lesions or bleeding.

More about The Head to Toe Assessment