Head-to-Toe Assessment
For this assignment, perform a complete head-to-toe assessment on one of your chosen participants. Your analysis should include the following:
- Topical headings to delineate systems.
- For any system for which you do not have equipment, explain how you would do the assessment.
- Detailed review of each system with normal and abnormal findings, along with normal laboratory findings for client age.
- An analysis of age-specific risk reduction, health screen, and immunizations.
- Your expectation of normal findings and what might indicate abnormal findings in your review of systems.
- The differential diagnosis (disease) associated with possible abnormal findings.
- A plan of care (including nursing diagnosis, interventions, evaluation).
- Client and age-appropriate evidenced based practice strategies for health promotion.
- Pharmacological treatments that can be used to address health issues for this client.
Provide your answers in a 6- to 7-page Microsoft Word document.
Support your responses with examples.
Cite any sources in APA format.
Submission Details
Name your document SU_NSG3012_W4_A2_LastName_FirstInitial.doc.
Incorporate topical heading to delineate systems =
o Perform a full head to toe patient assessment. Ensure the proper identification within your paper of each system you are assessing. For example: Cardiac- than describe your cardiac assessment of your patient, Respiratory- than describe your respiratory assessment of your patient, etc.
o For any system for which you do not have equipment, explain how you would perform the assessment =
o Explain how you as a healthcare provider, would conduct a physical assessment without medical equipment. For example, palpation techniques.
o Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age=
o Provide a detailed patient physical assessment for each major system (cardiac, respiratory, etc.), within a patient SOAP note, ensuring to provide both normal and abnormal patient assessment findings along with appropriate laboratory data.
o Analyzed and explained age specific risk reduction health screen and immunizations =
o Explain the age specific risk (the elderly and pediatric populations) to consider during the health screen and the possible needed immunizations.
o Provided expectations of normal findings and indicated abnormal findings in your patients review of systems =
o Create a full review of each system for a patient, head to toe assessment. Ensure to explain the normal findings, as well as possible abnormal findings in some areas. The abnormal findings will assist you to form appropriate nursing diagnosis and interventions.
o Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings =
o What are possible differential diagnosis (diseases) for your patient related to the health assessment.
o Designed a plan of care including nursing diagnosis, interventions, evaluation =
o Pick one or two main nursing diagnoses (NANDA approved) for your patient (s) based on your assessment findings. The formation of the nursing diagnosis must be: The nursing diagnosis related to (state the main reason the patient falls into this nursing diagnosis) as evidence by (states patient signs and symptoms that support the nursing diagnosis chosen.) For example: “Acute pain R/T bleeding along urinary tract AEB patient reports of pain 10 out of 10.
o Client and age-appropriate evidenced based practice strategies for health promotion
o Pharmacological treatments that can be used to address health issues for this client
o Written components =
o Ensure proper APA format. If you need assistance with APA format, please visit the “Academic Resources” section within the classroom, here you will find numerous sources to ensure academic success, including an APA guide.
