Case Study: Head-to-Toe Assessment Steps

Case Study: Head-to-Toe Assessment Steps

Introduction

Head-to-toe assessment is an important facet of nursing practice. The procedure should be conducted when the nurse and the patient interact for the first time. A thorough evaluation entails checking the emotional, mental, and physical aspects of the patient’s body (Weber & Kelley, 2007). In addition, the healthcare provider should appraise environmental and social issues affecting the client presented to them. During the procedure, the nurse needs to ask questions needed to provide a comprehensive picture of the client. In this paper, the author will describe a head-to-toe assessment with all the steps involved. A case study of Mr. Simon Quan is used.

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Head-to-Toe Assessment Approach

Scenario

Mr. Simon Quan is a 45-year-old male. He reported to the hospital with various complaints. The client reports that he is suffering from a persistent headache. He also complains of phases of blurred or double vision and shortness of breath.

Assessment Procedure

Integument

In this segment, three key areas are assessed. They include skin, hair, and nails. A person’s skin should be of uniform color. In addition, it should be free of blemishes and foul odor (Jensen, 2011)Case Study: Head-to-Toe Assessment Steps. Mr. Quan has a good skin turgor. In addition, the skin’s temperature is normal. Mr. Quan’s hair is thick and well distributed. Tests reveal no signs of infection or infestation.

The client has light brown convex curved nails. Their texture is smooth and well attached to the epidermis. Nail assessment is done through the Blanch test (Amico & Barbarito, 2007). After pressing them between the fingers, the nails return to normal color in about three seconds. The reaction is an indication of normalcy.

Head

The areas assessed in this stage include the head, the skull, and the face. Mr. Quan’s head is rounded. The skull lacks nodules and depressions when palpated. On its part, the face appears smooth with no signs of masses. The findings do not reveal any abnormality.

Eyes and Vision

The assessment of eyes and vision entails checking the eyebrows, eyelashes, eyelids, and eyes as a whole (Wilson & Giddens, 2009). The client’s eyebrows and eyelashes are well distributed. Eyelids reveal no presence of discharge or discoloration. However, abnormalities appear in the form of internal lesions. The blood vessels show signs of dilation. The primary instrument used for the assessment is the penlight.

Ears and Hearing

Normal ears should have a color that is similar to that of the facial skin (Weber & Kelley, 2007). Mr. Quan’s auricles are symmetrical and aligned with the outer canthus of the eye. There is no presence of external lesions. In addition, the membrane is intact, flat, and with no scarring. To check levels of hearing, a watch tick test is conducted.

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Nose and Sinus

Mr. Quan’s nose does not show any signs of abnormality. A normal nose is symmetric, straight, and uniform in color (Amico & Barbarito, 2007). To test for tenderness and lesions, the nose is palpated lightly. About the mouth, the client’s lips are moist, smooth, and symmetric. One test entails asking Mr. Quan to purse his lips when whistling. The teeth and gums also appear normal. For example, there is no sign of discoloration on enamels or gums retraction. An assessment of the neck reveals muscles are of equal size and the trachea is palpable. The test entails asking the patient to move his head or swallow to detect any signs of discomfort (Jensen, 2011)Case Study: Head-to-Toe Assessment Steps.

Thorax, Lungs, and Abdomen

An analysis of the client’s lungs reveals that the chest wall is intact. In addition, it lacks tenderness and masses. However, there is an abnormal pounding and slight pain. The test procedure is conducted while the client is in the supine position (Weber & Kelley, 2007). The abdomen contains normal symmetric movements caused by respiration patterns. Tests involved palpating the bladder and listening to bowel movements. During the heart check-up, the primary abnormality observed is the increased heartbeat, which is above the normal level.

Differential Diagnosis

Various abnormalities were observed in the course of the assessment. They include irregular heartbeat and blood pressure, which was above 140/90mmHg. In addition, there were damaged blood vessels in the retina. Excessive pounding on the chest was also recorded. In addition, Mr. Quan had breathing difficulties. The possible disease associated with the signs could be hypertension.

Plan of Care

People with hypertension can manage the problem in various ways. However, Jensen (2011) points out that lifestyle modification is essential in overcoming the problems associated with high blood pressure. A care plan for Mr. Quan will include encouraging him to eat a balanced diet and to reduce salt intake. Regular physical exercises will also be encouraged. In addition, Mr. Quan will be advised to avoid tobacco smoke. Other measures include managing stress and taking medications as prescribed.

Conclusion

Head-to-toe nursing assessment is important in the entire nursing process. The practice entails interviews, observations, and auscultations. Other elements include palpation and percussion. The procedure is regarded as a prerequisite to the provision of quality healthcare. The reason behind this is that incorrect check-ups may lead to wrong diagnoses and care plans. In addition, they may result in incorrect intervention and evaluation.

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References

Amico, D., & Barbarito, C. (2007). Health and physical assessment in nursing. Upper Saddle River, N.J: Pearson Education.

Jensen, S. (2011). Nursing health assessment: A best practice approach. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

Weber, J., & Kelley, J. (2007). Health assessment in nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.

Wilson, S., & Giddens, J. (2009). Health assessment for nursing practice (4th ed.). St. Louis, Mo: Mosby/Elsevier. Case Study: Head-to-Toe Assessment Steps

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