| System | Findings (normal/abnormal) | Equipment needed | Laboratory findings |
|---|---|---|---|
| General status and neurological system | Lyle M. Jackson is a 65-year-old Caucasian male with a healthy-looking physique and a good physique. He is very hygienic, something that is reflected in his dental health. He is very articulate and passionate in his speech, indicating that his neurological system is normal. His vital signs, namely the pulse rate, body temperature, blood pressure, and breathing rate, are normal. However, he says that he has recently been in pain, has trouble sleeping, his skin is dry despite hydrating constantly, and he has blood in his urine. | The equipment used includes a pulse oximeter, thermometer, pulse oximeter, heart rate monitor, nebulizer & spirometer, and stethoscope. | His vital signs are normal for a 65-year-old male with a temperature of 97.8⁰F, a pulse rate of 65 beats per minute, breathing at 13 breaths per minute, and blood pressure 120/80, despite reporting that he is in pain and other recent development in his health status. |
| Head, skin, nails, and the integumentary system at large | Mr. Jackson had neither bruising nor rashes on his skin, but his skin was rough and dry on the face and all over the body despite constantly rehydrating and not being out in the sun for the past six hours. Given his general appearance, the current status of Mr. Jackson's skin does not look normal. | The equipment used in this assessment includes a hand-held magnifying lens, a clear and flexible ruler, fluorescing lesions were viewed with a wood lamp and a flashlight. | Mr. Jackson's capillary refill was normal; no lesions were detected on his skin, his skin temperature normal. However, there is redness on his hips, buttocks, elbows, and hells. He has no lice, has a headful of hair, and has not experienced any form of hair loss whatsoever. His nails were normal, indicating cardiovascular problems, chronic bronchitis, and emphysema (Purpora & Prion, 2018). |
| Head and neck (neurological system) | In the assessment, Mr. Jackson's eyes were checked for drainage, and his pupillary response was inspected with a light, as well as his facial symmetry, being all normal, indicating no neurological impairment whatsoever. | The equipment used in this examination was a flashlight swung back and forth to both his pupils to test for the pupillary response to light. Additionally, he brought his diet diary with him to help whether the recent developments in his health are due to allergies. | According to his diet diary, Mr. Jackson's recent health developments are not allergic responses to his diet as his diet has been constant and based on red meat for the past ten years. However, his mucous membrane was hydrated. |
| Abdomen (genital urinary and gastrointestinal system) | Mr. Jackson reported experiencing abdominal pains regularly over the past month, indicating that this genital urinary and gastrointestinal system were not normal. Thus, placing the need for a urine and bowel movement. Additionally, Mr. Jackson reports an increased urge to use the bathroom and indication that his kidney filters might also be comprised s (Misra et al., 2017). | A digestive diagnostic procedure was done on Mr. Jackson, and a defecography was used to check for his stool's completeness after filling his rectum with a soft paste. Urinalysis tools like a clinical centrifuge, urine analyzer, and a conical centrifuge tube were done to check for any kidney-related diseases (Sarnak et al., 2019). | Albumin to creatinine ratio test was conducted in the urinary analysis. His ACR levels were found to be 115 mg-dL, thus indicating macroalbuminuria, the increased presence of proteins in his urine; however, his defecography results indicate that his stool is consistent despite having very abnormal urinalysis. |
| Extremities (cardiovascular system) | Mr. Jackson's legs and arms were inspected for pain, and his skin integrity was checked. His grip's equality and strength were assessed, and his palpation and were all found to be normal. However, further lab tests would be done to check for any underlying issues. | A pedal pulse palpation test was done on Mr. Jackson to check for any form of asymmetry in his cardiovascular system. Additionally, the color, sensation, and warmth of his hands and feet were matched and cross-referenced to determine his perfusion's adequacy. Most of this test required using the medical provider's hands and eyes no other external equipment (Purpora & Prion, 2018). | Mr. Jackson's cardiovascular health was normal, symmetrical, and rhythmic after using a pedal pulse test. Additionally, his grips were found to be equally strong despite having had surgery on his least harm about eighteen months ago. His capillary refill was also normal, indicating that he did not have any respiratory or cardiovascular dysfunction. |
| Back area and the central nervous system at large | The patient reports that he works out five days a week and has never had any back-related problems. His buttocks, back, and spine were inspected, and it indicated that the central nervous system was normal, as he did not have a curvature or any other form of abnormality or pain in his back despite being 65 years old. There were, however, concerns about the effects of his continuation with the constantly difficult physical exercises due to their impact on his body in the future (Purpora & Prion, 2018). | The instruments used to check for curvature on Mr. Jackson's back include a tape measure to check for his lumbar curvature, a gravity goniometer to determine his pelvic angle, and a parallelogram to measure his lumbar curvature. This was to determine whether the constant physical exercise for the past forty years of his life has had any adverse effects on his back (Bryant, 2017). | Mr. Jackson's back and central nervous system were formal and compromised by his constant difficult physical exercise and not affected by the recent kidney-related problems. His posture while standing, sitting, and walking is surprisingly upright given his age, something he attributes to the constant physical exercise and physiotherapy and posture exercises s (Misra et al., 2017). |
| Mobility (Central nervous system) | Mr. Jackson did not have any mobility problems, which he attributes to his persistence in physical activity over the years despite his age. He had no problem with his balance and did not needs any supportive devices. His coordination also looked normal, and he reported having not noticed any change in his coordination whatsoever (Purpora & Prion, 2018). | In the measure mentor Mr. Jackson's gain, the functional gait assessment was carried, which required using a screening tool modern technology like the computerized three-dimensional gait analysis used due to his physical exercises' adverse effects (Bryant, 2017). By observing his movement, Mr. Jackson does not need any form of aid no stand or move around. | A close assessment of Mr. Jackson's central nervous system indicates that he has no problems whatsoever despite his physical exercise and age intensity. The two systems that were found to have been recently compromised are his genital urinary, gastrointestinal, and integumentary systems. This indicates that Mr. Jackson has kidney disease supported by the urinalysis despite having no cardiovascular or blood pressure issues (Misra et al., 2017). His kidney disease does not seem to relate to his lifestyle as he lives a healthy life with diet and physical exercise, but its effect on his skin and abdomen would be treated. |
Head-to-Toe Assessment Example Analysis
An analysis of age-specific risk reduction health screening and immunizations
The patient in this head-to-toe assessment example is 65 years old and thus qualifies for disease screening for kidney cancer and vaccinations against pneumococcal disease and influenzas. This provides the health providers with an opportunity to protect the patient’s health while recovering the two systems that the kidney disease has possibly compromised. The patient will undergo routine checks on his mental health and his level of psychological and physical stress, and the time he dedicates to recovery (Bryant, 2017). Unlike the interventions related to the condition of his kidney, these preventative measures are optional.
Two differential diagnoses (diseases) associated with possible abnormal findings
The abnormalities found on Mr. Jackson’s body include rough and dry skin despite constant rehydration and suspected compromise on his kidney filters; he is at risk of chronic kidney disease or glomerulonephritis. The patient is expected to diseases with the condition in the long run, possibly for the rest of his life, despite the fact he showed no signs of high blood pressure. This indicates that the patient’s kidney functions have deteriorated (Misra et al., 2017). This disease will need immediate and long-term medical attention and even dialysis in case the patient’s kidney filters are completely compromised.
A plan of care (including two priority-nursing diagnoses, interventions, evaluation)
The two systems found to have abnormalities in Mr. Jackson’s body are the genital urinary and gastrointestinal, central nervous system, and integumentary systems. These abnormalities point to the patient being at the risk of kidney disease, which can be prevented by recommending that he get adequate rest. Additionally, he can explore stress-free activities in place of intense workouts, given the fact that he is 65 years old, eats healthy, and exercises regularly (Misra et al., 2017).
The patient will also undergo regular checkups and possible dialysis to determine the kidney disease’s progress and be made aware of the various methods he can use to rectify the medical problem. Close attention will be paid to the patient’s blood pressure levels over the next few months.
Pharmacological treatments can be used to address health issues for this client
To treat the patient’s kidney problems, various interventions can be used to manage the chronic kidney disease or glomerulonephritis so that his kidney filters can regain their function and filter out the excess water or waste. Additionally, the various complications associated with kidney disease can be traced and treated with medications, for example, medication for high blood pressure, anemia, protection of his bones due to intense exercise, and lowering his protein diet (Misra et al., 2017). Therefore, the medication required includes hormone erythropoietin for anemia and angiotensin II receptor blockers, incase problems with blood pressure are detected.
Client and age-appropriate evidenced-based practice strategies for health promotion
The most effective strategy to promote Mr. Jackson’s health and effectively manage his chronic kidney disease would target all his wellness and usurping that his physical and mental stress has been effectively reduced. This goes beyond the pharmacological treatment of the disease and the environmental factors that would help the patient regain use of his kidney filters and his skin recovers (Gao et al., 2020). Frequent medical checkups will help the patient keep track of the patient’s blood pressure, cholesterol levels, or any signs of swelling, especially on his legs.
Read Also: Patient Teaching Plan Examples
References
- Bryant, S. G. (2017). Keeping it in the program: second year nursing students as stand-in patients for first year head-to-toe assessment check-offs. Nurse educator, 42(2), 60-61.
- Gao, Z., Lee, J. E., McDonough, D. J., & Albers, C. (2020). Virtual reality exercise as a coping strategy for health and wellness promotion in older adults during the COVID-19 pandemic.
- Misra, A., Tandon, N., Ebrahim, S., Sattar, N., Alam, D., Shrivastava, U., … & Jafar, T. H. (2017). Diabetes, cardiovascular disease, and chronic kidney disease in South Asia: current status and future directions. bmj, 357.
- Purpora, C., & Prion, S. (2018). Using Student-Produced Video to Validate Head-to-Toe Assessment Performance. Journal of Nursing Education, 57(3), 154-158.
- Sarnak, M. J., Amann, K., Bangalore, S., Cavalcante, J. L., Charytan, D. M., Craig, J. C., … & Marwick, T. H. (2019). Chronic kidney disease and coronary artery disease: JACC state-of-the-art review. Journal of the American College of Cardiology, 74(14), 1823-1838.
