Head-to-toe assessment | Nursing homework help
Introduction Head-to-toe assessment is a comprehensive examination that enables a nurse to collect essential information regarding a patient’s health status. It involves assessing each body system for normal and abnormal findings and determining the client’s overall health status. This paper discusses a hypothetical patient, John Smith, who has two systems issues. A detailed review of each system with normal and abnormal findings will be provided using the head-to-toe assessment template. The paper will also include information on how to conduct an assessment for a system that cannot be examined due to lack of equipment. Normal laboratory findings for the client’s age, age-specific risk reduction health screening, and immunizations will also be analyzed. Two differential diagnoses associated with possible abnormal findings will be discussed, followed by a plan of care, pharmacological treatments, and client and age-appropriate evidenced-based practice strategies for health promotion.
System Being Assessed The patient, John Smith, will undergo a head-to-toe assessment, including the following systems:
- Integumentary System
- Musculoskeletal System
- Gastrointestinal System
- Cardiovascular System
- Respiratory System
- Nervous System
Detailed Review of Each System with Normal and Abnormal Findings
- Integumentary System The assessment of the integumentary system involves examining the skin for color, temperature, turgor, moisture, and lesions. In the case of John Smith, the skin was intact, and there were no visible lesions. The skin was pink, warm, and dry, with good turgor.
- Musculoskeletal System Assessment of the musculoskeletal system involves inspecting the patient’s posture and gait and palpating muscles and joints. During the assessment, John Smith reported pain in the joints of his right leg. There was no visible swelling or deformity, but there was tenderness on palpation.
- Gastrointestinal System The assessment of the gastrointestinal system involves auscultating bowel sounds, palpating the abdomen, and inspecting the anus and rectum. In the case of John Smith, bowel sounds were present in all quadrants, and the abdomen was soft and non-tender on palpation. Inspection of the anus and rectum did not reveal any abnormalities.
- Cardiovascular System Assessment of the cardiovascular system involves auscultation of heart sounds, palpation of pulses, and inspection for edema. During the assessment, John Smith had a regular heart rate of 80 beats per minute, with no murmurs or extra sounds. Pulse was palpable in all extremities, and there was no edema in the legs.
- Respiratory System Assessment of the respiratory system involves inspecting the chest, auscultating breath sounds, and measuring oxygen saturation. During the assessment, John Smith’s oxygen saturation was 97%, and there were no abnormal breath sounds. The chest was symmetric with good excursion.
- Nervous System Assessment of the nervous system involves assessing mental status, cranial nerves, and motor and sensory functions. During the assessment, John Smith was alert and oriented with intact cranial nerves. Motor and sensory functions were also normal.
Assessment for Systems Without Equipment If equipment for assessing a particular system is not available, there are alternative methods to assess it. For example, if a stethoscope is not available to assess lung sounds, the nurse can use tactile fremitus to assess the lungs. The nurse places the palm of their hand on the patient’s chest and asks the patient to say “99.” The vibrations felt on the chest indicate the presence of lung sounds.
Normal Laboratory Findings for Client Age Normal laboratory findings for John Smith’s age, which is 45 years, include:
- Blood glucose levels