Perform a complete head-to-toe assessment on one of your chosen participants. Yo

Question

Perform a complete head-to-toe assessment on one of your chosen participants. 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, along with normal laboratory findings for client age.

An analysis of age-specific risk reduction, health screen, and immunizations.

Your expectation of normal findings and what might indicate abnormal findings in your review of systems.

The differential diagnosis (disease) associated with possible abnormal findings.

A plan of care (including nursing diagnosis, interventions, evaluation).

Client and age-appropriate evidenced based practice strategies for health promotion.

Pharmacological treatments that can be used to address health issues for this client.

Explanation / Answer

A head to toe assessment involves the following.

Head, face and neck

1. Performing cognition test

2. Observing LOC(level of consciousness)

3. Sensory function

4. Vision

5. Cranial nerves

6. Hearing

7. Inspecting lymph nodes and neck vein

Chest

1. Inspecting though palpation of breast/chest

2. Inspecting lungs and heart through auscultation and percussion.

Abdomen

1. Inspecting through auscultation and palpation of four quadrants

2. Inspecting stomach, liver, and bladder through palpation and percussion

3. Status of bowel movement and urinary excretion

Skin, hair and nails

1. Inspecting scalp, hair, and nails

2. Evaluating skin turgor

3. Observing skin lesion

4. Assessing wound

Genitalia

Inspecting clients according to gender

Extremities

1. Palpating arterial pulses

2. Evaluating edema

3. Assessing joint mobility and strength

4. Assessing sensory function, and circulation movement

5. Assessing deep tendon reflexes

Various phrmacological treatments for different problems can be prescribed such as for lungs related bronchodillator; for heart and BP related beta-blocker, ACE inhibitors and statins; for abdomen antispasmodic, ursodiol, lactulose and for neurological problems clonazepam, and other sedatives can be used.

References

1. Joshi, S. (2012). Nursing assessment. Health & Medicine, Entertainment & Humor. Retrieved from https://www.slideshare.net/ShaellsJoshi/nursing-assessment-13173390

Normal findings Abnormal findings For head, face, and neck it will be an awake, alert, and oriented mental status along with intact memory; lymph nodes will be firm, tender/non-tender, and enlarged; all 12 cranial nerves like oculomotor, olfactory, optic, trochlear, trigeminal,abducens, vestibulocochlear, glossopharyngeal, vagus, accessory, and hypoglossal in perfect condition. Altered mental status like forgetfullness and mood swing; normal size of lymph node; problems with cranial nerves like reading, smelling, rolling of tongue,etc. For chest through palpatiion no pain of thorax; through percussion dull and tympanitic sound; and through auscultation non-adventitious sounds, and normal rhythm for heart. For chest through palpation bulging or retraction, scars and tenderness or pain of thorax; through percussion flat and dull; and through auscultation adventitious sounds, and abnormal rhythm for heart.
Normal arteria flow, pitch, frequecny through auscultation; mix of dull and tympanitic through percussion; no feeling of pain and masses. Hurried flow, increased frequency and pitch through auscultation; tympanitic sound through percussion; pain and mass type feeling on palpation. Normal, firm and pink nail. Palor and brittle. Normal pulse, no edema and proper circulation and movement. Raised or reduced pulse, edema, and stiffening.

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