Head to Toe Assessment Essay
These assessments evaluate the efficiency of the nursing interventions conducted on the patient in former times. The primary objective of this assessment is to establish the status of the patient and to record patient's responses to actual or prospective problems. This research essay entails a head to toe assessment of a 42-year-old Caucasian male who was one of the chosen participants. In the body of the research essay, there will be reviews for each system with normal and abnormal findings. These findings will go together with normal laboratory findings for different client ages. Concerning the nose, the nurse would inspect for congestion, difficulty breathing, drainage, and their sense of smell. Regarding the throat and mouth, the nurse would check mucous membranes, the presence of lesions, teeth or dentures, odor, their ability to swallow, the trachea, the lymph nodes and the state of the tongue (Jarvis, 2012).
The level of consciousness and orientation The nurse would test for awareness and orientation by asking the patient a series of questions like their name, place, and the time of the day. Criteria for testing orientation would be asking the patient the purpose of the assessments or whether they recognize essential equipment, the nurse is using (Jarvis, 2012). Skin As the nurse inspects the patient, they must examine and take note of the state of the integumentary system for any inconsistencies such as scars, lesions, wounds, redness, or irritation. The face would appear smooth with uniform consistency without nodules or masses (Jarvis, 2012). The eyebrows must comprise evenly distributed hairs with symmetrical alignment and similar movement when the nurse asks the patient to raise or lower the eyebrows.
For normal findings, the eyelashes should have equal distribution and curl outwardly. The eyelids must comprise no discharges, discolorations and the lids must close symmetrically with involuntary blinks at the rate of roughly 15 to 20 times per minute (Jarvis, 2012). Concerning the eyes, the bulbar conjunctiva must appear transparent without visible capillaries. When the nurse palpates the ears for texture, the auricles must be mobile, firm, and not tender. The pinna must recoil when the nurse folds (Jarvis, 2012). Regarding the nose and sinus, the nose must appear symmetric, straight, and uniform in coloration. The nose must not comprise of discharges, and when the nurse palpates them, there must be an absence of tenderness and lesions (Jarvis, 2012). The patient's mouth must comprise of a uniform pink color with evenly distributed moisture, symmetrical and consist of smooth texture.
There must be no visible pulsations on the aortic and pulmonic regions. The abdomen of the patient must comprise unblemished skin with uniform pigmentation. The contours of the stomach must be symmetric with symmetric movements related to the patient's respiration. The jugular veins must be visible to the nurse. When the nurse presses the patient's nails between the fingers, the nails must resume normal color in less than four seconds (Jarvis, 2012). For abnormal findings, the eyebrows would be asymmetrically aligned and comprise different movements. The eyelashes would curl unevenly outwards. The eyelids would consist of discharges, discoloration, and asymmetrical and voluntary blinking. The bulbar conjunctiva would have color and invisible or very visible capillaries. The sclera would have color. The neck would consist of tenderness and would flex with difficulty with the presence of masses during palpation.
The movement of the head would be uncoordinated with painful movements, and discomfort during rotation. The chest would appear asymmetrical. The breath sounds would be noisy without rhythm and breathe with effort. The abdomen would comprise asymmetrical movements during respiration. The nurse issued antibiotics to treat a bacterial infection and ointments for the eye. The nurse also recommended that patient maintain proper hygiene by frequently cleaning their hands. The nurse advised the patient to refrain from touching the eyes with hands, using clean towels, and not sharing personal clothing (Deman et al, 2000). The nurse also stressed the importance of avoiding cosmetics during conjunctivitis. These are the appropriate client and age-appropriate evidence based practices strategies for health promotion regarding conjunctivitis. Jarvis, C.
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