Head To Toe Assessment

The head-to-toe assessment is a very important process in client care, for it provides essential baseline data about the client. In evaluating my clients, I am able to determine if any change has occurred. As medical providers, a nurse, I often have to care for many patients. Therefore, a comprehensive and systemic method is important to assure a complete assessment in a reasonable timeline.

For this exercise, I am using my wife as my patient. My first step is to wash my hands between patients to prevent the spread of disease. Another important factor to keep in mind is to use standard precaution in assessing patients. I introduce myself and explain the purpose of the head-to-toe assessment. As I walk into the room, I observe if the patient

The abnormal finding would be the patient stating she is at the church and identifies the nurse as someone else. Giving the wrong date and time is not often an abnormal finding. When confined in a place for a while, patients may lose track of date and time. Further assessment would be necessary if he or she does not remember the year. “The nervous system can be divided into two parts: central and peripheral. The central nervous system includes the brain and the spinal cord. The peripheral nervous system includes all the nerves and fibers outside the nervous system (Jarvis, 2014, p. 633). How is the verbal response? Is it oriented or disoriented? Does the patient use inappropriate words or sounds, slur speech? This patient’s speech is clear and the responses appropriate to the verbal command. Next, I will access the eyes. Are the pupils equal, round, and reactive to light with accommodation? The abnormal pupil would be large, abnormal shape, with no reaction to light. Does she use glasses, contact lenses, or implants? Her pupils are round and react to light with accommodation. Next step would be the ears. I would need an otoscope for this exam. It is a medical instrument consisting of a magnifying lens and light. I would light it into the ear to examine the ear canal. I will access for cerumen and drainage. Is there any

This process consists of inspection, auscultation, percussion, and palpation. Auscultation follows inspection to prevent disturbance of the GI track. Before starting, I ask my patient if she wants to empty her bladder. The response is no. I ask about her last bowel movement. She answers it was this morning, and the consistency was normal. I will now analyze the mouth. The teeth are intact with no caries or denture present. The mucosa lining is moist and pink. I start by inspecting the abdominal contour and skin integrity. It is soft and flat. A firm abdomen maybe sign of constipation, lactose intolerance, or disturbance in the bowel, such as in the case of IBS. It may also be a sign of a more serious condition such as aortic aneurysm, which is the enlargement of the aorta, the main vessel that delivers blood to the abdomen. I now divide the abdomen in four quadrants to start listen to the bowel sounds, stating at the right lower quadrant (RLQ). I listen up to five minutes. Sounds are present in all found quadrants. Bowel sounds can be hyperactive, Hypoactive, and normal, absent. Hyperactive bowel sound simply means increase intestinal activity as in the case of diarrhea. Hypoactive bowel sounds are normal after surgery, with certain medications, or during sleep. A normal bowel sound, as in the case of my patient, is five to thirty gurgles per minutes. Absence of bowel sounds can be normal after surgery. It is often due to