Toe Head To Toe Assessment

○ Confirmation of diagnosis is made by radiographic examination of the skull (i.e., MRI of the head)

The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.

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

Mrs. Baker’s immediate assessment would include ensuring a patent airway, adequate breathing and circulation, and a brief neurological status. Once the immediate assessment is complete then a secondary assessment is conducted that includes a full set of vital signs with focused adjuncts, pain control, a full head-to-toe assessment with a patient history.

In other words, it can defined also as the series of questions the clinician ask to the client about each organ system or the body part during the first interview (history) and the physical examination to reach to the most appropriate findings about the client’s medical history and presenting illness. Example of the questions: the examiner can determine the history of fatigue, travel to other countries or the environment, any change in the lifestyles, any signs of fever or weight change. Moreover, the clinician can ask about the patient’s family; who live with the patient?, what is the patient’s relation with whom who s/he lives with?, and is s/he happy in his/her family?. Also can ask the patient about his/her hobbies and interest, does s/he have pets, does s/he exercise daily? And so

SEIDAL, H, M., BALL, J, W., DAINS, J, E., BENEDICT, G, W. (2006) Mosby’s Guide to Physical Examination. 6th edn. Philadelphia: Elsevier.

Physical exam: The doctor will exam the patient’s problem joints and observes the patient walking, bending, standing and sitting abilities.

Comprehensive assessments are fundamental in high acuity nursing as it allows nurses to establish a baseline for the patient, determine oxygen supply and demand, provide individualized patient care, and make clinical decisions (House-Kokan, 2012). The components of a comprehensive assessment, including a physical assessment, corroborative diagnostic data, and the family issues will be assessed (House-Kokan, 2012).

A head to toe assessment is the visual and manual inspection of each body part starting at the head and scalp and continuing downward to the feet and toes. These four techniques will be used: Inspection=what can be seen, Palpation=what can be felt, Percussion=what can be heard and Auscultation=what can be heard using a stethoscope. It is very important to perform a complete head to toe assessment on all patients at the beginning of the shift as this information will help determine if the patient is getting worse or starts having any unforeseen problems.

Sutures in the in skull fuse prematurely causing the patient to have a short, wide head with bulging eyes that are wide-set. The shallow eye sockets cause strabismus (the eyes to point in different directions). Because the skull is wider than normal the patient will have a beak-like nose and an underdeveloped upper jaw. This causes dental problems and can also contribute to hearing loss. In a normally developing individual, the eyes start lower on the head and move upwards as the child grows. With Crouzon patients, this is interrupted and the ear canals can become malformed. The chin will protrude and make the child look as if it has a concave face. The patient may also have a cleft palate or lip.

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.

One of the most effective ways to learn about the various types of head or face defects is by joining a group that promotes craniofacial information and general knowledge. It is also in these groups that patients having such defects would not feel judged and criticized, giving them hope and realizations by knowing that life is not so bad after all.

It is a bit difficult to coordinate the typed questions along with the physical assessment. However, I understand the concept of the experience is to learn how to complete a health assessment, as well as assess the patient’s

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

ing. It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a “general survey.” (Specific data to consider for the general survey are presented in Chapter 9.) As you proceed through the examination, start the assessment of each body system with inspection.