Importance Of Head To Toe Assessment

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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 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…show more content…
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? 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 presence of…show more content…
I put my patient’s head elevated at about thirty degree. First, I inspect for jugular neck veins distention, none present. I continue to examine the neck for carotid pulsations, which is present. I now palpate the carotid to feel the pulse, being very cautious not to palpate both carotids at the same time, and then auscultate with the diaphragm of my testhoscope for the presence or absence of bruit. The presence of a bruit would suggest arterial narrowing. None is present in my patient. I am examining the respiration patterns. My examination includes inspection, palpation, percussion, and auscultation of the posterior and anterior thorax. Thorax is symmetric with good expansion. Lungs sounds are resonant with vesicular breath sounds. No rales, wheezes, or rhonchi are noted. As stated prior, pulse oximetry is 98 percent in room air. I will now examine my patient’s abdomen. 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
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