HEAD TO TOE ASSESSMENT
Head to Toe Assessment
Name of student
Name of Institution
Head to Toe assessment is the physical examination often performed on patients to acquire information about their physical health. Often, it is carried out by nurses but, the assessment may be performed any qualified health practitioner. It is important to note that Head to Toe Assessment is mostly performed on adult patients. Also, nurses without this knowledge are required to undergo training to acquire Head to Toe Assessment skills (Jensen & Jensen, 2001). These skills are necessary when nurses encounter patients before sending them to a doctor. In point of fact, Head to Toe Assessment is considered the most vital aspect while examining a patient. Before performing this physical examination, nurses are required to have a stethoscope, an otoscope, penlight, tongue depressors, measuring equipment, fragrance, cotton balls, tuning fork and monofilaments (Jensen & Jensen, 2001). In this paper, I will critically perform a Head to Toe Assessment performed on a 35-year-old male adult patient.
Head to Toe Assessment
As prior mentioned, equipment is necessary for Head to Toe Assessment. Before I meet my patient, I ensure that I have arranged and organized my equipment accordingly.
It is important for me first to wash my hands before handling my patient. Failure to clean and wash my hands increases the chances of spreading disease (Beebe & Funk, 2001). The disease may either be transmitted from the patient to me or vice versa.
Getting to know the patient
According to Jensen & Jensen (2001), the next step is for me to familiarize myself with my patient. Here, I ensure that the patient understands the purpose of Head to Toe Assessment. It is necessary for me to explain the reasons for performing the assessment. My role is to inform the patient that the assessment does not guarantee the presence of disease. The patient is less nervous when they learn that they may not be unwell.
Conduct a general survey
Here, I am obliged to observe the patient on different elements. I may begin by observing my patient’s hygiene, eye contact mannerisms and overall appearance before embarking on an inference. According to Gasper & Dillon (2001), this general survey, may identify whether my patient is mentally stable or unstable. There are no abnormal findings.
Head and Neck
I check the head for bumps or tenderness. Also, it is important for me to check for other injuries to the head. Here, I also observe whether my patient has head lice. Lastly, I use an otoscope to check my patient’s ears for possible lacerations or injury. My findings are normal.
These are the pulse, temperature, breathing and blood pressure. Vital signs are important in determining any sudden change in my patient’s health. No abnormal findings.
Orientation of the Patient
I use open ended statements to ascertain whether my patient is aware of themselves. I avoid closed-ended questions the answers do not qualify for a complete orientation. Some of the statements I employ are:
Tell me your date of birth
Tell me who I am
My patient’s speech is quite clear thus normal findings.
I shine a light on each side of the pupil taking note of size and reaction of the pupil. My patient’s pupil constricts when exposed to light. I direct a ball point pen toward the direction of my patient’s eyes. With this, I observe the rate at which his eyes constrict to the closeness of the pen. These findings are normal.
Veins in the Neck
I check my patient’s jugular veins at this juncture. I ask him to sit at a 45-degree angle. My patient’s veins appear to be flat and not distended. The former depicts a normal fluid rate in his body. My findings are normal.
I use my stethoscope to check for my patient’s pulse rate. I check for the rhythm and sounds of his heart and they appear to be normal. His heart beats at a regular rate thus my normal findings.
I take bilateral checks on my patient to observe various symptoms:
The rate, regularity and strength of my patient’s radial pulses seem normal
Strength of hand
He has the capability of gripping two of my fingers. He seems strong thus the patient should not grip my whole hand. Strong grips may result in unwanted injuries. These findings are normal as I ensure that the strength is equally distributed in his hand.
Strength of leg
For this assessment, I place my hand on the patient’s thighs. I ask him to resist my hands so as to test the strength of his leg. I check for equal distribution of strength in my patient’s leg. My findings are normal.
Just like the radial pulse, I check for strength, regularity and rate of pedal pulses.
Refill of capillary
I use my patient’s nails to check on capillary refill. The color disappears and there is a capillary refill within a few seconds. My patient’s circulatory system is working fine thus my findings are normal.
I observe my patient’s skin for presence of skin turgor. I gently pinch his sternum and my patient’s skin returns to its original form. It takes a short time and my inference is normal. However, I also check his mucous membranes and conjunctiva to ascertain my findings. My patient’s skin color appears normal thus no skin turgidity. I check my patient’s temperature by placing the back of my hand on his skin. My patient’s skin feels warm hence there are normal findings.
I use my stethoscope’s diaphragm to check for my patient’s breathing. I check for both anterior and posterior breathing sounds and movements of my patient. I ask him to breathe deeply in and out within specified intervals. I ensure that I move my stethoscope in a stealthy manner to avoid causing hyperventilation in my patient. His breathing sounds are clear and have a great flow of air. These findings are normal.
I ensure thorough auscultation on my patient’s abdomen before placing my hand on it. I do not palpate my patient to avoid interfering with normal abdominal sounds and movements. My patient is not on gastric suction thus the process is short. I assess his bowel sounds and they seem to be inactive. I check on these sounds after every five minutes and obtain abnormal findings.
I check for Edema in my patient’s hands, feet and sacrum. I push my finger down to my patient’s aforementioned body parts. I do not observe any form of indentation thus my findings are normal.
Checking for Pain
It is my duty to inquire whether my patient is experiencing any form of pain. If so, there are certain questions that I should ask. He informs me of a slight pain in his right lower abdomen. I ask him the following questions:
Is it severe?
How long have you experienced this pain?
Does anything make it better?
Is it a sharp, stabbing or dull pain?
My findings for this assessment are abnormal.
Once again, I carry out an assessment of my patient’s skin. I observe any form or redness, swelling or injuries on his skin. For this assessment, my findings are normal.
For this assessment, I ask my patient to dorsiflex his left and right foot. I inquire from my patient whether he feels any pain in his calf. Fortunately, he has no pain thus normal findings. Beebe & Funk (2001) outline that any form of pain in the calf area means thrombophlebitis. However, this is a condition that often occurs during pregnancy. The Homan’s sign depicts the presence of pain in the calf area (Gasper & Dillon, 2001).
Close up and Closure
I inform my patient that I am through with his Head to Toe Assessment. Thereafter, I take the report to the doctor before returning to my patient. I ensure that the call light is reachable to my patient in case of any emergency.
Assessment of Findings
As per my findings, there were two instances of abnormality. My patient had abnormal bowel movements and this explained the stabbing pain in his lower abdomen. He informed me that it was not severe and lying down often makes him feel better. Also, he informed me that the pain had been on and off for about two weeks. For a 35-year-old man, having pain in his lower right abdomen delineated a symptom of appendicitis (O’Neill, 2002). I eliminated chances of an inflammation in his gall bladder because the pain was not in his upper abdomen. There are various pharmaceutical treatments that may be employed to treat the pain in his lower right abdomen. Strong antibiotics should be administered to my patient to prevent the pain from becoming worse. In case the condition worsens, my patient may be forced to undergo a surgical process-appendectomy- to remove his appendix (Gasper & Dillon, 2001).
Conclusions and Future Study
There are ways in which people may reduce age-specific health risks. Being immunized and undertaking various vacations greatly assists in reducing health risks. However, it is clear to note that some of the health issues are directly related to an individual’s way of life. For instance, appendicitis may be caused in three different ways: cancer, foreign material or stool. In point of fact, the rampant cause of appendicitis is the latter. Most individuals fail empty their bowels as required thus they cause accumulation of stool. When stool is in excess, it may result in blocking the excretory system thus appendicitis. Therefore, it is important for people to avoid some of the diseases that are not inevitable within their age brackets.
Additionally, there should be different evidence-based strategies set aside for health promotion. Evidence-based strategies are concerned with the planning and evaluation of programs that strive to improve matters of health in a given society. It should be noted that these strategies are often adopted from different models that have been tested to fit in the clinical setting. For evidence-based health promotion, individuals may self-manage themselves to reap effective benefits. Also, they may set goals and objectives and ensure that they follow them up to the latter. On a societal level, it is primary for individuals and groups to build a rapport with hospitals and providers of health. The aforementioned evidence-based strategies may be used for the purpose of health promotion.
Beebe, R. W. O., & Funk, D. L. (2001). Fundamentals of emergency care. Albany, NY: Delmar Thomson Learning.
Gasper, M. L., & Dillon, P. M. (2011). Clinical Simulations for Nursing Education – Learner Volume. Philadelphia: F. A. Davis Company.
Jensen, S., & Jensen, S. (2011). Pocket guide for nursing health assessment: A best practice approach. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
O’Neill, P. A. (2002). Caring for the older adult: A health promotion perspective. Philadelphia: W.B. Saunders.