analysis of age-specific risk reduction, health screen, and immunizations.

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.

On a separate references page, cite all sources using APA format.

 

Use this APA Citation Helper as a convenient reference for properly citing resources.

This handout will provide you the details of formatting your essay using APA style.

You may create your essay in this APA-formatted template.

Submission Details

Week 4 Assignment 2 Grading Rubric

Assignment components	Unsatisfactory 1	Emerging 2	Proficient 3	Exemplary 4	Score
Incorporated topical headings to delineate systems.	Incorporated topical headings to delineate systems. Details are vague or nonexistent.	Incorporated topical headings to delineate systems. Some examples used, but there is a lack of detail.	Incorporated topical headings to delineate systems. Explanations were good but could be more detailed..	Incorporated topical headings to delineate systems. Specific, detailed evidence is used to support ideas.	_ of 20 points
Analyzed and described how portions of the assessment would be conducted without certain equipment.	Did not analyze and describe how portions of the assessment would be conducted without certain equipment, or the details are vague or nonexistent.	Analyzed and described how portions of the assessment would be conducted without certain equipment. Some examples used, but there is a lack of detail.	Analyzed and described how portions of the assessment would be conducted without certain equipment. Explanations were good but could be more detailed..	Analyzed and described how portions of the assessment would be conducted without certain equipment. Specific, detailed evidence is used to support ideas.	of 20 points
Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age.	Did not provide a detailed review of each system with normal and abnormal findings and did not include normal laboratory findings for client age. Details are vague or nonexistent.	Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age. Some examples used, but there is a lack of detail.	Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age. Explanations were good but could include more detail and use of external resources to support findings.	Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age. Specific, detailed evidence is used to support ideas.	of 16 points

Page 1 of 3

NSG3012 Principles of Assessment for Registered Nurses

© 2015 South University

Analyzed and explained age-specific risk reduction health screen and immunizations.	Did not analyze and explaine age-specific risk reduction health screen and immunizations. Details are vague or nonexistent.	Analyzed and explained age-specific risk reduction health screen and immunizations. Some examples used, but there is a lack of detail.	Analyzed and explained age-specific risk reduction health screen and immunizations. Explanations were good but could be more detailed..	Analyzed and explained age-specific risk reduction health screen and immunizations. Specific, detailed evidence is used to support ideas.	of 16 points
Provided expectations of normal findings and indicated abnormal findings in review of systems.	Did not provide expectations of normal findings and did not indicate abnormal findings in review of systems. Details are vague or nonexistent.	Provided expectations of normal findings and indicated abnormal findings in review of systems. Some examples used, but there is a lack of detail.	Provided expectations of normal findings and indicated abnormal findings in review of systems. Explanations were good but could be more detailed.	Provided expectations of normal findings and indicated abnormal findings in review of systems. Specific, detailed evidence is used to support ideas.	of 16 points
Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings.	Did not Analyze and describe the differential diagnosis (disease) associated with possible abnormal findings. Details are vague or nonexistent.	Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. Some examples used, but there is a lack of detail.	Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. Explanations were good but could be more detailed.	Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. Specific, detailed evidence is used to support ideas.	of 16 points
Designed a plan of care including nursing diagnosis, interventions, evaluation.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Details are vague or nonexistent.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Some examples used, but there is a lack of detail.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Explanations were good but could be more detailed.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Specific, detailed evidence is used to support ideas.	of 16 points
Discussed pharmacological treatments that can be used to address health issues for this client.	Did not discuss pharmacological treatments that can be used to address health issues for this client. Details are vague or nonexistent.	Discussed pharmacological treatments that can be used to address health issues for this client. Some examples used, but there is a lack of detail.	Discussed pharmacological treatments that can be used to address health issues for this client. Explanations were good but could be more detailed.	Discussed pharmacological treatments that can be used to address health issues for this client. Specific, detailed evidence is used to support ideas.	of 20 points
Included evidenced based practice strategies for health promotion.	Did not include evidenced based practice strategies for health promotion. Details are vague or nonexistent.	Included evidenced based practice strategies for health promotion. Some examples used, but there is a lack of detail.	Included evidenced based practice strategies for health promotion. Explanations were good but could be more detailed.	Included evidenced based practice strategies for health promotion. Specific, detailed evidence is used to support ideas.	of 20 points

Written components.	Introduction is limited or missing entirely. Poorly organized document. Transitions are infrequent, illogical, or missing entirely. Conclusion is limited or missing entirely. Writing contains numerous errors in spelling, grammar, or sentence structure that severely interferes with readability and comprehension. No attempt at APA formatting.	Introduction is present but incomplete or underdeveloped. Poorly organized document that interferes with readability and comprehension. Transitions are sporadic. Conclusion is present, but incomplete or underdeveloped. Writing contains numerous errors in spelling, grammar, or sentence structure that somewhat interfere with readability or comprehension. APA format is attempted to paraphrase, quote, and cite, but errors are significant.	Introduction has a clear opening, provides background information, and states the topic. Loosely organized document that may have to be inferred. Transitions are appropriate and help the flow of ideas. Conclusion summarizes main argument and has a clear ending. Writing follows conventions of spelling and grammar throughout. Errors are infrequent and do not interfere with readability or comprehension. APA format is attempted to paraphrase, quote, and cite, but few errors are present.	Introduction catches the reader’s attention, provides compelling and appropriate background information, and clearly states the topic. Well organized document with an appropriate introduction. Transitions are thoughtful and clearly show how ideas relate. Conclusion leaves the reader with a sense of closure and provides concluding insights. Writing follows conventions of spelling and grammar throughout that helps establish a clear idea and aid the reader in following the writer’s logic. APA format is used throughout when appropriate or called for.	of 20 points
				Total Score	of 180 points

Running head: HEAD TO TOE ASSESSMENT 1

HEAD TO TOE ASSESSMENT 13

Head to Toe Assessment

NAME

South University Online

Head to Toe Assessment

This is a complete head to toe assessment of a teenage boy covering; normal and abnormal findings (listed if they exist), a description of risk reduction, health screenings, immunizations, and a plan of care for health promotion with possible treatments for abnormal findings.

Assessment

A complete head to toe assessment is essential in identifying the normal and abnormal findings in patients of all age groups. “Health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyze and synthesize the collected information in order to make judgement about the health status and life processes of individuals” (Guide to Good Nursing Practice Health Assessment, 2006). During the exam the cranial nerves will be assess and listed in parentheses and referenced to the web site; Test Your Cranial Nerves (n.d.).

Patient

Vital Signs: Height 6’ 1”, weight 162 pounds, B/P 132/ 61 (right arm) 134/67 (left arm), HR 72 (measured for a full minute), respirations 16 (measured for a full minute), temperature 98.0 F (oral). There is no pulse oximeter available, but the patient’s skin is clean, warm and dry with no signs of cyanosis. The patient states that he has no pain at this time.

The patient is in the 95th percentile for height and 78th percentile for weight (2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles, 2000). This patient’s body mass index (BMI) is 21.4 and this is considered a healthy BMI (BMI Percentile Calculator for Child and Teen, n.d.). The patient’s vitals are all within normal limits.

Appearance: The patient is well kept sixteen year old male with short brown hair and blue eyes, the patient walked into the room with a steady gait and no signs of distress noted. For the ease of the exam the patient is wearing bike shorts and no shirt.

Orientation: The patient is alert and oriented X 4 (name, date, location, and situation). The patient responds to questions in appropriate manner and follows directions. Speech is clear and well spoken (vagus- ten). Glasgow coma scale findings are: Eye opening – spontaneous (four points), verbal response- oriented (five points), and motor response- obeys commands (six points), for a total of 15; which is a normal response. “Glasgow Coma Scale, n.d.).

Head

The patient’s head is rounded and symmetrical with no signs of lesions, and upon palpation there are no signs of masses or depressions. The patient has short brown hair that is longer in the front than the back, and it is clean and soft with no signs of thinning or brittleness noted.

Face

The patient’s face is symmetrical with no signs of discoloration or lesions. The skin is clean, intact, warm, dry, and consistent with race. Palpation of face including the sinuses (above and below the eyes) showed no masses, depression, or pain noted. The patient has some regrowth of hair noted on cheeks and upper lip, and the patient stated “I have not shaved for a couple days”. The patient has no complaints of pain when palpating the lymph nodes; in front and back of the ears, base of the skull, jaw, and under the chin (Screening Head to Toe Physical Examination 2011 – 2012, 2012). Using a cotton ball and a cotton tip applicator (the sharp and soft end); the patient’s face is touched on his forehead and checks, left and right sides, and the patient feels each side equally (trigeminal- five). To assess for hot and cold sensation on the face an ice cube and a warm washcloth are used, touching forehead and face (left and right sides); the patient feels each equally (trigeminal- five). The patient is able to smile, raise his eyebrows, and puff out his cheeks (facial- seven)

Eyes and Vision

The patient has blue eyes that are symmetrical and evenly spaced with no signs of redness. Examining the pupils with a pen light the pupils are; equal, round, reactive to light, with a brisk reaction. Accommodation is tested by having the patient focus on the examiners finger and bringing it towards the patient’s face, and the patient maintains focus in both eyes (oculomotor -third). The pupil size is a 3 millimeter. Using the pen light the patient is instructed to follow the pen light with his eyes only; the patient is able to follow the light up, down, side to side, and diagonal (trochlear- four and abducens- six). Using a Snellen eye chart, that was printed out, and a tape measure, measured twenty feet, the patient’s vision is 20/20 in both eyes(optic- two) (Snellen Eye Chart, n.d.).

Nose

The nose and nasal septum are midline and the patient is able to breath out of each nostril without difficulty. There is no discharge noted, the nasal mucosa is pink in color, and there is no pain or masses with palpation. To test the patient’s sense of smell the patient is asked to close his eyes and a cup of coffee is placed under the patient’s nostrils. When asked what the patient smells, he states “coffee” (olfactory-one).

Mouth and Throat

Mouth: The patient’s lips are intact with no breaks in the skin. The patient has braces on his teeth and is using rubber bands as part of his orthodontic treatment, his gums a slightly puffy and his teeth have food residue on them. Using the pen light for inspection the patient’s uvula is midline and moves up and down when the patient says ah, and the patient is able to swallow with no difficulties noted (glossopharyngeal- nine and vagus- ten). The patient has a strong gag reflex and this is assessed using the patient’s tooth brush, as there is no tongue depressor available (glossopharyngeal- nine). The patient is asked to stick his tongue out and move it from side to side, with no difficulty noted (hypoglossal- twelve).

Abnormal Findings: The patient’s puffy gums and food residue in the teeth.

Throat: Palpation of the patient’s neck shows no signs of pain or masses. The skin is intact, clean, warm, dry, and consistent with race. When the patient looks up and swallows water there is no evidence of any masses on the front of the neck. Palpation on the back of the neck while the patient drinks water and turns his head reveals no masses.

Ears

The ears are symmetrical and the skin in intact, clean, warm, dry, and consistent with race; the patient has no pain upon palpation, and there are no masses or lesions. Using a pen light to look into the ear, there is some cerumen noted and this is a normal finding. An examination of the inner ear was not able to be performed as there was no otoscope available, but the patient stated that he has no pain. A hearing test using whispering and standing two feet from each ear, was performed and the patient heard without any difficulty (Vestibulochoclear- eight) (Screening Head to Toe Physical Examination 2011 – 2012, 2012).

Chest and Back

The skin on the chest and back has no signs of masses or lesions and is intact, clean, warm, dry, and is consistent with race. There is a small amount of hair noted on the patient’s chest (normal finding). The patient has no pain upon palpation of chest and back. He is able to shrug his shoulders with examiners hands pressing down on the shoulders without any difficulty (accessory- eleven). Percussion of the chest and back presents no abnormal findings. To assess for curvature of the spine, the patient is assessed standing straight and bending over at the waist; and there are no signs of curvature of the spine.

Breast: With the patient lying on his back on the bed, the patient’s breast and axillae are examined and no findings of; masses, lesions, or reports of drainage from the nipple. There is hair in the axillae, which is a normal finding for a male.

Lungs: With the patient sitting up, the lungs are assessed using a stethoscope and listening on the patient’s back in twelve different locations (six on each side of the spine); starting at the apex of the lung (upper back), and working down the patient’s back near bottom of the rib cage. To include, auscultation at the lateral rib area on the rib side to assess the right middle lobe of the lung. The lungs are clear, with equal rise and fall of chest, and no shortness of breath or dyspnea noted. The patient states that he does not have difficulty breathing or a cough.

Heart: With the patient sitting upright the jugular vein is assessed for distention, none noted. With patient lying flat, auscultating the heart using the diaphragm of the stethoscope; starting at the aortic area (right second intercostal space), pulmonic area (left second intercostal space), Erb’s point (left third intercostal space), tricuspid area (left fourth intercostal space), mitral area (left fifth intercostal space- midclavicular). Then using the bell of the stethoscope and listening again, and working backwards on the patient’s chest through the areas again; S1 and S2 noted, but no abnormal cardiac sounds noted. The patient’s pulses (radial, femoral, popliteal, posterior tibial, and dorsalis pedis) are equal on all extremities and no edema is noted. The patient’s capillary refill is less than two seconds, and there are no signs of clubbing of the fingers.

Abdomen

The patient’s abdomen is flat and symmetrical with a small amount of hair noted and no masses, lesions, or scars visible; skin is intact, clean, warm, dry, and consistent with race. Auscultation of bowel sounds with a stethoscope in all four quadrants reveals bowel sounds present and active. Percussion is within normal limits (although difficult to perform). Palpation reveals no masses or complaints of pain from the patient. The patient states he had normal bowel movements every day, and is not having any nausea or vomiting.

Genitourinary

The patient’s genitalia is within normal limits with no masses or lesions noted; skin is clean, warm, dry, and consistent with race. Dark hair is densely dispersed. The patient states that his urination is normal with no changes is frequency or amount urinating. The patient states that he is not sexually active.

Musculoskeletal

The patient’s skin on his legs and arms is intact, clean, warm, dry and consistent with race. The patient has densely dispersed brown hair on bilateral legs and sparsely dispersed hair on bilateral arms. On bilateral upper arms the patient has small bumps that are non-pruritic or painful. The skin on the patient’s hands and feet is intact, clean, warm, dry, and consistent with race. There is no edema noted. A safety pen is used to test sensation on his arms and legs in various locations, and the patient is able to state where the pen is being used and if it pen prick is sharp or dull (based on pressure applied to pen).

When the patient is asked to walk across the room his gait is fast and steady with no signs of distress noted. He is able to walk on tip toes and heels without any difficulty or pain. He is able to raise both arms and legs against the resistance of the examiner pressing against them. The patient is able to raise both arms over his head and out to his side without any difficulty or pain. Gripe strength in both hands are equal.

Abnormal Findings: bilateral upper arms small bumps that are non-pruritic or painful

Risk Reduction

An important risk reduction for a patient of this age group is safe sex, abstinence of drugs and alcohol, vehicle safety, and depression/anxiety. The patient has already states that he is not sexually active; however, handouts on sexually transmitted disease (STDs in Adolescents and Young Adults, 2014) and birth control (Martinez, & Abma, 2015) are given and the topics are discussed.

Education on drugs and alcohol is discussed and the patient states he has tasted alcohol before and did not like it at all, the patient also lives in a household that does not have any alcohol or drugs (to include cigarette smoking), and so he has no plans on breaking his abstinence. A handout is given to the patient (Prevent Underage Alcohol Use, n.d.).

The patient has taken a drivers safety course and loves his new care that his parents bought him, so he drives safety and always wears his seat belt. The patient pointed out that he does not use his cell phone while driving; even though his car has a hands free Bluetooth device, he does not use it. A handout is given to the patient (Teen Drivers: Get the Facts, 2015).

The patient states that he does have anxiety and depression due to school and his grades, he is taking very difficult classes in his junior year of high school and wants to get into a good college. He talks with his friends and family, and they offer good advice which helps with the anxiety and depression. He states that he has no thoughts of suicide or self-harm. Handouts are given on depression (The Balanced Mind Parent Network, 2009) and anxiety (Lyness, 2014)

Abnormal Findings: Depression and anxiety, although at this age it can be normal.

Health Screenings and Immunizations

The patient states that he goes to his doctor every year for his physical, and this is consistent with research (Gavin, 2015). On his last visit he was told to increase his activity and to eat better. Is the last two months, the patient has started an exercise program with a friend and goes to the gym four-five times a week. He is also eating healthier by cutting out simple carbohydrates, and not drinking any soda products. The patient reports increased energy and he has lost ten pounds. He also noticed that working out helps his depression and anxiety.

The patient is up to date on all of his immunization to include his human papilloma virus (HPV), he will need a booster of his meningococcal vaccination before he turns eighteen (Recommended Immunization Schedules for Persons Aged 0Through 18 Years, 2015).

Plan of Care

Nursing Diagnosis

Altered oral mucous membrane related to lack of hygiene as evidenced by the patient’s puffy gums and food residue in his teeth.

Intervention

1. The patient will brush his teeth two times a day using the timer given to him by his orthodontist.

2. The patient will use his water pick every night.

3. The patient will floss his teeth every morning and use the special floss provided to him by his orthodontist.

Evaluation

The patient has noticed that his gums are not as puffy and are feeling better; he plans to continue with the interventions.

Nursing Diagnosis

Impaired Skin Integrity related to dry skin as evidence by bilateral bumps on the upper arms that are non-pruritic or painful.

Intervention

1. The patient will apply a non-perfume lotion to his arms every day after his shower.

2. The patient will not pick at the bumps to possibly cause an infection.

3. The patient will not change any of his lotions, soaps, or detergents until the bumps have improved.

4. If there is no improvement, the patient will see a dermatologist for possible prescription medication.

Evaluation

The patient has just started using the lotion and reports improvement; he has not picked at his arm or changed any of his products.

Nursing Diagnosis

Anxiety and depression related to grades and school as evidenced by patient’s statements.

Intervention

1. The patient will continue to talk with pears and family about fears and listen to their input.

2. Patient will keep a journal to write down what feeling or actions are causing the depression and anxiety, in an attempt to decrease these feelings and learn warning signs for the future.

3. The patient will continue his workouts to help reduce his depression and anxiety.

Evaluation

The patient has already stated that working out has been helping with his anxiety and depression and he plans to continue the workouts. The patient states he will try harder to talk with his family and friends, even though he gets embarrassed to do so. He admits that writing in a journal will be the hardest of the interventions, but he is willing to try.

Conclusion

The assessment of this sixteen year old male proved that he is a healthy young man working towards bettering his health by diet, exercise, and being responsible in his health promotion and risk reduction. The abnormal findings have been discussed and the patient is working towards his goal of better hygiene and anxiety/depression reduction. A systematic thorough head to toe assessment is the best practice for patients, and the result is better interventions and plan of care for the patient to correct any abnormal findings.

References

2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles. (2000). Retrieved from http://www.cdc.gov/growthcharts/data/set1clinical/cj41c021.pdf

BMI Percentile Calculator for Child and Teen. (n.d.). Retrieved from http://nccd.cdc.gov/dnpabmi/Result.aspx?&dob=2/21/1999&dom=11/1/2015&age=201& ht=73&wt=162&gender=1&method=0&inchtext=0&wttext=0

Gavin, M. (2015). Medical care and your 13- to 18-year-old. Retrieved from http://kidshealth.org/parent/system/doctor/medical_care_13_18.html#

Glasgow Coma Scale. (n.d.). Retrieved from http://www.cdc.gov/masstrauma/resources/gcs.pdf

Guide to Good Nursing Practice Health Assessment. (2006). Retrieved from http://www.nchk.org.hk/filemanager/en/pdf/health_assessment_e.pdf

Lyness, A. (2014). Anxiety Disorders. Retrieved from http://kidshealth.org/teen/your_mind/mental_health/anxiety.html#

Martinez, G., & Abma, J. (2015). Sexual activity, contraceptive use, and childbearing of teenagers aged 15–19 in the United States. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db209.htm

Prevent Underage Alcohol Use. (n.d.). Retrieved from http://www.toosmarttostart.samhsa.gov/media/LessonPlan.pdf

Recommended Immunization Schedules for Persons Aged 0Through 18 Years. (2015). Retrieved from http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined- schedule.pdf

Screening Head to Toe Physical Examination 2011 – 2012. (2012). Retrieved from http://www.siumed.edu/oec/CCX_ASSESSMENTS/Y4_folder/HEAD toTOE Guidelines 2012.pdf

Snellen Eye Chart. (n.d.). Retrieved from http://www.i-see.org/snellen.gif

STDs in Adolescents and Young Adults. (2014). Retrieved from http://www.cdc.gov/std/stats13/adol.htm

Teen Drivers: Get the Facts. (2015). Retrieved from http://www.cdc.gov/MotorVehicleSafety/Teen_Drivers/teendrivers_factsheet.html

Test Your Cranial Nerves. (n.d.). Retrieved from https://faculty.washington.edu/chudler/cranial.html

The Balanced Mind Parent Network. (2009). Retrieved from http://www.thebalancedmind.org/learn/library/facts-about-teenage-depression