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Head to toe Assessment Essay

It is an assessment that is done to a patient admission that is used to determine the hemodynamic context and the status of the patient. The assessment includes check to all body system, and findings will show doctor or nurse the overall condition of the patient. However, unusual findings will assist healthcare professionals to take necessary action to solve that effect on the body system of the patient. Therefore, physical examination includes a collection of the objective data by use of techniques of palpation, inspection, auscultations, and percussion. (Giddens and Wilson 2013). Therefore this paper entails the physical assessment I would perform on the patient who visited health care center, the process of the assessment and then the finding collected from the patient.

There is safety consideration that I will take into account regarding the policy of the health center (hospital), these are: I will perform on my hand’s hygiene, check the room to contact precaution, I introduce myself to the patient. I confirm the patient identity by observing his ID. Then I explain the process to the patient. I organize myself for assessment, and I use appropriate questioning and listening skills, I assure the patient’s dignity, and privacy is secret. I will apply all the principle of safety and asepsis, check for the vital signs and finally. I will completely focus on assessment. In the delineate system of the healthcare organization, the assessment will be limit within the policy of the organization. Therefore I will follow all the regulation and the policy of the organization when interacting with the patient.

In case there is no equipment to perform my assessment, I will use the available method to that illness that will make me get results. For example, I will palpate on the body of the patient to see if the patient feels my touch. Also, body temperature can be estimated by touching the patient. Although I may not get an exact measurement of the temperature, I will discover if the temperature of the patient is high through touching him. Other symptoms of the illness are observable like shivering when the patient feels cold. Therefore in case, there is no possible equipment I will use the observable method to assess the patient to get the detail of his or her condition or status.

The following is some of the assessment done to the patient and record the abnormal and normal findings base on my assessment. Therefore the normal find of the patient condition is as follows. The general appearance of the patient is observed if the patient can move, he is clean or has other unusual behavior. This is symptoms that can be inspected by observation. In the normal appearance the patient should clean, he is not experiencing anxiety, and he is mobile. Therefore some of the actual assessment that I did on the patient is as follows:

The assessment was on the head of the patient to identify if there was any problem on his head and another component of the head.

The normal finding on the skull was round with prominences in the occipital and frontal areas. There was no tenderness noted by palpation. The client was lighter in color than the complexion. It looks moisture. There was scar noted due to cut injury. The client scalp was free from nits, dandruff, and lice. Noted no lesion and no masses or tenderness was experienced on palpation. The hair of the client was observed to be brown. There was no evidence of alopecia because the hair was evenly distributed on the whole scalp. Hair was thin and smooth.

Sensory function of the trigeminal that I request the client to close her eyes, then I run cotton wisp over her forehead, jaw and check on both sides of her face asking her if she feels it and at what particular point she feels it. I then checked for corneal reflex by use of cotton wisp. The normal response to all that should be blinking.

The normal finding of the client’s face shapes round, and its face is symmetrical. There was no involuntary muscles movement. The client can move facial muscles at her will. She has intact cranial nerves.

The abnormal finding on the patient is the unusual thing the patient experience on his or her body. This experience can be observable like swelling part of the body, or the patient feels pain on some part of the body. In this situation, I will examine the cause of the problem by asking the patient some question like, when did the problem start? How are you feeling? Did you take some drug when the problem began? This conversation will assist me to identify the status of the illness on the patient. After the useful conversation, I will assess the illness in the laboratory by examining the sample from the patient body in a laboratory. Test in the laboratory will show main cause of the problem, and I analyze the treatment measure to take so that the patient should be healed.

The age of the patient is a very important consideration when dealing with the patient. Some of the diseases are common to people at the certain age. According to the assessment people from the age of thirty-five years are likely to experience cancer in their body. Therefore this needs a proper assessment of the patient at this age to know their status. For proper assessing the patient his or her health problem health screening one of a better method to diagnose the health of the patient by blood testing. Health screening will assist me to identify some of the abnormality the patient is experiencing in his or her body. Therefore it provides essential information for diagnosis, treatment and preventive measure that should be taken for the disease. Frequent health screening for healthy persons assists in detecting some developing illness at an early stage, which makes the treatment of the illness more effective than when the disease is discovered at the later stage. For example, when I assess individual with cancer at its starting stage, it can be treated, and the person becomes healed that when discovering cancer at its later stage where it has developed more harm in the body. It may be treated, but its effect remains in the body.

It is essential for an individual to analyze his or her life to know where the problem in his or her life is. To reduce risk in the body, the patient should change his or her lifestyle. In some case, some of the illness is developed by our lifestyle and the diet we normally use every day. For example, excess use of red meat can lead to illness. Therefore it’s important that the patient should change to proper diet so that his body remain healthy. The other method to reduce the risk of the disease is by immunization. Immunization is the process in which the individual is immune or made resistant to the influence of certain disease by providing a vaccine. Therefore vaccine stimulates the body immune system that defends the individual against disease. Therefore I advise the patient I assess to take the vaccine if they did not take so that his body will be defended from subsequent infection. Immunization is the proper way and tool to eliminate and protect life-threatening infections on the human body.

There are many normal finding when I assess the patient but letter stage in becoming abnormal finding. For example of the patient who experiences shivering at morning hour. It may be normal finding because of it cold hours of the day. However, during the daytime when the solar radiation is hot, the individual may still experience shivering. This show an abnormal finding of the individual. Therefore medical check of the patient is important to know the cause of the problem. At this moment blood test is essential to diagnose the cause of the shivering. This is done in the laboratory by use of medical tool and substance. The result of the assessment in the laboratory will be used to treat the patient by providing proper treatment method.

Every disease has different symptoms that make it uniquely identified in the medical field. The symptom that is general to all disease but appeared in different ways. For example of shivering is abnormal finding that may be caused by different illness. In my assessment, the patient experience shivering because of the malaria illness. After the blood test, the patient identified to be suffering from malaria. However, there is another disease that has the same symptom of asthma, yellow fever, and others. Therefore it’s important to assess the disease correctly before treating it. Otherwise, the patient may be treated the wrong disease.

The plan to care

This is the strategy developed that is followed by the medical profession to care for patients. It has the well-defined flow of the activities from the time the patient enters the health center to the time he or she leaves. Therefore the plan I use in this assessment is as follows:

Patient assessment; at this point essential details of the patient is taken. Also, the patient illustrates his problem to the nurse or doctor. The assessment is based on the following abilities that are emotional, physical, functional, age relation, psychosocial and cognitive. This will give the correct condition of the patient and resemble the symptoms that are observed by the patient on his body.

Medical test: it’s the second step where the patient sample is taken to the laboratory to be examined. This test will provide a result of the cause of the disease and the extent of the illness. Therefore medical test gives full identification of the disease.

Treatment: after the disease is identified, proper treatment begins on the patient. The doctor instructs the patient to drug to take for his healing

The intervention process between the doctor and the patient is documented in the healthcare record for future reference

The age of the patient is considered in the promotion of his health because it gives the doctor the correct dose the patient is required to take for that illness. A difference in age varies the number of drugs the patient should take.

Pharmacology treatment of the patient is important as it deals with identifying the illness on the patient and treating it using correct drugs with will heal the illness on the body of the patient.

References

KM, F. (1999). Does the physical examination have a future? Canadian Medical Association Journal.

Krogsbøll, L. T., & Jørgensen, K. (2012). General health checks in the adults for reducing morbidity and mortality from the disease.

McAlister FA, S. S. (2000). High marks for the physical exam. Canadian Medical Association Journal.

Vera, M. (2012). Ultimate Guide to Head-to-Toe Physical Assessment. Fundamentals of Nursing.

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