Scribd Logo
Upload

Welcome to Scribd!

  • 29 views

    Head To Toe and 13 Areas of Assessment

    Uploaded by

    SMJ DRD
    The document provides a head-to-toe assessment of a patient. Key findings include bilateral periorbital edema, barely distinguished hearing, dry mucous membranes, neck vein engorgement and supple neck. Chest examination found rapid, shallow breathing, tachypnea, wheezing and crackles. Cardiac examination noted an abnormal rate and irregular rhythm with aortic regurgitation murmur. The abdomen was soft with moderate ascites and absent bowel sounds. The skin was very dry and thin with decreased turgor. Lower extremities had 2+ edema, numbness, impaired sensation and capillary refill over 3 seconds.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Head To Toe and 13 Areas of Assessment

    Uploaded by

    SMJ DRD
    29 views7 pages
    The document provides a head-to-toe assessment of a patient. Key findings include bilateral periorbital edema, barely distinguished hearing, dry mucous membranes, neck vein engorgement and supple neck. Chest examination found rapid, shallow breathing, tachypnea, wheezing and crackles. Cardiac examination noted an abnormal rate and irregular rhythm with aortic regurgitation murmur. The abdomen was soft with moderate ascites and absent bowel sounds. The skin was very dry and thin with decreased turgor. Lower extremities had 2+ edema, numbness, impaired sensation and capillary refill over 3 seconds.

    Original Title

    Head to Toe and 13 areas of Assessment

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document provides a head-to-toe assessment of a patient. Key findings include bilateral periorbital edema, barely distinguished hearing, dry mucous membranes, neck vein engorgement and supple neck. Chest examination found rapid, shallow breathing, tachypnea, wheezing and crackles. Cardiac examination noted an abnormal rate and irregular rhythm with aortic regurgitation murmur. The abdomen was soft with moderate ascites and absent bowel sounds. The skin was very dry and thin with decreased turgor. Lower extremities had 2+ edema, numbness, impaired sensation and capillary refill over 3 seconds.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    29 views7 pages

    Head To Toe and 13 Areas of Assessment

    Uploaded by

    SMJ DRD
    The document provides a head-to-toe assessment of a patient. Key findings include bilateral periorbital edema, barely distinguished hearing, dry mucous membranes, neck vein engorgement and supple neck. Chest examination found rapid, shallow breathing, tachypnea, wheezing and crackles. Cardiac examination noted an abnormal rate and irregular rhythm with aortic regurgitation murmur. The abdomen was soft with moderate ascites and absent bowel sounds. The skin was very dry and thin with decreased turgor. Lower extremities had 2+ edema, numbness, impaired sensation and capillary refill over 3 seconds.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 7

    A.

    Head to Toe Assessment

    The head is round,


    normocephalic, and
    atraumatic ,there are no
    HEAD Inspection Palpation lesions present. The
    head is appropriate to
    the size of the body.
    Conjunctiva and EOM are
    normal. Pupils are equal,
    EYES Inspection round, and reactive to light.
    No scleral icterus. Bilateral
    periorbital edema present.

    Cannot hear clearly and barely


    EARS Inspection Palpation
    distinguished voices.

    Assessed normal findings, No


    NOSE AND SINUSES Inspection
    Abnormalities noticed.

    MOUTH AND PHARYNX Inspection Dry Mucuos Membranes

    (+) Neck vein Engorment,


    NECK Inspection
    Neck supple

    Noticed rapid, shallow


    breathing, Chest pain rate in
    6/10, Tachypnea present, (+)
    CHEST/PULMONARY wheezing noted, Fine bilateral c
    (ANTERIOR AND POSTERIOR Inspection Palpation crackels, decreased air
    WALL) Auscultation movement bilaterally. The
    patient was barely able to finish
    a full sentence due to shortness
    of breath.
    Abnormal rate, Noticed
    irregular rhythm, and abnormal
    CARDIAC Inspection Auscultation
    heart sound with aortic
    regurtitaton murmur.

    Soft, Flat, Noticed moderate


    Inspection Auscultation
    ABDOMEN ascites. and absent bowel
    Palpation Percussion
    sounds. No tenderness noted.

    Notice irregular positioning of


    spine, with weakness, equal
    size on both sides of the
    body, decreased movements
    MUSCULOSKELETAL Inspection
    noted by measuring range of
    motion, no equinus (plantar
    flexion of foot), no
    tenderness.
    Noticed Very dry and thin
    INTEGUMENTARY Inspection Palpation
    skin. Decreased skin turgor.

    No edema, Weakness and


    Tingling sensation. Noticed
    UPPER EXTREMITIES Fine tremors. Normal
    Inspection Palpation
    Capilliary Refill, Noticed
    Clubbing nails
    +2 bilateral pedal edema,
    Numbness and impaired
    LOWER EXTREMITIES Inspection Palpation sensation , Capillary refill >3
    seconds, partial pulse rating
    (+1) faint but detectable,

    1. Psychosocial and Psychological Status


    In Erik Erikson’s Stages of Psychosocial Development, the patient falls under Ego integrity vs.
    Despair applicable for older adult. Patient is a 75-year-old Male, a Lutheran from Wangal, La
    Trinidad. Patient is known also to be outgoing. Alert, awake, able to protect his airway. Moving all
    extremities. No sensation losses
    2. Mental and Emotional Status
    Patient is oriented to time, place and person. He can identify things or names being asked. He
    can recall recent and remote memories he experienced. He is able to readand write and can
    speak tagalog and kankanaey. He is responsive and answers to the questions being asked.
    cooperative at staff nurse and student nurse even to the doctor.
    3. Enviromental Status

    The patient is originally from kapangan, Benguet, currently residing in Wangal, La Trinidad .
    They live in a concrete house . During hospitalization, the patient was able to minimally sleep
    well despite the busy surroundings especially when he was calm. he was admitted to the
    medical ward in a room with a table, away from the window.

    4. Sensory Status

    Visual Status
    The patient does not use any eye glasses and sees any objects around her at a certain
    distance. he was able to identify the proper color of objects; used two different colors for to help
    her distinguish which is which, her white-water bottle and the other blue bottle. We also used
    the counting-fingers test, so we asked her to tell us how fingers she could see. We do the peace
    sign and she was able to answer correctly, there’s two. No lesions were noted on both eyes.
    Pupils are equally round, reactive to light, and accommodated by pointing penlight on both
    eyes.

    Auditory Status
    During the assessment, the patient barely distinguish voices in distance. he is responsive to
    verbal stimuli at times; was able to distinguish studentnurse voice through a whisper test and reacts
    when her name is called. No auditory device noted being used by the patient. No abnormalities
    findings noticed.
    Olfactory Status
    The patient does not have any difficulty distinguishing different scents. The student nurse provided
    fragrant smell to patient and identified appropriately. This was used to test if the patient can
    differentiate various smells. The patient answered correctly signifying that she can smell
    normally. No obstruction and discharge noticed.
    Gustatory Status
    Upon Assessment, the patient is not using any dentures. Difficulty of swallowing was observed.
    Noticed pale pink and dry mucuos membrane For this test, the patient was asked to taste
    random foods and able to identifiedaccordingly. Patient X has no trouble in distinguishing flavors.
    Tactile Status
    The patient was able to differentiate between hot and cold sensations. When he is cold. As for
    the cold sensation, We used sharp and dull pen ends for this test as well. Noticed numbness in
    lower extremities . We also asked her how he felt when the pricking test was he said it was a
    little painful.
    5. Motor Status
    Upon Assessment, Noticed minimal hand tremors. unsteady may be due deficiency in cardiac
    output and side effects of medication . Due to his present illness the patient has difficulty in
    coordinating movements and performing activities of daily living.

    6. Thermoregulatory Status

    Date Time Temperature Finding and


    Implications
    March 20, 2023 8 am
    12 pm
    4 pm

    March 21, 2023 8 am


    12 pm
    4pm

    March 22, 2023 8 am


    12 pm
    4pm

    7. Respiratory Status

    Date Time Respiratory Rate Finding and


    Implications
    March 20, 2023 8 am
    12 pm
    4 pm
    March 21, 2023 8 am
    12 pm
    4pm

    March 22, 2023 8 am


    12 pm
    4pm

    8. Oxygen Saturation Status

    Date Time SPO2 Rate Finding and


    Implications
    March 20, 2023 8 am
    12 pm
    4 pm

    March 21, 2023 8 am


    12 pm
    4pm

    March 22, 2023 8 am


    12 pm
    4pm

    9. Circulatroy Status

    Date Time CR Finding and


    Implications
    March 20, 2023 8 am
    12 pm
    4 pm

    March 21, 2023 8 am


    12 pm
    4pm

    March 22, 2023 8 am


    12 pm
    4pm
    10. Blood Pressure Status

    Date Time BP Finding and


    Implications
    March 20, 2023 8 am
    12 pm
    4 pm

    March 21, 2023 8 am


    12 pm
    4pm

    March 22, 2023 8 am


    12 pm
    4pm

    9. Nutritional Status
    Prior to admission, Patient is in Diet As Tolerated with 2 Egg whites meal intake three times a day.
    The food served is usually vegetables, fish and sometimes meat with egg whites. He always eats fruit.
    During admission, the food is served patient is low in salt and fat. He was advised by the doctor to
    eat food rich in protein and carbohydrates.

    10. Elimination Status

    During hospitalization, the patient verbalized that he has swallowing and urinating. , There is an
    altered Input and Output ratio with a total Input of 450 mL and an Output of 730 mL. M i n i m a l
    d e f e c a ti o n a t l e a s t 1 x a d a y , d u r i n g t h e 3 d a y s h i ft a t m e d i c a l w a r d .

    11. Sleep, Rest, and Comfort Status

    Prior to hospitalization, the patient stated that she rests and sleeps about 6 to 7 hours a day. He
    stated that sometimes her sleep is interrupted when student nurse get vital signs early in the
    morning, During assessment, the patient has disturbed sleep and feels restlessness and fatigue due
    from the usual rounds, intensive observation of the patient. Also, he verbalized that he is
    uncomfortable due to laying on the bed for too long and having severe back pain.

    12. Fluid and Electrolyte Status

    Prior to admission, the patient stated that she drinks about 5 glasses per day. During hospitalization.
    Noticed very dry skin and decreased skin turgor, Edema was observed on the lower extremities.

    13. Integumentary Status


    During the assessment, she has a poor skin turgor (>3 secs), no history of skin allergy. brown in color,
    wrinkled and dry. His hair is thin and fine. His conjunctiva is slightly pale and sclera is white in color.
    His nails are long and nail beds are pale in color. Clubbing of nails noted upon inspection

    You might also like