...The Head to Toe Assessment Principles of Assessment for RN’s Edward is a 45 year old male who is present today for his Annual Physical Examination. He is asymptomatic and has no complaints. Subjective: History: The patient has a history of Chicken Pox at 5 years old. He has been a smoker for 25 years and currently smokes 2 packs a day. He consumes alcohol daily 2-4 glasses of wine. He reports of history of depression and anxiety 3 years ago after separating from his wife. His is not currently on any medications. He also has a history of a positive TB skin test with no active disease. The patient spent 15 years in the military traveling overseas. He had right rotator cuff surgery 10 years ago. Objective: Head to toe Assessment: The patient is smiling Alert and oriented to self, place and time. Conversation is appropriate. His skin is normal, warm and dry and turgor is good, He has good posture and answers all questions appropriately without delay. He is 6ft. 195 pounds and has not complaints about appetite. He reports that he is eating well. There are no obvious physical deformities. Gait is steady Head and Face The hair, Scalp and cranium are normal on palpation. The hair and scalp are not too oily or too dry. There are no visible or palpable masses on the cranium and it feels intact. Visual inspection of the eyebrows, palpebral fissures, nasal-labial folds, and sides of the mouth are symmetric indicating that Cranial Nerve VII is intact. Pulses on the temporal...
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...Head to Toe Assessment DO IT! SAY IT! Gather Equipment Enter Room, wash hands 1. Good morning, my name is “Student” & I’m am going to be your student nurse today. How are you doing? 2. Pull Curtain closed * Can you tell me your name and date of birth (match it to the wrist band) * I have reviewed your health history and I see you have already changed to a gown, have you been able to provide a urine specimen? * I am going to do a head to toe assessment on you, this will assess your body systems and their functions During this assessment I am going to ask you some questions, inspect, touch, and listen with my stethoscope to different areas of your body. If you have any questions now or throughout the assessment, please feel free to ask questions and if at any time I make you feel uncomfortable, please let me know. Do you have any questions before we begin? Level of consciousness * Can you tell me where you are and why you are here? * Can you tell me what day it is? **Patient is alert & oriented x 4 to self, place, time, & situation Observe posture, body movements NV and V speech and expressions, mood, expressions **Body posture, speech, NV and verbal communication is appropriate for the situation. Based on conversation mood, feelings and expressions/perceptions are appropriate for this patient. Patient understands current situation at hand...
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...event log and CD, also he is specifically responsible for monitoring the patient’s vital signs during the procedure, spending the most of the procedure behind the computer, taking pressure measurements, making printouts, and providing other information as needed (Watson & Gorski, 2011). In centers with many laboratories, there may also be an X-ray technician who is responsible for maintenance and smooth running of the X-ray equipment. It has been learned that the optimal patient care is given when staff members cross-train; that is, they are trained and able to work comfortably in each job area in the lab. (Watson & Gorski, 2011). Nursing role, A- Before heart catheterization Proper assessment, planning, and evaluation of medical condition and overall health for the patients undergoing cardiac catheterization procedures are necessary, to ensure good outcomes. Preparing patients and their families decreases anxiety, promotes cooperation, improve their capacity for understanding, and provides an opportunity to define patient concerns, educate, and establish a trusting nurse-patient relationship (Moser, & Riegel, 2008). Verifying that the cardiologist has explained the procedure and its risks and benefits to reduce patient anxiety, Anxiety can affect the cardiovascular system (CVS) by stimulating cardiac irritability and increasing basal metabolic rate, broncho-dilatation, blood pressure, catecholamine release (De...
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...Steps of the nursing process: 1. Assess 2. Diagnose 3. Plan 4. Implement 5. Evaluate What each step means to me: The first thing that you have to do is go in and introduce yourself to the patient. After you introduce yourself and get to know your patient a little, you can begin with the first stage. The assessment stage is when you have to do a head to toe assessment on your patient. In your head to toe assessment, you need to include the following: head, eyes, ears, nose, throat, mouth, level of consciousness and orientation, skin, heart and lungs, abdomen, and extremities. It is very important to include every part in your head to toe assessment; otherwise you will not fully know everything about your patient. The next step is diagnose, and this means to use a nursing diagnosis for your patient. The next step is to plan. As the nurse, you need to make a plan for your patient based on the diagnosis that you came up with. This is when nursing care plans are usually used. The fourth step is the implementing step. In this step, the nurse takes the care plan and everything from the diagnosis and plan and puts it to use with their patient. The nurse needs to make sure to use every part of their plan and puts it to use with their patient. If they forget one part, then their patient might not get all the care that they need. Each step in the nursing process is just as important as the...
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...There are many similarities between a RN and an APRN physical examination, yet there are differences as well. Both a RN and an APRN are conducting physical exam to determine and differentiate normal from abnormal findings. Both will used a general survey to gather patient history and perform head to toe physical exam. Both might gather information on family history, smoking history, nutrition history, and so forth. In addition, they will perform complete head to toe assessment of the body systems. In an acute care setting, I believe that a RN spend more time on initial assessment during admission and on subsequent days the assessment is not thorough. In addition, the RN are entitled to check vital signs in acute setting or an LPN checks vital...
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...CaucasianWeight: 109 kg 240 poundsHeight: 183cm 72 inchesReligion: ProtestantMajor Support: Jon (son) Phone: 869-555-3452Allergies: no known allergiesImmunizations: Influenza last fall; tetanus – 4 years agoAttending Physician/Team: Dr. Frank BakerPast Medical History: Diabetes Type 2 diagnosed ______ (insert month that is six months prior)History of Present illness:Developed an ulcer on his big toe that was treated at home for 2 weeks. Son brought patient to ER 6 days ago and patient was treated for sepsis with IV antibiotics.Social History: Widower; Son (Jon) lives nearbyPrimary Medical Diagnosis: SepsisSurgeries/Procedures & Dates: L4-5 laminectomy – 25 years ago; transurethral resection of the prostate – 6 years agoNursing Diagnoses: Impaired Walking; Impaired Skin Integrity; Ineffective Health Maintenance; Ineffective Self Health Management | Psychomotor Skills Required Prior to Simulation Basic head to toe assessmentAssisting a patient with ambulationWound assessment and wet to damp dressing changeCognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]SBAR or other standardized communication tool (R)Readings on functional decline in the hospitalized older adult (R)Tools in the Try This ® and How to Try This Series, available at www.ConsultGeriRN.org.Specific tools recommended for this scenario are theKatz...
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...wishes. J.L. was referred to our clinic by his neurologist to determine his assistive technology needs. CLINICAL CONSIDERATIONS: J.L.’s consistent motor access points consisted of four areas: bilateral hip ab/adduction(L2, L3) – manifested through his knees; right foot (L4, L5, S1); Tibialis Anterior, Extensor Hallicis, Gastrocnemius – manifested by dorsi/plantar flexion of the ankle and extension of the great toe, and head movement was intact. It was clear that J.L. had multiple motor points at the time of the initial assessment; however, as the pathology progresses, the OP and other team members have to take into consideration the possibility that those motor points will degenerate and prepare for the possibility of only one switch site. Thus, how and where the switch(es) would be mounted was an issue that needed careful consideration. TREATMENT/APPROACH: After thorough assessment, and extensive equipment trials, the team determined J.L.’s assistive technology prescription. J.L.’s consistent motor access points consisted of four areas: his knees, his big toe, and his head. It was very important to choose appropriate devices that would be flexible to adapt as...
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...Clinical Foundations – Semester 2, 2013 Clinical Practice Examination: Systematic approach Student: Student Number: Overall Mark: Systematic Approach to Patient Assessment Examiner : 2nd officer: Concept Area and description of performance criteria Approach to scene The student should describe to the examiner the use of PPE, standard precautions and safety equipment. Focus points Explains the use of standard or additional precautions Describes the use of the following gloves; glasses; clothing helmet reflective vest Explains the type of information being sought in the following areas and provides professional inferences on patient condition number of patients exact location time of day weather time to scene / time to hospital partner & qualifications back-up (level & time away) access and egress enquires about nearest appropriate hospital TO TAL /6 Pre brief The student should describe to the examiner the concepts of a systematic pre brief. /10 Concept Area and description of performance criteria Primary survey The student should discuss and demonstrate the primary survey with the examiner and explain their actions. Focus points Explains the type of information being sought in the following areas and provides professional inferences on Danger Verbalise (Assessment of hazards to self; partner patient; bystander and other emergency services) Introduce self and partner Takes time to observe and comment on patient’s overall presentation...
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...Associate Level Material Appendix B Security Assessment Directions: Choose one of the Facts for Consideration sections from Ch. 3 of the text and list the page number for the section you chose. Then, complete the following table. List five threats appropriate to the environment from the section you chose. Rate the risk for each threat from 0 (low) to 10 (high). Then, list five appropriate countermeasures. Once you complete the table, write a brief explanation of the countermeasures for the two threats with the highest risk total, stating how the countermeasure reduces the risk associated with that threat. This assessment is based on the Facts for Consideration on page _93___ | | | | |THREAT |RISK |COUNTERMEASURE | | |Probability |Criticality |Total | | |Example: | | | | | |Physical assault |9 |4 |13 |Highly visible officer presence | |Missing prisoners |4 |10 |14 |Check prisoners and count each...
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...1. The roles of the nurses in the Emergency Department: The nurses receive brief report from the paramedics and sign the report. Because the patients normally have multiple signs and symptoms, the ER nurses need to perform a focused assessment and head to toe assessment. They find out the causes of the chief complains and conduct several tests. The nurses ask pertinent questions in regard to additional signs and symptoms. In trauma, they perform immediate treatment and to prevent respiratory distress by following ABC’s rule. Since emergency rooms in the hospitals provide rapid care to the patients, the triage nurse is to select the patient who develops sudden and serious symptoms of disease. The triage nurses are a very valuable team member because they take patient’s vital signs and reasons for visiting the ER. Then they evaluate the patients to determine the urgency of their needs. 2. The critical thinking necessary to work in Emergency Department nursing: Emergency Department nursing is different from other kinds of nursing. It requires specific skills to assess the immediate needs of the unstable patients. Reevaluating and prioritizing care of the critical phase of illnesses or injuries are necessary to work in Emergency Department. Since the diagnosis and the cause of the diseases are not yet known, the ER nurse need excellent nursing practices to advocate for patient safety. 3. Types of patients in ER: Some patients that I cared for...
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...Timely recognition and prompt diagnosis of an atypical presentation in elderly patients can improve the patients’ outcome, and reduce the risk of death and prolonged hospitalization (Gray-Miceli, 2005). Performing a comprehensive assessment is necessary to evaluate the current symptoms and illnesses of the patient. In the case scenario, it says that the onset of the patient’s decline in mental status and physical condition worsened 3 weeks ago. It might be a great idea to ask the daughter how did her presenting symptoms started. This way, I can have a better understanding of the progress of the patient’s presenting symptoms. I will also ask Ms. N’s daughter how is her mother’s health in general. This will help me understand and evaluate Ms. N’s overall health status. It is vital to find out if the patient is complaining of pain. Chronic pain is common in older adult and their persistent pain can manifest multiple symptoms such as confusion, eating and sleeping disturbances...
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...Focussed Assessment In the given case study patient has persistence vomiting for eight days and she took Antaacids to relieve the symptoms. She is dehydrated, and her lab results shows she has metabolic alkalosis. In focused assessment, detailed nursing assessment of particular body system(s) connected to the current problem is required. One or more body system may be involved.Nausea and vomiting can ocurr due to different reasons like food poisoning,chloecystitis or intestinal obstruction..For the patient with vomitting,intially the health care provider need to pay attention to signs of dehydration. Like assessing monitoring blood pressure and observing for hypotension, skin turgour and mucous membranes changes (McCance, Huether, Brashers, & Neal, 2014). General Assessment: Patient had dark circles under the eyes. She looked worn out. She was feeling anxious. Her energy level was very low. She was speaking very slowly. Abdominal Examination: Abdomen is soft to touch. Patient has some epigastric pain. Bowel sounds are decreased.No bloating or acidity. Signs of hypo-motility may indicate an increased risk for nausea and vomiting. Cardiovascular system: Patient is hypotensive with tachycardia. No heart regurgitation or murmur. Heart rhytm is regular. Patient is feeling tired and dizzy. Pulmonary system: Patient is in metabolic alkalosis. Respirations rate is low 12 breaths per minute. Patient is taking deep regular breaths. Lungs are clear to ausculation...
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...A comprehensive assessment of the geriatric patient is very important for many reasons and the first being a baseline if nothing else. Today when we use the term geriatric or elderly this does not mean that this person is in a wheelchair or walking with a walker, it is in regards to where they are in their lifespan. Therefore a comprehensive assessment for one may be totally different for another. The healthcare provider needs to keep in mind that this could make the geriatric patient have feelings of hopelessness and helplessness. Comprehensive geriatric assessment (CGA) should being with collecting a health history by interviewing the patient and their family members if needed. The healthcare provider wants to promote an efficient exchange of information and build a rapport with the patient and family. The healthcare provider needs to speak clearly and minimize distractions, give a brief overview of what you will be doing (Lynder, 2011). The CGA can also be done with an interdisciplinary team (Hirth, 2003). The healthcare providers are looking for current and past medical history. A list of current prescription and non-prescription medications are to be recorded. Next we can move to the physical examination, head-to-toe assessment. The healthcare provider would start by assessing: * The skin, looking for moles that are dark or irregular in size, bruising and elasticity of the skin. Checking for pressure ulcers or sores that are not healing properly (Lynder, 2011). ...
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...one-to-one interaction with others (Interact between men and women). That’s may be a reason the husband refuse to leave the room. In other to obtain an interview and process to physical examination, the first thing nurse should do is to building trusty relationship with them. I would show them the sensitive of culture awareness. I will explain to them the important of thorough head-to-toe assessment to evaluation for any invisible injury and the need to provide privacy to the patient. Once gain the trust, I then can ask the husband to leave the room for a short period of time during the physical assessment. Naturally, because of the injury it is suspected a domestic abuse case. I start the Abuse Assessment Screen (AAS) question to assess if there is an intimate partner violence case (Jarvis, 2012). If she still says no and avoid eye contact. I will explain to her that she is at the most softest place right now and she is protected. In addition, “an instrument such as the Women’s Experience with Battering (WEB) scale might be used” (Jarvis, 2012) Reference Jarvis, C. (2012). Physical examination and health assessment (6th ed.). Toronto: Saunders Elsevier. Interact between men and women. Retrieved on 1/20/2014 from http://echodepiction.wordpress.com/category/arab-culture/page/2/ Arab Culture Awareness. Retrieved...
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...Health Assessment Physical Assessment Documentation Form Date: __3/3/16 Patient Information Patient Initials | LD | Age | 30 | Sex | Female | General Survey Does patient appear to be their stated age? | Yes | Level of consciousness | Alert and Oriented x3 | Skin color | Caucasain | Nutritional status | No malnurishment noted, pt she eats three meals a day | Posture and position | Patient maintains good posture and position | Obvious physical deformities | No physical deformities noted | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet, ankles, and arms, no Involuntary twitches or movements noted | Facial expression | No abnormal facial expressions noted, pt has nice smile | Mood and affect | patient appears to be in good spirits, patient has smile on face, pt cooperative and answers questions when prompted | Speech: articulation, pattern, content and appropriate, native language | patient speaks English appropriately, patient articulates and enunciates well, all content related to pt’s health | Hearing | patient denies hearing problems, patient able to hear and follow commands when directed | Personal hygiene | patient appears clean, no dirty skin visible, no foul smells noted | | | | | Measurements and Vital Signs Height | 5 foot...
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