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Head-to-Toe Assessment

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Head-to-Toe Assessment

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 (in addition to the template) formatted in APA style, discuss the remaining criteria for the assignment.

Please note that the title and reference pages should not be included in the total page count of your paper.

In your paper, address each of the following criteria:

Use the template and include:

  • System being assessed.
  • Detailed review of each system with normal and abnormal findings.
  • For any system for which you do not have equipment, explain how you would do the assessment.
  • Normal laboratory findings for client age.
  • An analysis of age-specific risk reduction health screening and immunizations.
  • Two differential diagnoses (diseases) associated with possible abnormal findings.
  • A plan of care (including two priority-nursing diagnoses, interventions, evaluation).
  • Pharmacological treatments that can be used to address health issues for this client.
  • Client and age appropriate evidenced-based practice strategies for health promotion.

On a separate references page, cite all sources using APA format. Helpful APA guides and resources are available in the Online Library. Below are guides that are located in the library and can be accessed and downloaded via the American Psychological Association website also provides detailed guidance on formatting, citations, and references at APA Style.

  • APA Citation Helper
  • APA Citations Quick Sheet
  • APA-Style Formatting Guidelines for a Written Essay
  • Basic Essay Template

Head-to-Toe Assessment

References

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Carpenito-Moyet, L. J. (2017). Nursing diagnosis: Application to clinical practice (16th ed.). Philadelphia, PA: Wolters Kluwer.

Fitzgerald, K. (2019). Head-to-toe assessment in a clinical setting. Journal of Nursing Education and Practice, 9(1), 50-56.

Herdman, T. H., & Kamitsuru, S. (2018). NANDA International nursing diagnoses: Definitions and classification 2018-2020. Thieme Medical Publishers.

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.

American Psychological Association. (n.d.). APA Style. Retrieved from https://apastyle.apa.org/

NursingWorld.org. (n.d.). Nursing Practice: Scope and Standards of Practice. Retrieved from https://www.nursingworld.org/

 
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Head-to-Toe Assessment

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Head-to-Toe Assessment

(Head-to-Toe Assessment)

For this assignment, perform a complete head-to-toe assessment on one of your chosen participants. 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, along with normal laboratory findings for client age.
  • An analysis of age-specific risk reduction, health screen, and immunizations.
  • Your expectation of normal findings and what might indicate abnormal findings in your review of systems.
  • The differential diagnosis (disease) associated with possible abnormal findings.
  • A plan of care (including nursing diagnosis, interventions, evaluation).
  • Client and age-appropriate evidenced based practice strategies for health promotion.
  • Pharmacological treatments that can be used to address health issues for this client.

Provide your answers in a 6- to 7-page Microsoft Word document.

Support your responses with examples.

On a separate references page, cite all sources using APA format.

General Survey

  • Observe the client’s overall appearance, level of consciousness, and vital signs.
  • Normal: Alert, oriented, well-groomed, stable vital signs.
  • Abnormal: Confusion, disheveled appearance, abnormal vital signs (e.g., hypertension, fever).

Head and Neck

  • Inspect scalp, face, eyes, ears, nose, mouth, and throat.
  • Normal: Symmetrical features, clear conjunctiva, intact tympanic membranes.
  • Abnormal: Lesions, jaundice, hearing loss, dental issues.

Respiratory System

  • Assess chest shape, breathing pattern, auscultate lungs.
  • Normal: Symmetrical chest expansion, clear breath sounds.
  • Abnormal: Wheezing, crackles, abnormal respiratory rate.

Cardiovascular System

  • Inspect and palpate precordium, auscultate heart sounds.
  • Normal: Regular rhythm, normal heart sounds (S1, S2).
  • Abnormal: Murmurs, irregular rhythm, edema.

Abdominal Assessment

  • Inspect, auscultate, palpate, and percuss the abdomen.
  • Normal: Soft, non-tender, normal bowel sounds.
  • Abnormal: Distension, pain, abnormal bowel sounds.

Musculoskeletal System

  • Assess posture, gait, muscle strength, joint function.
  • Normal: Normal posture, full range of motion.
  • Abnormal: Pain, swelling, limited mobility.

Neurological System

  • Evaluate cranial nerves, motor and sensory function, reflexes.
  • Normal: Intact cranial nerves, normal reflexes.
  • Abnormal: Weakness, numbness, abnormal reflexes.

Skin and Nails

  • Inspect skin color, texture, moisture, and nails.
  • Normal: Smooth, even color, no lesions.
  • Abnormal: Cyanosis, pallor, lesions, brittle nails.

Age-Specific Considerations

  • Risk reduction: Encourage regular screenings (e.g., mammograms, colonoscopies).
  • Immunizations: Ensure up-to-date vaccinations (e.g., flu, pneumonia).

Expected Findings

  • Normal: No significant abnormalities.
  • Abnormal: Indicate potential diseases like hypertension, diabetes, COPD.

Differential Diagnosis

  • Example: Abnormal breath sounds may suggest asthma, COPD, or pneumonia.

Plan of Care

  • Nursing Diagnosis: Risk for falls related to unsteady gait.
  • Interventions: Educate on fall prevention, use assistive devices.
  • Evaluation: Monitor for falls, reassess gait stability.

Health Promotion

  • Strategies: Educate on diet, exercise, smoking cessation, regular health screenings.
  • Evidence-Based Practice: Use CDC guidelines for immunizations.

Pharmacological Treatments

  • Address issues like hypertension (antihypertensives), diabetes (insulin), respiratory problems (bronchodilators).

This comprehensive assessment ensures thorough evaluation and targeted interventions, promoting overall health and well-being for the client.

 
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