Nursing assessment complete head to toe
You completed your full head-to-toe assessment skills demonstration last week and now will document your results. Continue to document only the objective findings for this section without bias or explanation.
Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief. Do not write a book!”
Title: Nursing assessment complete head to toe
Documentation of the complete head to toe physical assessment.
Purpose of Assignment:
To demonstrate the ability to document the findings of an objective head to toe assessment and identify abnormal findings.
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.
Apply assessment techniques for the neurological and respiratory systems.
Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.
- Use of three sections: Subjective, Objective, and Abnormal Findings
- Short descriptive paragraph of findings for each section, including strengths and weaknesses.
- Standard American English (correct grammar, punctuation, etc.)
Documentation Grading Rubric- 20 possible points; Nursing assessment complete head to toe
|Levels of Achievement|
|Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.Failure to provide any objective data will result in zero points for this criteria.
|Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.||Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information||Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information|
|Points: 9||Points: 12||Points: 13.5||Points: 15|
|Strength and Weakness
|Lists one strength and one weakness with no description or reason for selection of them. Failure to provide both one strength and weakness will result in zero points for this criteria.||Provides brief description of one strength and one weakness with no reason for identification of the strength and weakness.||Provides description of one strength and one weakness noted on assessment. Gives reason for identification of the strength and weakness.||Detailed description of one strength and one weakness noted during assessment. Detailed reason provided for identifying the strength and weakness.|
|Points: 1.8||Points: 2.4||Points: 2.7||Points: 3|
|Spelling and Grammar
|Six or more spelling or grammar errors. Detracts from the readability of the submission.||No more than five spelling or grammar errors, minimally detracts from the readability of the submission.||No more than three spelling or grammar errors. Does not detract from the readability of the submission.||No spelling or grammar errors.|
|Points: 1.2||Points: 1.6||Points: 1.8||Points: 2|
|Points: 12||Points: 16||Points: 18||Points: 20|
Subjective: Nursing assessment complete head to toe
Last week’s assessment that I did is explained below;
Ruth Anderson, a 38-year-old single woman rushed into the emergency room (ER) for muscle weakness, double vision and fatigue while eating solid foods in the last 2 days. According to her sister who accompanied her to the ER, she was diagnosed with Myasthenia Gravis a year ago. Her doctor prescribed pyridostigmine, but patient does not take it regularly. She reports having slight headaches from time to time, and she takes ibuprofen to take the pain away. She has no allergies to food or medicine. Familial history reveals that her mother had hypertension, and her father died from complications of lupus.
Nurse Lily: Hi, I am Lily. I will be your nurse today. Can you verify your full name and birthdate?
Ruth: Ruth Anderson. 6/10/1982.
Nurse Lily: Can you tell me what has been going on? And how’ve you been feeling?
Patient: I have recurring episodes of weakness. Last week, I had to put extra effort to brush my teeth. Also, I have had a couple of times when my right eyelid started drooping.
Nurse Lily: Do you experience any pain?
Patient: No, not really. But this is just frustrating because the weakness keeps on repeating. I am afraid that if this progresses further, I will not be able to do anything!
Upon interview, I observed that patient began having shortness of breath while talking, and there was presence of intermittent slurring. There is also mild difficulty in standing up from a sitting position; she sometimes used her arms to help herself get up.
Her vital signs were BP 110/80 mmHg; HR 102 bpm and tachycardic; respiratory rate 18 breaths/min with shortness of breath with exertion; temperature 98.4 degrees Fahrenheit. She is oriented to person, place, and time. Cranial nerves II through XII are intact. Myasthenia Gravis Composite done by physician with a total score of 10 (Alexion Pharmaceuticals, 2017). Muscle bulk and tone are good, with a strength rating 4/5.
Ruth is a 38-year-old woman who was diagnosed with Myasthenia Gravis (MG) a year ago. MG is prevalent in about every 20 cases per 100,000 people, and women have a higher chance of developing the disease (Goldenberg, 2018). She was diagnosed when she was 37 years old; females mainly get diagnosed before they turn 40 years old (Orpha.net, 2014).
A family history of somebody suffering from an autoimmune disease is a risk factor for developing MG. Her father suffered from lupus, which is an autoimmune disease, which may have increased her chances of developing MG (Intermountain Healthcare, 2017). The presence of recurring incidences of muscular weakness, including supporting of self while getting up, putting extra effort when performing some activities, drooping eyelids, intermittent slurring of speech, and experiencing shortness of breath are signs that the disease is progressing.
However, she has not been consistent with taking her medication, and this may be the reason why the signs are getting worse. The severity of the weakness changes all throughout the day. Usually, symptoms are least severe in the morning and they worsen as the day progresses. This is especially true when affected muscles are subjected to prolonged use (Howard, 2015).
Normally, nerve endings release acetylcholine, a neurotransmitter that binds with the acetylcholine receptors found on the muscle. In MG, there is an error in how nerve impulses transmit messages to the muscles. There is an interruption at the place where muscles and the nerve cells that control them meet (neuromuscular junction). Antibodies either alter, block, or destroy the acetylcholine receptors found at the neuromuscular junction. This then prohibits the muscles from contracting and causes the onslaught of symptoms such as muscle weakness (National Institute of Neurological Disorders and Stroke, 2020).
Anti-acetylcholinesterase agents like pyridostigmine are prescribed to allow acetylcholine to stay for longer periods at the neuromuscular junction. This then gives the chance for more receptor sites to become activated. There is an increase in muscle engagement and conductivity (Myasthenia Gravis Foundation of America, n.d.). Cranial nerves II through XII are intact which means that her nerves are working well.
Alexion Pharmaceuticals. (2017). Assessment Instruments for Your Patients with Myasthenia Gravis (MG). https://info.soliris.net/wp-content/uploads/2017/12/Assessment_Tool_Booklet.pdf
Goldenberg, W. D. (2018). What is the prevalence of myasthenia gravis? Medscape. https://www.medscape.com/answers/793136-158055/what-is-the-prevalence-of-myasthenia-gravis
Howard, J. F. J. (2015). Clinical Overview of MG. Myasthenia Gravis Foundation of America. https://myasthenia.org/For-Professionals/Clinical-Overview-of-MG
Intermountain Healthcare. (2017). Fact sheet for patients and families: Myasthenia Gravis. https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529310818
Myasthenia Gravis Foundation of America. (n.d.). Treatment Strategies & Goals. https://myasthenia.org/What-is-MG/Treatment-Strategies-Goals
National Institute of Neurological Disorders and Stroke. (2020). Myasthenia Gravis Fact Sheet, NIH Publication No. 20-NS-768. National Institutes of Health. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Myasthenia-Gravis-Fact-Sheet.
Orpha.net. (2014). Myasthenia gravis. https://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=GB&Expert=589