NSG 3012 Week 4 Project – Head-to-Toe Assessment

NSG 3012 Week 4 Project – Head-to-Toe Assessment

When carrying out a head-to-toe assessment, the practitioner must ensure that they examine the patient comprehensively, assessing all body systems. It is vital to ensure the patient is inspected in every part to identify any anomalies and strange results. According to Jarvis (2015), the physical examination requires one to come up with technical skills and an understanding base. It is through the technical skills that the data is collected. The practitioner uses the five senses to collect the information during the physical assessment. The fundamental techniques used to perform physical examination include inspection, palpation, percussion, and auscultation. These approaches are carried out separately and in a specific order.

Head-to-Toe Assessment on the Selected Patient

The assessment involved a 35-year-old Black American male patient who had chief complaints of acute pain in his stomach. Even with such symptoms, the patient looked well-groomed and healthy. He pointed out that he has been experiencing tenderness and some abdominal pain for the last six days. These symptoms were accompanied by some diarrhoea and bloating, along with vomiting and nausea. According to the patient, he had a medical history of diverticulitis. However, he denies any other medical history or past diagnosis. He cannot remember the last time any of his family members were diagnosed with such symptoms. The patient asserted that he had not taken any medications, thus no medication intolerance, and he had an allergy to fish and other proteins since he was age 5. Due to his occupation, he reports that he takes a lot of food at a time, consumes 2 to 3 beers daily and does not smoke. That being said by the patient, all required tools and equipment are available to conduct a head-to-toe examination. The assessment will be performed along with a lab test and radiological imaging to confirm inflammation (Shah & Cifu, 2017). All the tests and examinations will be conducted in a laboratory or acute care setting.

Review of the Body Systems

Neurological

The patient had clear speech, stood in an upright posture and demonstrated a good tone. He walked independently with good balance and a steady pace. The patient has proper deep tendon reflexes.

Skin, Hair, and Nails

The patient’s skin resembles the African American ethnicity, no blemishes distinguished, and no smell exhibited. He demonstrates no oedema. His hair’s colour is black, smartly cut and uniformly distributed. The scalp is clear and does not have any dandruff, parasites, or lesions. His nails are clean, curved, and smooth-edged. After carrying out the Blanch Test, the colour of the nails returned to normal in about 2 seconds.

NSG 3012 Week 4 Project – Head-to-Toe Assessment

Head, Face, and Neck

The patient has a round, symmetrical head. No nodules, depressions or masses were noted after the palpation of his skull. His face is rounded and balanced, with no masses or nodules. He is capable of moving and controlling his neck in either direction with no limitations. Upon palpation, no anomalies were noted at his neck.

Ears and Eyes

Notably, his ears are equivalent, with no lesions, depressions, or lumps. Upon palpation, the ears are firm, and no tenderness was noted. An otoscope was used to inspect the patient’s inner ear. The ear comprised no discharge, and there was a light brown, waxy cerumen in both ears. Using the otoscope, his head was tilted towards the right shoulder; examining the left ear, the pinna is pulled up and back while holding the otoscope upside down to ensure it is steady when in the patient’s ear. The inspection shows that the Tympanic membrane is standard, with a shiny and translucent colour. The patient passed all hearing tests without any problem.

The patient’s eyes appear regular, and the eyebrows are intact and symmetrical. This is noted when the patient raises and lowers his eyebrows. His eyelashes are evenly distributed. Eyelids seem normal, and no discolouration was identified. Also, no discharge, swelling, or puffiness was noted. The eyeballs are equal, round, reactive to accommodation, and light. No protrusions were noted. There is a brown dot identified at the edge of his left eye. The patient claim that the dot was a result of a knock he had when he was about ten years old. The patient does not report any other difficulty in his eye. The conjunctiva is normal, and no anomalies were noted. Throughout his life, the patient reports that he has never worn glasses. The patient underwent a Snellen Eye Chart, performed on both eyes and showed a normal visual acuity of 20/20.

Nose, Mouth, and Throat

The nose is symmetrical and midline and appears proportional to the facial features. A nasal cavity appears smooth, moist, and red. No flaring, swelling, bleeding, or discharge noted. There is no deviation on the nasal septum. No tenderness or pain was recognized on the sinus section after palpation. The mouth is inspected, and it is notable that the patient’s lips appear healthy, smooth, and moist with no signs of lesions or cracking. The tongue seems pink and somehow rough. There is no infection or anomalies noted on the tongue. Also, no abnormalities were pointed out on the teeth and gums. Buccal mucosa, uvula, and palate do not exhibit any defect. Upon palpation, the thyroid is regular and uniform. The tonsils appear pink with an average size. The patient asserts that he brushes at least twice per day. Besides, he visits a deontologist once a month.

Respiratory

The chest of the patient is regular. A vertically aligned spine uniformly separates the shoulders and hips. Upon auscultation, the lungs are clear. Respiration is steady and uniform. There is no discolouration, depression, or lesions identified on the chest or his back. No tenderness upon palpations.

Cardiovascular

The apical pulse, SI, S2, and standard heartbeat rate are noted – 68 beats in one minute and 3+ pulses. No anomalies were noted after palpating bilaterally on the patient’s carotid artery. No clicks, murmurs, or any sounds indicated. The blood pressure was normal, and no oedema was identified.

Abdomen

The patient’s abdomen is flat, soft and regular. Abdominal tenderness was noted upon palpation. No lesions, distention or discolouration were noted. All four quadrants comprise bowel sounds. The patient asserts having persistent pain in the lower quadrants. Internal haemorrhoids and slight bleeding are reported, especially when the patient experiences diarrhoea.

Musculoskeletal

Upon bilateral inspection, the patient’s extremities are regular in length and size. There is no limitation noted when moving into the exam room. All bones are fine, and no muscle tremors were noted. Also, no tenderness in his joints.

Analysis

During the assessment, the health screen and age-specific reduction were noted. However, no immunizations are required to prevent diverticulitis. According to Jarvis (2015), suitable management involves fluid and rest when a patient experiences diverticulitis. Interventions aimed to reduce the risk can be encompassed in the management and treatment approaches. These interventions include lifestyle changes, meal planning, smoking cessation, and weight management. The patient can be advised on the diets he should take and those he should avoid. In fact, consuming high-fat food may bring about inflammation and may result in numerous abdominal complications. Additionally, drinking caffeinated beverages is not advisable. The patient will be provided with a list of the various foods and drinks he must consume as part of the health screen.

NSG 3012 Week 4 Project – Head-to-Toe Assessment

Differential Diagnosis

Since the patient has a medical history of diverticulitis, it is essential to perform a physical examination. His condition warrants a continuous evaluation to manage various symptoms such as vomiting, diarrhoea, and nausea. Ensuring that the necessary lab tests are conducted is essential to making the right diagnosis and care plan.

Care Plan

Based on the patient’s medical history, it would be crucial to refer him to a health professional to determine the underlying cause. Imaging tests would be useful to determine whether there is any other gastrointestinal problem. Most importantly, the knowledge deficit forms the basis of the care plan for this patient. It is essential to educate the patient on lifestyle changes, meal planning, and diet intake. The gastrointestinal pain can be managed through interventions such as taking a low-fatty diet and taking anti-diarrheal medications. The patient can be directed on the issues of nutrition and if necessary, referred to a dietician for follow up consultations (Jarvis, 2015). Regular evaluation should be considered to examine the progress of the patient.

Age-appropriate evidenced-based practice strategies

Evidence-based practice (EBP) is significant to use when caring for patients to enhance the outcomes. Hall et al. (2010) point out that antibiotics and dietary changes have been confirmed to help patients with acute diverticulitis. In complicated scenarios of diverticulitis, advanced care is required, and surgery may be carried out. It should be noted that a patient with diverticulitis requires a suitable treatment to alleviate gastrointestinal complications. EBP strategies should be implemented in all patients to improve their health and prevent this illness.

Pharmacological treatments

Outpatient treatment can be appropriate in this case unless there are other complications related to the illness at hand. Various pharmacological therapies can be used to treat gastrointestinal pain and infections. Shah and Cifu (2017) recommend antibiotic therapy with anaerobic organisms. The patient’s illness can also be treated using antibiotics such as Moxifloxacin, Bactrim, Ciprofloxacin, Augmentin, Timentin, Zosyn, Tygacil, or Invanz. It is advisable to educate the patient on limiting the use of anti-inflammatory drugs. Several preventative measures should be put in place to ensure that outpatient management is successful.

References

Hall, J., Hammerich, K., & Roberts, P. (2010). New Paradigms in the Management of Diverticular Disease. Current Problems in Surgery, 47(9), 680-735. doi: 10.1067/j.cpsurg.2010.04.005

Jarvis, C. (2015). Physical Examination and Health Assessment (7th Ed.). St. Louis: Saunders.

Shah, S., & Cifu, A. (2017). Management of Acute Diverticulitis. JAMA, 318(3), 291. doi: 10.1001/jama.2017.6373

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For this assignment, perform a complete head-to-toe assessment on someone of your choice or a hypothetical person who has at least two (2) systems issues. Use the head-to-toe template here to document your assessment (add more lines as needed). In a Microsoft Word document of 4-5 pages