Question

1. In a complete full head to toe assessment, Discuss a better ways in gathering and organization of your assessment data.

2. discus abnormal findings

Answer 1

Ans){1) A complete health assessment is a detailed examination that typically includes a thorough health history and comprehensive head-to-toe physical exam. This type of assessment may be performed by registered nurses in community-based settings such as initial home visits or in acute care settings upon admission.

- During an assessment, the first thing that should be noted is the patient’s overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.”

Here is a quick order of a head-to-toe assessment:

General Status
Vital signs
Head, Ears, Eyes, Nose, Throat
Neck
Respiratory
Cardiac
Abdomen
Pulses
Extremities
Skin
Neurological

2) Abnormal findings:

Check for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.
Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes.

Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure.

Check hair for the presence of lice and/or nits (eggs), which are oval in shape and adhere to the hair shaft.

Chest expansion may be asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, or pneumothorax.
Use of accessory muscles may indicate acute airway obstruction or massive atelectasis.

Jugular distension of more than 3 cm above the sternal angle while the patient is at 45º may indicate cardiac failure.

The presence of crackles or wheezing must be further assessed, documented, and reported. Unusual findings should be followed up with a focused respiratory assessment.

Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.
Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum.

Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.

Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis.

Unusual findings in urine output may indicate compromised urinary function. Follow up with a focused gastrointestinal and genitourinary assessment.

Unusual findings with bowel movements should be followed up with a focused gastrointestinal and genitourinary assessment.

Check for curvature or abnormalities in the spine.
Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.