Comprehensive Head-to-Toe Assessment Video Script

Comprehensive Head-to-Toe Assessment Video Script

Hello, I am Marion Lamin, and I will be your nurse today. Thank you for your cooperation in this entire head-to-toe physical evaluation. This evaluation will allow us to get a good picture of your state of health, considering your conditions. I will be explaining every step as we proceed, and I would like you to point out anything that feels unnatural. My goal is to ensure that you are aware, comfortable, and engaged in the entire process.

To begin, I’ll look at your overall appearance and attitude. You appear alert but exhausted, and I see a slow, deliberate gait which might be suggestive of pain or impaired circulation to the lower limbs. Your look is adequate, but signs of limited resources can be observed, which corroborate your account of subsisting in your vehicle. Moving on, your speech is easy to understand, though subdued, and you have little eye contact, which could indicate chronic stress or emotional fatigue. These results already give a dismal picture of your physical and psychosocial state.

I’ll now check your vital signs. I notice that you have a blood pressure of 145 over 92 millimeters of mercury and an even pulse of 88 beats per minute. Your respiratory rate is 18 per minute, and your oxygen saturation of 97 percent on room air. Your temperature is normal, and this is good. Your height and weight reveal your body mass index as overweight, and may complicate diabetes and vascular-related problems. It is also relevant to mention that you have not been taking your prescription drug for diabetes in the recent months, and this should have been taken seriously.

And now in the head, eyes, ears, nose, and throat section of the examination, when I look, I do not notice anything unusual or lesions on either your facial skin or scalp. Your pupils are homogeneous, round, and responsive to light and accommodation, although you have reported vision as a problem, and this is observable in diabetic retinopathy. Your mucous membranes in your mouth are dry, indicating dehydration, and your tongue is lightly coated. Your ears are not discharging or tender, and your nasal passages are clear with moist mucosa. There are no acute conditions here in general, but the visual symptoms are serious enough to be referred to an eye specialist.

Next, I’ll examine your neck for pathology. Your trachea is midline, and I have no palpable thyroid enlargements or lymph nodes. Your neck has a full range of motion with no pain or restriction. I’ll now palpate your carotid arteries, and they are strong and symmetric bilaterally, and I don’t hear any bruits. All these observations help to exclude upper airway or vascular compromise at this time.

Now to your cardiovascular examination, I auscultate your heart tones and find a regular rhythm with equal S1 and S2 and no gallops, rubs, or murmurs. On examination of your peripheral perfusion, I find decreased pulses in the posterior tibial and dorsalis pedis arteries bilaterally. Your toes’ capillary refill time is greater than three seconds, and your lower extremities are cool and pale. You also have a dependent rubor and pitting edema of the ankles, which is also in testimony against an impaired arterial circulation. Classically, they are observed with peripheral vascular disease, a recognized complication of poorly controlled diabetes.

Moving on to the respiratory system, I auscultate all of your lung fields and have equal and clear breath sounds bilaterally. You have an even rise of your chest and are using no accessory muscles, which tells me your respiratory effort is normal. There is no shortness of breath, wheezing, or cough, and oxygen saturation is within normal limits. These reassure and inform that your lungs do not manifest themselves in your underlying conditions at the moment.

As I palpate your abdominal region, it feels neither distended, nor tender to palpation, and soft. You have sounds from all four quadrants and are not experiencing nausea, vomiting, or changes in bowel habits. No organ or masses are palpable in the absence of gastrointestinal symptoms currently. While there are no gastrointestinal complaints present now, gastroparesis is a complication of diabetes that we will monitor in the future. Based on today’s exam, there are no emergent gastrointestinal complaints.

For your musculoskeletal and nervous systems, I see diminished muscle bulk in your lower legs that is likely secondary to disuse or nerve damage. You have tingling, burning, and stabbing pain in your feet, both at night and when you are sleeping, which are classic presentations of diabetic peripheral neuropathy. Sensory testing of light touch and vibration is diminished on both feet. Your deep tendon reflexes are diminished at the ankles, and your gait is not stable. All these affirm neuropathy that predisposes you to falls and injury.

On my full skin exam, I note dryness, flakiness, and calluses, particularly on your foot soles. There is a shallow, non-healing ulcer over the lateral margin of your right foot. Additionally, there is erythematous and calloused tissue around it, indicative of chronic pressure as well as compromised vascular supply. The loss of hair on the shins, as well as the rubor on dependent surfaces, is consistent with the peripheral arterial disease. Such results confirm the necessity of emergent wound management, foot care, and vascular assistance.

Now that I have done the physical examination, I would like to share the findings and how they confirm your existing diagnoses. Your diagnosis is Type 2 Diabetes Mellitus complicated by diabetic peripheral neuropathy and peripheral vascular disease. Your high blood sugar levels for a prolonged time have damaged nerves and blood vessels in your lower extremities. These complications are the cause of pain, numbness, and impaired healing of the wound that you are having. The finding of low peripheral pulses, color change, and a non-healing ulcer is highly suggestive of peripheral vascular disease (Goyal et al., 2023).

In an effort to understand this better, diabetes makes the body less sensitive to insulin and reduces the metabolism of glucose. Having the blood glucose maintained at a high level over time continues to damage the endothelial lining of the blood vessels, so that they are less flexible and result in atherosclerosis. Reduced blood supply to the limbs, in particular, results in ischemia, delayed wound healing, and susceptibility to infection. Concurrently, hyperglycemia results in nerve fiber damage, and patients lose not just their neuropathic pain but also their sensation (Galicia-Garcia et al., 2020). Together, these complications increase the risk for such catastrophic outcomes as ulceration and amputation if unmanaged.

Pharmacologically, returning to your initial prescription of metformin is the key initial action to take. Metformin is a first-line medication for Type 2 Diabetes and works to reduce hepatic glucose output and increase insulin sensitivity. Given your elevated hemoglobin A1c, you may require combination therapy with a second oral hypoglycemic or a GLP-1 receptor agonist. Peripheral vascular disease can be treated with the drug cilostazol. Cilostazol is a phosphodiesterase III inhibitor that has the effects of improving lower limb perfusion by inhibiting platelet aggregation and inducing vasodilation (Balinski & Preuss, 2023). However, this medication has side effects of headache and palpitation, and is contraindicated in heart failure patients as well, so monitoring is required.

There are a couple of things that must be done together in your priority care. First is the reestablishing of glycemic control by following medication, ongoing monitoring, and diet adjustment. Second is the maintenance of wound care of foot ulcer and the implementation of measures of prophylactic foot care. Third, falls prevention must be instituted, including physical therapy and supportive shoes. Last, your social determinants of health, including housing instability and food insecurity, must be addressed by connecting you with community support services and low-cost clinics. According to the American Diabetes Association (2023), diabetes control over the long term and prevention of its complications necessitate a multidisciplinary and patient-centered strategy.

As I conclude, I greatly appreciate your cooperation and hard work during this assessment. I do realize the challenges you are facing, concerning coping with a chronic condition while not having a stable shelter and access to food, and health care. As medical professionals, we are here to help you with both your medical and social issues. We can achieve a healthier future when interventions, appropriate resources, and care coordination are combined to make a difference.

References

American Diabetes Association. (2023). American diabetes association releases 2023 standards of care in diabetes to guide prevention, diagnosis, and treatment for people living with diabetes | ADA. Diabetes.org. https://diabetes.org/newsroom/american-diabetes-association-2023-standards-care-diabetes-guide-for-prevention-diagnosis-treatment-people-living-with-diabetes

Balinski, A. M., & Preuss, C. V. (2023). Cilostazol. StatPearls. https://pubmed.ncbi.nlm.nih.gov/31335083/

Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martin, C. (2020). Pathophysiology of type 2 diabetes mellitus. International Journal of Molecular Sciences, 21(17), 1–34. https://doi.org/10.3390/ijms21176275

Goyal, R., Jialal, I., & Singhal, M. (2023, June 23). Type 2 diabetes. National Center for Biotechnology Information; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513253/

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Comprehensive Head-to-Toe Assessment Video Script

Create a 10 to 15 minute video recording of yourself performing a head-to-toe assessment on a volunteer who will be acting like one of the patients from the scenario case studies in this course.

Comprehensive Head-to-Toe Assessment Video Script

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Introduction
Click to view the NURS-FPX4015 Course Wrap-Up Video.

As you grow as a nurse, the ability to conduct a comprehensive and precise physical assessment of a patient is paramount, serving as the foundation for all subsequent healthcare decisions. This skill is closely tied to the crucial task of formulating an accurate differential diagnosis, which guides the course of treatment and significantly impacts patient outcomes. Incorporating an understanding of pathophysiology and pharmacology not only aids in the diagnostic process but also informs the development of an effective treatment plan. Lastly, the nurse’s role extends beyond these technical aspects, encompassing the vital responsibility of communicating these findings and plans to the patient, thereby fostering a collaborative and informed approach to healthcare.

This assessment must be completed on camera. You should use Kaltura to make your recording.

If you need more information on how to create and submit your video, please refer to Using Kaltura.

Instructions
Remember, your assessment submission will not be graded if you have not completed and submitted the Comprehensive Head-to-Toe Assessment Waiver. If you have not, complete and submit the waiver for Assessment 1.

The purpose of this assessment is to allow you the opportunity to demonstrate your ability to conduct an accurate and thorough examination of a patient, which is a critical skill for nurses. Patient assessments that are either inaccurate or not thorough can lead to nursing misdiagnoses or suboptimal health outcomes for patients.

For this assessment, you will submit a video of yourself conducting a head-to-toe assessment on a volunteer based on one of the Sentinel U case studies presented in this course. Your head-to-toe assessment should include a detailed analysis of the underlying pathophysiology of the selected disease process, the expected assessment findings, and the patient’s pharmacological needs. Additionally, you should discuss nursing implications for the selected disease process, from a pathophysiology, pharmacology, and physical assessment perspective.

Your video submission will be assessed on the following:

Comprehensive and Professional Assessment: Perform a comprehensive, thorough, and accurate assessment of a patient based on a selected disease process.
Remember, that the person standing in as your patient should be acting out one of the diagnoses from the Sentinel U case studies in the course.
Be careful and thorough in your assessment, make sure the camera can see what you are doing or make sure you are describing what you are doing to the patient.
Discussion of Diagnosis and Findings: Explain the diagnosis and findings of the physical assessment with the patient.
What did you find in your assessment?
How did the findings help you arrive at your diagnosis?
Are you communicating the findings to the patient in a way that provides context and helps the patient understand your findings?
Understanding of Pharmacological Needs: Discuss the pharmacological needs of the patient within the context of their disease process and current best practices.
What are the standard pharmacological treatments for the patient’s diagnosis?
How does the patient’s health history, other conditions, and other medications impact the decision making process related to pharmacological treatment options?
What other information does the patient need to know related to potential side effects or things to avoid related to any new pharmacological treatments for their condition?
Understanding of Pathophysiology: Explain the underlying pathophysiology of the disease process to the patient.
How does the disease process work in the body? Which systems does it impact?
How is the patient likely to feel if the disease process progresses?
How might symptoms of the disease process look or sound like to the patient?
Critical Thinking and Clinical Reasoning: Synthesize assessment findings with knowledge of the disease process, pharmacology, and pathophysiology to establish care priorities for the patient.
What are the care priorities for the patient?
How have you used your assessment findings, combined with what you know about the pharmacology and pathophysiology to arrive at these priorities?
What evidence-based or best-practices support these priorities?
Communication and Professionalism: The nurse displays professionalism and communicates clearly and effectively with the appropriate use of terminology with the patient throughout the assessment.
Additional Requirements
Total Length of Submission: Your video assessment must be 10 to 15 minutes in length.
Captions: Make sure that your Kaltura has been auto-captioned by the system before turning it in. This helps to support accessibility best practices and can help faculty more effectively assess your video.
Kaltura captions are automatically generated within 24 hours of you uploading the video recording to your Kaltura library. So, make sure you are not making your recording at the last minute.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Explain how pathophysiology, pharmacology, and physical assessment comprise a holistic approach to nursing care.
Synthesize assessment findings with knowledge of the disease process, pharmacology, and pathophysiology to establish care priorities for the patient.
Competency 3: Educate individuals on prevention and management of health conditions, across the life span and including special populations, based on pathophysiology, pharmacology, and physical assessment knowledge.
Discuss the pharmacological needs of the patient within the context of their disease process and current best practices.
Explain the underlying pathophysiology of the disease process to the patient.
Competency 4: Perform comprehensive and focused physical assessments using appropriate techniques and tools.
Perform a comprehensive, thorough, and accurate assessment of a patient based on a selected disease process.
Explain the diagnosis and findings of the physical assessment with the patient.
Competency 5: Apply scholarly writing standards to communicate evidence based strategies that support safe and effective patient care.
The nurse displays professionalism and communicates clearly and effectively with the appropriate use of terminology with the patient throughout the assessment.