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Nov 24, 2024

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Running Head: HEAD-TO-TOE ASSESSMENT 1 Head-to-Toe Assessment of an Adult Male Lianet Puente South University October 25, 2016

HEAD-TO-TOE ASSESSMENT 2 Subjective data 42 year old black American female is alert and aware of her surroundings, appears to be happy and is smiling, is well-dressed and looks to be fairly good health. Patient has stated that she had a previous head injury when she was in her teens and how has been experiencing headaches off and on over the years but believes that seeking help is irrelevant. Patient stated that she has no other symptoms associated to her headaches. Patient appears to have a cough and stated that it has been on-going for about 8 days but verbalized that she has no other symptoms. Review of Systems Constitutional:  No fatigue, fever or pain.  No appetite changes Skin  No skin discoloration, bruising lesion or bleeding is identified  Head: headachse on and off and no dizziness Eyes:  No change in vision  No blurry vision Ears  No hearing problems,  No ringing in her ear as well as earaches Nose/Throat and Mouth  No sore throats  dry throat

HEAD-TO-TOE ASSESSMENT 3  No toothache  No running noses Respiratory  Complains of persistent coughs that are at times productive and produces a clear sputum  No breathing difficulties Cardiovascular.  No chest pain or palpitation because she has been using a pacemaker  No edema in her legs. Gastrointestinal  Denies vomiting  No nausea as well as constipation Genitourinary  She denies hematuria, polyuria and polydipsia.  No pain when urinating Neurologic  No headaches and she state that stroke attacked her recently.  Weakness in her legs after stroke attacked her.  She experiences difficulties in moving her legs  She cannot recall the past event with ease. Musculoskeletal  No back pains  No joint pain Endocrine:

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HEAD-TO-TOE ASSESSMENT 4  No changes in thirst  No weight loss has been experienced Hematopoietic:  No bleeding or bruises is identified Psychiatric;  Memory problems and cannot remember most of her past events  Denies depression and she has never had suicidal thoughts  No fluctuating moods. Physical Examination  Vital signs  Blood pressure is at 128/72  Respiratory rate is 16 breaths per minute  Pulse rate is at 60 bpm  Temperature afebrile to touch  BMI 28  Generally, the patient is well dressed, overweight, and she appears as per her age. She is cooperative and well oriented. Objective HEENT: Head: Headaches; Normocephalic with no apparent lesions or masses. Hair distribution even, thin. Scalp shows evidence of seborrhea and exhibits no tenderness on palpation. No involuntary facial movements.

HEAD-TO-TOE ASSESSMENT 5 Eyes: EOM intact; Optic discs are of suitable size and appearance. No vessel variations from the norm or discharge. Eye lids are normal; conjunctivae are pale respectively. No evidence of discharge, ptosis or edema. Pupils are round, symmetric, and show immediate and consensual reactivity to light. Visual fields are normal. Ears/Nose/Throat: Outside ears and nose are of symmetric, of customary shape and size. No scars, sores, masses or outside bodies. No delicacy to palpation of ears, nose, or sinuses. External auditory canals seem pink, with trivial cerumen. Tympanic layers are clear and in place. Rinne and Webber tests were normal, and patient was capable of understanding whispered syllables bilaterally. Septum and turbinates are regular and symmetric. Nasal mucosa is moist and pink with no discharge. No evidence of dehydration. Mouth / Dental: Teeth are yellowish in color. Gums are slightly tender to palpation. Patient stated that at times when brushing and flossing they bleed. Oral mucosa, tonsils, tongue, palate, and posterior pharynx are all healthy. No evidence of masses, lesions or other abnormalities. Salivary glands are even and symmetric, and there is no tenderness to palpation. Neck: Neck is symmetric, with no obvious masses, injuries, outside bodies, or different variations from the norm. There is no tenderness to palpation. The trachea is midline. No clear crepitus. Thyroid is symmetric, and of fitting size. The isthmus is found midline, beneath the cricoid ligament. No clear masses, injuries, outside bodies or different variations from the norm. No substantial lymph nodes. Respiration: Chest size and shape are normal. Cough with no evidence of sputum. Tactile fremitus normal when palpated. Right lung well-aerated is resonant to percussion. Crackles, wheezes, rhonchi were heard on auscultation of right lung.

HEAD-TO-TOE ASSESSMENT 6 Skin: Warm to touch and normal in color. Well hydrated. Multiple bullae on back varying in different sizes. Freckles on face. Abdomen: All four quadrants were examined. Hypoactive bowel sounds in the right upper quadrant on auscultation. None noted in other three quadrants. Dull sound of right quadrant by liver on percussion. Slightly tender on palpitation of right quadrant. Cardiovascular: Chest is symmetric, no scars. No cardiac heaves or lifts. Symmetrical expansion with respiration, no other wall motions. No thrills appreciated. Point of maximal impulse (PMI) (apical impulse) noted at mid-clavicle line, in 5th intercostal space. Normal S1 and S2, with regular rate and rhythm. S2 > S1 at the base, S1 > S2 at apex. No splitting of the heart sounds heard. No murmur. Extremities: Full range of motion in all extremities. No bone fracture or deformities. Patient is able to counter act gravity and resistance on ROM. Extremities are of bilaterally equal in size and length. Assessment According to this patient’s head-to-toe assessment, her vital signs are normal, except for her BMI, which would indicate that he is slightly overweight. Her HEENT assessment is typically normal in nature, however a one abnormal finding was present. This patient’s only abnormal finding was that her teeth were discolored yellow and that her gums when palpated were deemed tender. Considering that this patient may have gingivitis there is no real lab or imaging test that would be performed to confirm a diagnosis. Looking at the patient’s respiration findings, her chest is of normal size; however, her right lung appears to be abnormal since there was an indication of wheezing, crackles and

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HEAD-TO-TOE ASSESSMENT 7 rhonchi on auscultation. Lung sounds are not quite the same as transmitted voice sounds. Lung sounds are created inside the lungs, not at all like transmitted voice sounds, which are produced by the larynx. Lung sounds comprise of breath sounds and extrinsic, or strange, sounds heard or distinguished over the mid-section. Ordinary breath sounds are heard over the mid-section divider or trachea. Essentially, breath sounds contains foundation commotions, on which extrinsic sounds are now and then superimposed. Breath sounds are characterized into typical tracheal sound, normal lung sound or vesicular breath sounds, and bronchial breath sound (Sarkar, Madabhavi, Niranjan, & Dogra, 2015). One test that should be performed would be a pulmonary function tests (PFTs), which would measure the capacity, lung volume, gas exchange and rate of flow. The skin assessment shows normal temperature and color with no dehydration. One abnormal finding of the skin was that the patient has multiple bullae on her back and varied in size. Although this could also be bullous, there are a host of varying lab test that can be performed for the confirmation of this diagnosis. These tests consist of CBC with differential, UA, liver function test, and blood urea and electrolytes test would be most beneficial. Abdomen findings were both normal and abnormal. Patient experienced tenderness on palpitation of the right quadrant with a dull sound over the liver. Cardiovascular assessment was normal; no abnormal finding found. Extremities assessment were found to be all normal with no abnormalities. After reviewing all systems of the patient the expectation of normal findings would include the discoloration of her teeth due to possible smoking, which the patient indicated that he was a smoker and had been one for over 25 years. The tenderness of her gums would indicate that due to her smoking and not properly caring for her dental hygiene she has now got

HEAD-TO-TOE ASSESSMENT 8 gingivitis. In terms of her respiration and abdominal assessment, it appears that the patient may be suffering from possible bronchitis and/or some type of liver dysfunction, since there were sounds found within her right lung and tenderness in the right quadrant by the liver. All of these can be contributed to her smoking and her being overweight. Differential Diagnosis Although the patient may have a host of varying conditions, such as gingivitis, bullae of the skin, bronchitis, and some sort of liver condition. Since the patient is a smoker, has yellowish teeth and tender gums he may also be diagnosed with periodontal disease, which would be an infection of the gums and can affect the bone structure that supports our teeth. The skin lesions on her back could be dermatitis herpetiformis, an autoimmune blistering disorder. Although the patient, has some abnormal lung sounds on her respiration assessment, it would likely be diagnosed with bronchitis. However, with like most respiratory there are many differential diagnosis, such as pneumonia, CPOD or asthma; just to name a few. The tenderness of palpation in her right quadrant by this liver can also having varying diagnoses. These vary from liver cancer to cholecystis, to Crohn’s disease. However, formal diagnostic and lab test need to be carried out in order to confirm the right diagnoses. Considering the patient’s age, there are a host of age-specific health screenings that she needs to have done. First and foremost, it is important that this patient get her blood pressure tested every two years, along with a cholesterol screening and diabetes screening. These screenings will help to determine if she has any underlining conditions that are accompanied with aging. In addition, she will need to get a prostate sand colon cancer screening performed. Although she is only 42 years of age, getting tested early will help in preventing her from further complications later on in life.

HEAD-TO-TOE ASSESSMENT 9 Hence, it is best that she also gets a dental exam and physical examination done yearly, at which time she can also get her flu shots taken care of. In terms of other vaccination, it would be best that every 10 years she gets a tetanus shot done (Martin & Zieve, 2016). Plan The nursing care plan for this patient would be to first education her on how to quit smoking. Many of the symptoms that she is experiencing could all be contributed to him smoking for many years. Since the patient had been smoking for 25 plus years, it may be beneficial for her to get into nicotine replacement therapy. Although this particular type of therapy is pharmaceutical based (i.e. patches), having a group session with others that are quitting smoking would offer this patient a greater responses to quitting. It would be best to refer the patient to a gastroenterologist to get a liver function test. In addition, I would also refer this patient to pulmonologist to check her lung function since there was a small abnormality finding during her assessment. Furthermore, I would recommend that the patient make long lasting lifestyle changes, such as eating healthier foods like fresh fruits and vegetables, lean proteins and for him to start a regular exercise regimen that would allow for him to lose some weight since is a tad bit overweight. I would also recommend that he start seeing her primary care physician and dentist, yearly to keep up on all and any health screenings that he may need and also prescribe him medications for the possible bronchitis. I would them advise him to follow-up with all appointments with me as well as with all her specialty physicians and that we collectively work together in helping this patient get better and to make certain that the patient is on the right track. Pharmacological Treatments

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HEAD-TO-TOE ASSESSMENT 10 There are a few pharmacological treatments that this patient would need. Like stated above, he can be placed on a nicotine replacement therapy (i.e. patches, gum, etc.) to help him quit or be prescribed Zyban for him. Hence, another pharmacological treatment that would be beneficial would be PerioGard for treat the gingivitis. Various other type of antibiotics would be prescribed to this patient once a formal diagnosis was confirmed. References CDC. (2009). Reducing Tobacco Use | The Community Guide. Retrieved from https://www.thecommunityguide.org/topic/tobacco#Publications Haugh, K. H. (2015). Head-to-toe. Nursing , 45 (12), 58-61. doi:10.1097/01.nurse.0000473396.43930.9d King, B., Pechacek, T., & Mariolis, P. (2014). Best practices for comprehensive tobacco control programs--2014 . Retrieved from Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health (OSH) website: http://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/ comprehensive.pdf Martin, L. J., & Zieve, D. (2016). Health screening - men - ages 40 to 64. In U.S. National Library of Medicine . Bethesda, ME: MediLine Plus. National Research Council. (2003). Fulfilling the Potential for Cancer Prevention and Early Detection. The National Academies Press . Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015). Auscultation of the respiratory system. Ann Thorac Med , 10 (3), 158. doi:10.4103/1817-1737.160831

HEAD-TO-TOE ASSESSMENT 11

heent week4

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