Head-to-Toe: Physical Assessment Report (Assessment)

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SYSTEM/NORMAL FINDINGSABNORMAL FINDINGS
Eyes
Inspect
  • Sclera white and moist and pink conjunctiva indicating no drainage.
  • Equal palpebral fissures and no lid lag.
  • Ears
  • Gray tympanic membrane with intact hearing.
  • Visible landmarks. No bleeding or drainage.

Neck

  • Pea-sized lymph nodes

Respiratory
Inspect/Auscultate

  • Standard respiratory rate, which is unlabored and regular
  • Clear breath sounds with no coughs
  • Cardiovascular
  • Auscultate
  • Absence of truits

Gastrointestinal
Inspect

  • Round and soft abdomen with upbeat bowel sounds.

Genitourinary
Inspect

  • A pink, intact external genitalia
  • Full range of motion.
  • Neurological
  • Intact cranial nerves and sensations with coordinated movements.
  • Redness of conjunctiva and drainage suggest infection or an allergy. Both of them may involve the nose and sinuses.
  • Lid lag and exophthalmos are associated with hyperthyroidism,
  • The altered appearance of the tympanic membrane and hearing changes and landmarks are associated with fluid accumulation.
  • Bleeding from the nose and ear signals possible skin fracture,
  • Palpate lymph nodes indicate the presence of an inflammatory process.
  • Tachypnea cough and whizzing may indicate asthma.
  • Bounding temporal paired arteries with pain suggests temporal arteritis
  • Bruits of the carotid arteries indicate carotid stenosis.
  • Oral problems indicate jaundice.
  • STDs may cause oral lesions.
  • Limitations of motion and pain indicate arthritis.
  • Changes in sensation and coordination indicate a neurological disorder.

The assessed systems are the respiratory, cardiovascular, gastrointestinal, genitourinary, and neurological. The respiratory system comprises specific organs used to exchange gases, including the removal of carbon dioxide when one exhales. A healthy individual has a heart rate ranging from 60 to 100 beats per minute. A high breathing rate can lead to a condition known as dyspnea. One will experience shortness of breath and tightness in the chest. Frequent coughs may be a sign of asthma, which leads to discomfort. The gastrointestinal tract allows the passage of the digestive system from the mouth to the anus. A round and soft abdomen shows that the rectus muscle is relaxed hence no discomfort during palpitation. Oral hygiene is essential in keeping a healthy gastrointestinal tract, failure to which may lead to a disease called jaundice.

In the genitourinary system, pink, intact external genitalia indicate regular functioning of the vagina. Oral lesions are an ulcer that sexually transmitted infections may cause, and they comprise a painful abnormal mouth cell growth. Limitations of motion and pain indicate arthritis that occurs as swelling of one or more joints. A neurological system with intact cranial nerves suggests sensory functioning, including the nerves and veins. Neurological disorders affect the nose, speech, eating, and facial expression muscles. To measure the breathing rate without the required equipment may be arrived at by counting the number of heartbeats. A patient can be directed to sit and relax to record their breathings rates from the chest. The oral lesions might be assessed by looking at the patient’s mouth to evaluate any cell growth. The absence of a magnetic resonance imaging machine to detect arthritis could be substituted by keen observations of the nature of swell joints.

The normal laboratory age finding of the client was 67 years. The elderly are at high risk of getting infections due to weak immune system compared to youths. Health screening is an essential practice in reducing age-related risks (Tański et al., 2021). A simple blood test can be performed to check for the aforementioned disorders. It lets one know if they have an existing or developing heath condition and curbing it. Additionally, health personnel can offer guidance on how to stay healthy by exercising and taking a balanced diet.

Certain chronic diseases among the adults take time to be detected, hence, early awareness of their existence can reduce further complications. Similarly, immunization at an early stage of development can prevent one from being infected by some disease. As one ages, immunity deteriorates, finding it hard to fight contaminations. Update of vaccines also protects the immunity from further damages caused by illnesses. Immunizations can prevent complications such as flu, pneumonia, and shingles. One is also to protect people around them since some ailments are easily spread through the air.

Two possible diseases diagnosed by the patient were asthma and arthritis. The frequent coughs and abnormal rate were a clear indication. Further, a spirometer test was done to assess the working of lungs by instructing the sick to take a deep breath. Swelling joints indicated an arthritis condition that may be worsening. X-rays performed on the patient showed joint disjoint and some bone damage, which brings difficulties and discomfort while walking, making one less effective in their daily activities. Other symptoms are joint tenderness, stiffness after getting out of bed, and a crunching sound of bone rubbing.

Plan Care

The nurse has a significant role in restoring the health of the sick by recommending good practices treatments and offering advice. Keeping warm and frequent exercises to boost immunity to reduce asthma effects. The respiratory rate and depth must also be checked, and the level of anxiety. Breath sounds and signs of dyspnea, which indicate distress, should not be forgotten. To reduce the risks of arthritis, the nurse can message and provide relaxation techniques to the patient. They can offer pillow comforts warm compression to relax muscles and loosen rigid joints. Cold reductions to decrease swelling and also alleviate pain remedies can be adopted.

Finally, evaluation is done to assess whether any change has taken place. This could be effected by examining whether the swelling of joints is increasing or decreasing. The patient can also be asked to give a detailed explanation of how they are feeling. Ultrasound can be performed to inspect the quality of ligaments, tendons, bones, and synovial tissue. The asthma condition can be reviewed by looking at the condition of the throat, nose, and upper airways. The skin can also be investigated for signs of allergic conditions such as hives and eczema.

Another treatment plan includes the administration of pharmacological drugs. To treat asthma, a series of measures can be taken. Inhaled corticosteroids are long-term control medications that include budesonide, fluticasone, and mometasone (Gaffin et al., 2022). Leukotriene modifiers such as zafirlukast and zileuton can also be administered. Combination inhalers, theophylline, and biologics can also be additional therapies. For arthritis, methotrexate is the most effective treatment plan. Steroids, nonsteroidal anti-inflammatory can also relieve pain and reduce inflammation.

Strategies to promote good health cooperates with healthy practices, thus, the medications prescribed must be used appropriately and on time. Failure to finish the prescribed dosage may worsen the health condition. In case of severe and uncontrollable side effects, the patient should seek further direction. The medications might be changed, or other possible solutions could be suggested. Older adults should strive staying active by avoiding sedentary lifestyles. The rate of breathing and functioning of the lung should be monitored frequently. Any abnormal inhalation patterns should not be taken for granted.

Smoking should be avoided since they damage the lungs by making them less effective, leading to the development of other opportunistic diseases. Regular exercising of the body can keep the bones strong and healthy (Ravalli et al., 2022). This prevents unnecessary fluid accumulations, which are very risky. Any pain in the joints or hands should not be assumed as they may be indicating the onset of a terrible condition. A healthy diet plan must be embraced to provide the body with essential nutrients. Weight loss for obesity should be encouraged to avoid strain to the joints.

References

Gaffin, J., Castro, M., Bacharier, L., & Fuhlbrigge, A. (2022). The role of comorbidities in difficult-to-control asthma in adults and children. The Journal of Allergy and Clinical Immunology: In Practice, 10(2), 397-408. Web.

Ravalli, S., Roggio, F., Lauretta, G., Di Rosa, M., D’amico, A. G., D’agata, V., Maugeri, G. & Musumeci, G. (2022). Heliyon, 8(2), e08991. Web.

Tański, W., Wójciga, J., & Jankowska-Polańska, B. (2021). Association between malnutrition and quality of life in elderly patients with rheumatoid arthritis. Nutrients, 13(4), 1259. Web.

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