Head-To-Toe Assessment on a 52-Year-Old Man with Joints and Chest Pains

Introduction

Being a nurse is a very demanding job as it requires them to do so many things to their patients. However, one of the essential functions of a nurse is to conduct a head-to-toe assessment on all their patients. A head-to-toe assessment can be defined as the health assessment or a physical examination done on every patient. This is what forms the basis on which doctors and nurses understand health problems affecting a patient. This paper will do an in-depth head to toe health assessment on a 52-year-old man who has come to visit a hospital complaining of pains in his chest and leg joints.  

Preparation of the head-to-toe assessment

This paper will do a deep head to toe assessment of a 52-year-old male that visited a health institution after complaining of chest and joint pain. The assessment will be comprehensive, and it will cover normal and abnormal findings, lab screenings, a description of risk reduction, immunizations. The procedure will also come up with a plan to help promote the right living and healthy life of the patient. This is what will also be used in treating all the abnormal findings that will be noted in the patient. 

To conduct the head to toe health assessment well, one should ensure they have the following equipment: 

• Gloves, 
• blood pressure cuff, 
• Thermometer, 
• Watch, 
• Height wall ruler, 
• Scale, and
• Tape measure and stethoscope

A nurse may also have the following equipment for additional examinations:

• Ophthalmoscope, 
• An otoscope,
• Reflex hammer

Safety is also paramount when conducting a head to toe assessment and for this reason, the following should be done:

• Always start by cleaning hands
• Introduce yourself to the patient and explain to them what it is you want to conduct on them and why this is very important 
• Ask the patient to identify themselves and state `how old they are 
• Make clear the process of what you are about to do to the patient.
• Observe all simples cues on the patient and act accordingly
• Establishing trust is very important to this process, and it helps the patient open up about themselves and their health issues more easily
• After all the above have been established, the head to toe assessment procedure should commence in a private room

The nurse should then start by evaluating the patients ABCCS and determine if they are functioning well. The ABCCS is the abbreviation for the Airway, Breathing, Circulation, Consciousness, and Safety evaluation.

Conducting the head-to-toe assessment

Nurses need to be well prepared before they perform any physical assessment. This procedure entails an organized and methodical approach, as this is the only way comprehensive measures can be taken to ensure that the system is done well. All procedures associated with palpation, examination, percussion, and auscultation should be done procedurally. When this process is being conducted, the nurse needs to make sure that the patient is comfortable and that they trust the nurse completely. This is why, as aforementioned, the nurse has to ensure that they gain the trust of the patient before commencing the procedure. This can be attained through a normal conversation where the nurse will have to introduce themselves to the patient. They should go on to explain to them why they want to assess them. The nurse should also engage the patient and ask them to tell them their name and their date of birth. This is important as it will start to make the patient open up about themselves and how they feel both physically and emotionally.  

Patient: This segment identifies the general physical attributes of the patients 

Vital signs: 

• Height 6’1’’, 
• weight 205 pounds, 
• B/P: 140/80 mm Hg,
•  Breathing: 18 breaths per minute, 
• Pulse: 77 beats per minute,
• Temperature: 98.6°F
• All the vital signs of our patient are within normal limits.

The general appearance of the patient

From what I could observe, they had no glaring abnormality. Apart from a slight limp that was very noticeable when he walked, he seemed reasonable. He had no oral impairment, and all his teeth were present. He was relaxed, and he answered any question asked by me very eloquently and clearly. His was in full control of all his faculties 

Abnormal findings: pain in the chest area and he walked with a slight limp because he complained of pain in his leg joins and more so in the knee and the feet sections of the leg. 

Skin, nails, and hair: 

It is essential to observe and note down the patient’s skin, nails, and hair and more so the appearance and texture. The patients’ skin was looking good for a 52-year-old man. There were no observable bruises, lacerations, and it was well moist and smooth. The areas around the knees, elbows, heels, and behind the neck were a little bit red, and this can be attributed to the pressure that these areas take when one is walking or doing any physical exercises.

The buttocks area were had its skill darker than the rest of the body. This indicated that the patient spends most of his time sitting down, and this was very bad for his health. As a nurse, I advised him to be walking around and doing many physical exercises, as this was one of the best ways to improve his health. While walking in the office, I also advised him to be talking small breaks and walk around the office a bit. A thorough inspection of his hair was done. The hair and general scalp area were very healthy. They were very clean, and there was no infestation of insects such as lice that can indicate the bad hygiene of the patient. This was commendable. The nails were also inspected, and they were very clean. The nails did not have any dirt under them and but they were a bit long, and the patient was advised to cut them short.

Head and neck: 

The eyes were healthy as no drainage was observed. They also had a routine eye color, and this indicated there was no injury, infection, or any allergy had affected them. The mucous membrane of the eyes was normal. The neck was regular, and he could turn it sideways and upward and downward without feeling any pain. He could also swallow both food and liquids easily without any problems. 

Abnormal finding: No abnormality was seen in these two areas. 

4. Chest: The rib cage was not regular. It was expanded, and this indicated there might be some issues with the chest. Further studies should be done on the chest to help determine if the patient is suffering from complications like pneumonia, atelectasis, fractured ribs, or pneumothorax. The jugular was reasonable, and it did not show any signs of swelling. The swelling of the jugular can indicate problems with the heart and other conditions that can lead to cardiac arrest. The patient was wheezing an indication that there was something wrong with the patient’s lungs.  

Abdomen: the abdomen area was healthy. There was no tenderness, soreness, or abdominal pains observed. This shows that many organs located in the abdominal area were very healthy and functioning correctly. These organs include the liver, appendix, kidney, and the small and large intestines. The bowel movement was perfect. The urine output was about 50 ml per hour. The urine passed was bright in color, and it did not have any foul odor. All these indicated that the patient’s urinary system was functioning correctly and that he did not have any infection in the system.  

Genital assessment: 

The genital area was also observed, and this was what was found. It was clean, and there was no rash, no odor, rashes, lesions, or lumps, or lesions. This was very important because genital areas that have foul smell can indicate sexually transmitted diseases or even cancer. There was no bulge in the groin or the scrotum; a bulge in the groin can indicate hernia whereas an enlarged scrotum can be due to hernia, cyst or a tumor.

Anus and rectum inspection: 

It is essential to inspect the anus and rectum sections when conducting a health assessment. From what was observed, this area had intact skin, and it was smooth. A more in-depth inspection did not discover any hemorrhoids. This was a good indication because hemorrhoids in the rectum and anus can indicate deeper health issues with the patient.

Risk Reduction

 To help reduce the pains in the chest and joints, the patient will be advised to take his medication. He will also be required to understand that he needs to have some lifestyle change and avoid the foods and drinks that advance his gout or arthritis. The issue of chest pains is a serious one, and it should be determined what it is that is leading to these chest pains. The patient should then be given medication to help him solve the issue. 

Health Screenings

 The fact that the patient is getting old and more susceptible to the health problem, the patient was advised to be going for a head to toe physical assessment each year.  

Plan of Care

The pain the patient is experiencing in the legs is a result of poor eating habits. To help resolve this issue, the patient will be advised to take healthy meals. Red meat and excessive drinking and smoking are the biggest reasons why people have arthritis. The meals he should be eating should be rich in calcium and iron. He should eat a lot of vegetables and fruits. In addition to this, he should be exercising regularly. This is very important as it would ensure that his body burns out excessive calories and that he avoids being overweight. The patient should also make sure that they maintain their mental health. This can be attained by avoiding stressing factors that can negatively affect their moods. They should also ensure that they in contact with family members as well as close friends.

References

Burton, M., & Ludwig, L. J. M. (2014). Fundamentals of nursing care: Concepts, connections & skills.

Cohen, J. A., Mowchun, J. J., Lawson, V. H., & Robbins, N. M. (2016). A 30-Year-Old Male Requiring Management of Progressive Weakness. Oxford Medicine Online. doi:10.1093/med/9780190491901.003.0006 Haugh, K. H. (2015). Head-to-toe. Nursing, 45(12), 58-61. doi:10.1097/01.nurse.0000473396.43930.9d