NSG 3012 Week 5 Head-to-Toe Health Assessment

You have performed assessments of different parts of the body as part of your application assignments. For this assignment, perform a complete head-to-toe assessment. 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 and include normal laboratory findings for client age.

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

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

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

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

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APPROACH TO HEAD-TO-TOE ASSESSMENT EXAMPLE

Physical examination is a medical examination by a healthcare professional to determine the individual’s health, identify risk factors for disease, and devise strategies for disease prevention. I conducted the physical examination of one my patient. Her name is Mrs. Rodriguez 48 years female. She came to the hospital due to shortness of breath, cough, and fever. When I took the health history, she stated that she has a past medical history of COPD and HTN. She stated that has lifestyle risk factors which include a 19 years history of smoking 3 pack of cigarettes a week and she also drinks half a bottle of vodka per day. She is working in a hotel as a sweeper. Her chief complaint is shortness of breath with exertion, productive cough and mild fever. No past surgical history. Family history includes mom has a history of HTN, HLD and breast cancer. Patient has no drug allergies. Patient home medicine includes Amlodipine 5mg BID, Symbicort inhaler. Before starting a physical examination, we have to gather all supplies or equipment include hand sanitizer, gloves, scale, stethoscope, thermometer, pulse oximetry, penlight, otoscope, tuning fork, tongue depressor, tape measure, reflex hammer, cotton ball, alcohol wipes, sphygmomanometer, and Snellen chart.

Techniques of Physical Assessment: NSG 3012 Week 5 Head-to-Toe Health Assessment

Inspection
Palpation
Percussion
Auscultation

GENERAL INSPECTION

Physical Appearance and Hygiene: patient appears unkept and odorous.
Body Structure and Position: patient looks malnourished, anorexic, with a barrel chest while sitting in a tripod position and performing pursed lip breathing
Body Movement: unbalance gait, slow walking, uncoordinated and trimmers noted
Emotional and Mental Status and Behavior: Patient alert and oriented to person, place time and situation. Patient displays anxiety and restless behavior by continuously pacing back and forth and tapping feet.

MEASUREMENT OF VITAL SIGNS, HEIGHT AND WEIGHT

= 101.4 ̊ F
Pulse= 110b/min
= 26/min
P= 146/92 mm of hg
Oxygen Saturation = 87% without oxygen
Weight = 95lbs and Height = 5’3”

INTEGUMENTARY SYSTEM (skin, hair and nails)

Inspection and palpation

First, I inspect the condition and distribution of body hair and the integrity of the scalp. I assess the hair I checked for distribution, thickness, texture, and lubrication of hair. I also inspect for infection or manifestation of the scalp. I examined her face to assess for blemishes and color while palpating her forehead to check for oiliness or a fever. Upon assessing her arms, I assess for cuts and bruises. I assessed the nails for shape, contour, consistency, color, thickness, and cleanliness. The back of her hand was used to assess for skin turgor while the palm was assessed for coolness. I inspected the trunk for discoloration or wounds such as sacral ulcers. Upon assessing the lower extremities, I inspected the skin for dependent edema, bruises, cellulitis, discoloration, dryness, weeping blisters or wounds such as ulcers.

Findings

Skin found dry and intact, no any redness, no any lesion or patches.
Hair is thin, brittle and dry.
Well hydrated and rise in temperature
Cyanosis of the nails, skin and lips due to hypoxia
Nail clubbing noted due to hypoxia
+1 pitting edema noted in lower extrimities.

ORDER NSG 3012 Week 5 Head-to-Toe Health Assessment

HEAD AND NECK

Head(inspection)

-I assess the skull for shape and size.

-Inspect for facial symmetry

Head(palpation)

Palpate the head with finger tips to find out Scars or abnormal bone structure, Injuries, trauma

Findings

Patients head is round in shape

and size. No any swelling,

Lesions, scars, injuries noted. Face is symmetrical.

Eyes (Inspection)

– I Inspected eyes for position and drainage. Infections.

– I Inspected eyes for pupillary reaction to light.

– Inspected for swelling of eyelids, color of sclera, discharge, redness, change in vision.

Eyes (Palpation)

I palpated the patient’s eyelids, eyebrow and lacrimal glands.

EOM test with my finger

Findings

-Both eyes are equal in size.

-Discharge not present, eyelid noted mild swelling. no bulges and drooping of eyelids.

-Sclera- clear white in color

-conjunctiva noted pink and moist.

Patient able to read newspaper without glasses.

EOM intact, and parallel tracking of object with both eyes noted.

Ears (Inspection)

I inspect the ear for External structures, internal canal and hearing (CN8)

Ears (Palpation)

I move the pinna and push on tragus. I palpate the mastoid areas for pain, gland swelling and infection.

I test auditory function by whisper test.

Findings

Patient’s ears noted symmetrical, no redness, no drainage.

Pinna and tragus feel firm, no pain noted.

Pt has no hearing loss.

Nose(Inspection)

–shape and size

– I inspected patients external nose structure, internal nares and drainage

Nose (Palpation)

-palpate the paranasal sinuses

-Assess patency for nares.

-Palpate for any nasal deviation, abnormal growth.

Findings

-Patient’s nose noted symmetrical and midline.

-Nostril are uniform in size -& do not flare

-No septum deviation, polyps and discharge noted.

Mucus membrane noted dark and pink.

Mouth(Inspection)

-Inspected patient’s lips, teeth, tongue and gums

-Inspected oral mucosa, palate, uvula, throat.

Mouth (Palpation)

-palpate the structure of mouth for any abnormality.

Findings

-lips, mucous membrane noted Dark, moist.

-Missing teeth bilateral and denture noted.

No any discharge but foul odor noted.

-Thrush noted on mouth due to Symbicort.

Neck(Inspection)

Inspected patient’s neck for appearance and position.

Inspect for Abnormal growth, scars, injuries and range of motion.

Neck(Palpation)

-patient’s neck palpate for anatomic structure, pain, tenderness, muscle strength, thyroid gland and lymph nodes.

Palpated carotid pulse bilaterally but can’t auscultate bruit without instrument

NSG 3012 Week 5 Head-to-Toe Health Assessment

Findings

-Trachea noted centrally located and neck full ROM, no pain, no injury, no stiffness.

-Thyroid glands not visualized and palpable.

-No swelling or lumps no distend veins no lymph node enlarges noted.

Carotid pulse pulsation bilateral.

RESPIRATORY SYSTEM/ CHEST

Inspection

I inspect my patient posteriorly thoracic cage, respirations and scapula location.
I inspect my patient’s anterior thoracic cage, respirations pattern, chest expansion, Rate and quality of breathing.

Palpation

I started Palpation from anterior and posterior chest wall to find out tenderness, symmetry, bulges and thoracic expansion.
I placed one hand posteriorly on each hemi thorax near the level of the diaphragm, palms facing anteriorly with thumbs touching at the midline.
I felt the texture and consistency of the skin over the chest and the alignment of vertebrae.
I checked for tactile fremitus – I tell the patient to say phrase ‘’99’ and repeat the phrase then I felt vibration through chest wall.
I Use both hands simultaneously to compare the two side of the posterior chest wall.
I Repeated the same procedure as used for the anterior chest wall.

Percussion

I start percussion with my right hand, so I stand a bit to the left side of the patient’s back.
I Ask the patient to cross her hands in front of her chest, grasping the opposite shoulder with each hand.
I Press the distal phalanx of the middle fingerfirmly on the area to be percussed and raise the second and fourth fingers off the chest surface;
I use a quick, sharp wrist motion to strike the finger in contact with the chest wall with the tip of the third finger of the other hand.
I percuss between the proximal and distal interphalangeal joints of patient

Auscultation

I tell the patient to sit in upright position and breathe deeply and slowly through mouth.
I used the diaphragm of stethoscope, auscultate breath sound in systematic manner over the posterior and lateral chest walls
I Listen carefully during inspiration and expiration and compare both chest side.
I heard vesicular breath sounds over the periphery of the lungs, bronchovesicular breath sounds over the main bronchi and bronchial sounds over the trachea.

Findings

– Noted Barrel chest and prolonged expiration.

– Noted patient has productive cough and respiratory rate 26 b/min.

– Breathing sound Noted wheezing and decreased breath sound bilaterally.

– Chest percussion: noted hyperresonance sound over the lungs

-Patient’s oxygen saturation noted 87% with pulse oximetry. If we don’t have pulse oximetry we can assess by patient’s color, difficulty breathing, retraction or bulging of the intercostal muscles.

Laboratory values to a respiratory systems assessment include an arterial blood gas (ABG). ABG measure the partial pressure of oxygen PAO2, carbon dioxide PACO2, bicarbonate HCO3, PH of the arterial blood and SAO2 oxygen saturation. Normal ABG value should be PAO2= 75-100mmhg, PACO2=38-48mmhg, PH = 7.38-7.42, SAO2=94-100% and HCO3 =22-28. PH low indicate acidosis and higher indicate alkalosis. My patient PH was 7.6, PAO2 was 55, PACO2 was 50. Sputum for AFB should check. My patient AFB is negative.

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CARDIOVASCULAR SYSTEM

Inspection

Cardiovascular system assessment begins with inspecting the patient appearance. I inspect patient’s cardiac system for distended jugular veins, any palpation, haves, chest pain and surgeries and edema.

Palpation

I Palpate the apical pulse of my patient by placing the fingertips over the apex of the heart of the 5^th intercostal space and left midclavicular line. I feel for heaves. And I checked capillary refill in bilateral lower and upper extremities.

Auscultation

I auscultated the patient’s heart sounds with the diaphragm in following areas.

Aortic valve area: – 2^nd intercostal space on right sternal border
Pulmonic valve area: – 2^nd intercostal space on left sternal border.
Erb’s point: – 3^rdintercostal space 0n left sternal border
Tricuspid valve area: – 4^th intercostal space on left sternal border
Mitral valve area: – 5^thintercostal space on left midclavicular line

I use the bell of the stethoscope to listen carotid artery for bruit.

Findings

Clients who have chronic obstructive lung disease have overinflated lungs, which may displace the pulse of maximum impulse downward and to the right (Swartz, 2006).
No surgical scars, heart murmurs, palpitation, heaves noted.
Patient’s heart rate noted fast 110b/min due to fever. And noted mild edema in bilateral lower extremities.
NSG 3012 Week 5 Head-to-Toe Health Assessment

Cardiac system laboratory includes Lipid Profile. Lipid profile measure the cholesterol, Triglyceride, high density lipoprotein cholesterol. HDL also known as good cholesterol and LDL is bad cholesterol. Normal adult total cholesterol should be less than 200mg/dl. HDL should greater than 40mg/dl, LDL should less than 100mg/dl and triglyceride should less than 150mg/dl. Next text CBC. Normal CBC for this age group women should RBC=3.90-5.03, Hemoglobin =12-15.5grm/dl, Hematocrit 34.9-44.5, WBC=3500-10500cells/mcl, Platelet=150000-450000. My patient’s CBC was low. If patient have s/s of MI, we have to check Troponin level. A normal value is less than 0.01ng/ml AD dimer test is used to determine abnormal blood clot. Normal level should 250ng/dl.

GASTROINTESTINAL SYSTEMS

Inspection

I inspect abdomen for contour, symmetry, skin, pulsations and veins.
Assess for eating pattern, dysphagia, weight loss or weight gain, food intolerance, nausea, vomiting, diarrhea, constipation, diabetes or inflammatory bowel disease.

Auscultation

I listen the abdomen for bowel sounds are present in all 4 quadrants.

Percussion

I percuss the patient’s abdominal to evaluate gas, solid or fluid filled structure.

Liver to determine span and descent.

Size for spleen and liver.

Palpation

I palpate the umbilicus for bulges, umbilical ring and nodules.
I palpate liver for lower border and tenderness: I place the left hand under the 11^th and 12^th ribs to lift liver closer to the abdominal wall. I Place my right hand parallel to the right coastal margin and press down and under the costal margin. I ask the patient to take deep breath when I palpate.
I palpate Spleen for tenderness and border.

Findings

I found patient’s abdomen flat and uniform in shape and size.
Bowel sound found present in all quadrant. clicks & gurgling sound
tympanic & dullness found in scattered area when I percuss.
No enlargement of liver and spleen found.
Abdominal reflex found positive. No nausea, vomiting, diarrhea.
Patient stated, she loose 4lb weight in 2 months.
NSG 3012 Week 5 Head-to-Toe Health Assessment

REPRODUCTIVE SYSTEM

Inspection

My patient is female, so I inspect both breast for shape size and any abnormal discharge.
I inspect genitalia for any abnormal discharge, lesions, s/s of infections, pelvic floor musculature. And bulging in vaginal wall with straining.

Palpation

I palpate both breasts smoothly for any abnormal masses, lumps, lesions, local areas warmth, tenderness and pain, dumplings.
I palpate External genitalia for triangular hair distribution, lesions or swellings and Bartholin glands for tenderness.

Findings

No any abnormal finding present. Patient have 3 kids already grown. Patient stated, she had menopause when she was 45. No vaginal itching, irritation, s/s of infection, tenderness noted. Patient stated she had mammogram done 6month ago and it was normal.

Reproductive system lab should check blood work and cultures to test sexually transmitted disease, Pap smear.

MUSCULOSKELETAL SYSTEM

Inspection

I inspect the patient’s cervical spine, shoulders, elbows, wrist and hand, hips, knees for alignment, color contour, symmetry, size, swelling, mass, range of motion and deformities.
I inspect Muscles size and symmetry

Palpation

I palpate all extremities for any edema, muscles wasting, pain and tenderness.
I Palpate bilateral extremities for range of motion, deformity and joint stability.

Findings

No any bone & joint deformities, no redness or swelling of joint, no muscle wasting found.
Patient able to move joints freely no sign of pain and tenderness noted.
Spine noted is in middle, slightly curved out from the neck & gradually curving inward at the waist normal. Peripheral extremities noted mild edema.

In muscular skeleton system ESR should check to find out infections or rheumatoid arthritis. Normal ESR rate for this age group women should 0-22mm/hr.

NEUROLOGICAL SYSTEM

I Assess the patient for level of consciousness
I Assess patient for mental status
I Assess the patient’s cranial nerve function
I assess motor function and balance with eye close.

Findings

Equal strength in both hands & feet, no muscular weakness
Noted patients have trimmers in bilateral hands and fingers due to alcohol.
Pt walk slow and unsteady with out cane.
Movement found Coordinated.
Positive planter reflex.
Deep tendon reflex found normal.
she has sensation for touch, pain and temperature equal on both sides of the body

Endocrine System

To perform an endocrine system assessment health history is important to obtain including genetic, sleeping patterns, nutritional habit and patterns of elimination. I already assess thyroid gland above in chest and neck. I inspect the thyroid gland for any thyroid issues. I palpate the thyroid gland using the anterior and posterior method. No any abnormal masses, swellings, pain, tenderness found.

Laboratory labs in endocrine system include thyroid function test, Blood glucose test and metabolic test. Thyroid stimulating hormone, thyroxin and triiodothyronine are just a few possible labs that may be performed when thyroid function is questioned. TFT includes Iodine, thyroxine, t3 and t4. Normal TSH level in women should 0.5 to 4.5uU/ml. T3 should 80-180 and t4 should 4.6-12ug/dl. Normal fasting blood sugar level should in between 70-99mg/dl and after 2 hours eat should less than 140mg/dl. Normal range of hemoglobin A1c level is 4% to 5.6%. women normal basal metabolic rate should 1400calories in American women.

Renal system/ Urinary system

To perform renal urinary system assessment, heath history is very essential. I inspect the patient’s skin color, edema and skin turgor. I assess urinary pattern, frequency, burning, and difficulty urination and urine for color and odor. I observe the abdomen and flank region for symmetry. I auscultate the renal arteries for bruit with stethoscope. I palpate abdomen for bladder distension and palpate the kidneys to assess tenderness. I percuss the bladder with my finger to find out bladder distension.

Findings: Kidneys feel smooth, firm and non-tender. Bladder was non-distended. Patient’s urine noted slight cloudy.

Laboratory for this system include Kidney function test, urine analysis. Normal kidney has BUN level should 7 to 20mg/dl, creatinine level should 0.6-1.2mg/dl. 24 hours urine test can be used to measure the kidney function. A BMP measure glucose, calcium, sodium, potassium, carbon dioxide, chloride, blood urea nitrogen and creatinine. The BMP evaluate the status of the kidneys and electrolyte balance. I will show the all lab value of my patient down in chart. NSG 3012 Week 5 Head-to-Toe Health Assessment

Laboratory findings for patient age.

Chest x-ray noted B/L infiltration.
ECG noted Sinus tachycardia.
Computerized Tomography (CT scan) of chest: emphysematous changes in both lungs tissue.
Pulmonary function test : FEV1 was less than 60%
Urine R/E- Normal
ABG
Sputum for AFB – Negative
Complete Blood Count and BMP

ORDER NSG 3012 Week 5 Head-to-Toe Health Assessment

Diagnostic Data	Results	Normal Lab Values	Significance of my patient
WBC	14.9	4.0-11.0K/mmcu	Low hemoglobin, low potassium and high BUN noted.
RBC	2.65	3.63-5.04 m/mm cu
HGB	9.5	12-15g/dl
HCT	30.4	34.7-45.1
Platelets	350 k/mm cu	150-450 k/mm cu
BUN	30	7-25
Creatinine	1.2	0.6-1.3 mg/dl
Sodium	140	133-144
Potassium	3.2	3.5-5.1
Chloride	106	98-107 mmol/L
Calcium	9.0	8.6-10.3 mg/dl
T Protein
Albumin	3.2	3.5-5.7 g/dl
SGOT
SGPT
Alk Phos
Magnesium
Amylase
Lipase
eGFR
CK
CK-MB
Troponin I		0-.03ng/dl
Myoglobin
LDI
Phosphorus	4.1	2.5-4.5 mg/dl
Iron	41.0	50-212
Vitamin B-12	110	180-914pg/ml






Diagnostic Data	Results	Normal Lab Values	Significance of my patient
Urinalysis
Color	dark	yellow	My patient’s urine was dark cloudy color may be due to decrease fluid intake.
Character	clear	clear
Spec. Grav.	1.010	1.005-1.025
pH	7	4.5-8
Protein	120	Less than 130mg/dl
Glucose	118	Less than 130mg/dl
Blood	2	Less than 3 RBCS
Nitrites	negative	negative
RBC	1.9	Less than 2
WBC	3	Less than2-5

Urine Culture

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

Bronchiectasis
Pneumonia
Chronic asthma
Emphysema
Anemia
Hypertension

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

-Ineffective breathing patterns related to broncho congestion, increased mucus production as evidence by shortness of breath.

-Alter body temperature related to infection as evidence by 101.4̊f.

-Activity intolerance related to inadequate oxygenation and dyspnea.

-Risk for electrolyte imbalance related to hypokalemia evidence by 3.2

Nursing Diagnosis	Intervention	Evaluation
1 Ineffective breathing patterns related to broncho congestion, increased mucus production as evidence by shortness of breath.	– I assess the general condition of patient -keep patient in semi fowler position. -monitored the pulse oximeter for oxygen saturation. -administered oxygen 3L/min via nasal cannula -administered Nebulizer -administered antibiotics as prescribed -encouraged for deep breathing & coughing exercises. NSG 3012 Week 5 Head-to-Toe Health Assessment	Patient condition improved within half an hour after nursing intervention. My set goals were fully meet.
2 Alter body temperature related to infection as evidence by 101.4̊f.	– I assessed general condition of patients. -loosen tighten and removed heavy clothes. -Maintained cross ventilation by opening windows & doors. -Provided tapping sponging. -provided plenty of fluids -Provided Tylenol as ordered -Reassess the temperature of patient.	Body temperature was reduced and comes to normal range 98.8-degree F.
3 Activity intolerance related to inadequate oxygenation and dyspnea.	– I monitored the severity of dyspnea & 02 saturation with & following activity. -Maintained supplement oxygen therapy as needed during activity. -scheduled active exercise after respiratory therapy or medication (e.g bronchodilator) -Assisted the patient in scheduling a gradual increase in daily activities & exercise. -advise to avoid condition that increase oxygen demand such as temperature extremes, excess weight & stress	During mild activity he had no dyspnea.

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

Smoking cessation.
Taking medications to dilate airways (bronchodilators, Corticosteroids, mucolytic, expectorants)
Vaccinating against flu influenza and pneumonia.
Deep breathing and coughing exercise
Regular oxygen supplementation
Pulmonary rehabilitation.
Control blood pressure.
Postural drainage and chest physiotherapy.
Promote exercise.
Improve general health (environmental sanitation)
Knowledge about COPD is needed to set specific, realistic, personal goals during rehabilitation – in order to avoid a sense of failure if goals cannot be achieved -, and to enhance working towards better self-management (Meis, Bosma, Spruit, Franssen

& Janssen, 2014).

m) Maintain electrolyte with balance diet.
n) Breast self-examination.

ORDER NSG 3012 Week 5 Head-to-Toe Health Assessment

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

Bronchodilator (Asthaline, Ipravent)
Oxygen therapy
Corticosteroid (Inj Hydrocortisone)
Antibiotics (Inj ceftriaxone)
Postural drainage and chest physiotherapy
Antipyretic (tab Tylenol)
Antacid (Tab pantop)
Tab Potassium
Tab Amlodipine

NSG 3012 Week 5 Head-to-Toe Health Assessment References

Jarvis, C. (2015). Physical examination and health assessment (7^th ed.). Retrieved from http://evolve.elsevier.com/Jarvis/

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L, Camera, I.M. (2011). Medical -Surgical Nursing: Assessment and Management of clinical problems (8^th Ed.). St. Louis, Mo: Elsevier/Mosby

Wilson, S.F., Giddens, J.F. (2009). Health Assessment for Nursing Practice (4^th Ed).St. Louise, Mo: Elsevier/Mosby