NURS FPX 4015 Assessment 5

NURS FPX 4015 Assessment 5 Comprehensive Head-to-Toe Assessment

Name

Capella University

NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care

Prof. Name

Date

Comprehensive Head-to-Toe Assessment

Introduction and Initial Observations

Hello, Ms. Jackson. My name is __, and today I will perform a comprehensive head-to-toe assessment to evaluate your overall health status. This evaluation will help us identify any health concerns and develop an appropriate care plan. Please let me know if you feel any discomfort during the assessment, and we can take breaks as needed.

Upon observing you, I note your posture, facial expressions, and overall demeanor. You appear slightly tense, with mild signs of fatigue. To assess your mental status, I will ask you a few questions. Ms. Jackson, can you state your full name? Do you know today’s date and your current location? Thank you for your responses. Additionally, I would like to understand your emotional well-being. Have you been experiencing mood changes, trouble sleeping, or persistent feelings of sadness or anxiety? Your mental health is just as important as your physical health, and together, we will develop a supportive plan to address any concerns.

Neurological and Cardiovascular Assessment

To evaluate your neurological health, I will begin with a pupil reaction test. Your pupils react equally to light, which is a good sign. Next, I will check your eye movements—please follow my finger without moving your head. Your eye movements appear smooth. Now, I will assess your reflexes by tapping below your knee, and I observe a normal response. Let’s test your grip strength—please squeeze my fingers tightly. Your strength is equal on both sides. Lastly, to assess coordination, please touch your nose with your finger and then reach out to touch my hand. Your coordination is intact.

Now, let’s examine your cardiovascular health. I will listen to your heart sounds using a stethoscope. Please take a few deep breaths. Your heart sounds are clear, and your pulse is steady. Next, I will check your blood pressure, which is 145/90—slightly elevated. Several factors, including stress and diet, can contribute to this, which we will discuss further. Lastly, I will check your capillary refill by pressing on your fingertips. Your circulation appears normal.

Respiratory, Abdominal, and Musculoskeletal Assessment

For the respiratory assessment, I will listen to your lungs by placing my stethoscope on different areas of your chest and back. Please take a deep breath in and out. Your lung sounds are clear, with no abnormal wheezing or crackles. Next, I will examine your abdomen by gently pressing on different areas—please let me know if you experience any discomfort. Your abdomen is soft, with no tenderness or unusual masses, and your bowel sounds are normal.

Now, I will assess your musculoskeletal system and skin. I will check joint mobility by asking you to raise your arms and move them in a circular motion. That looks good. Next, let’s assess your leg strength—please push against my hands with your feet. Your strength is equal on both sides. Lastly, I will examine your skin for any abnormalities. Your skin appears healthy, with no signs of sores, rashes, or swelling. Your nails also show no discoloration or abnormalities.

Table: Comprehensive Head-to-Toe Assessment Findings

Discussion of Diagnosis and Findings

Ms. Jackson, based on my assessment, you are experiencing symptoms that may be linked to anxiety and depression. These symptoms can contribute to fatigue, poor concentration, sleep disturbances, and changes in appetite. According to the Centers for Disease Control and Prevention (CDC, 2023), mental health conditions such as depression and anxiety can lead to physical health issues, including restlessness, fatigue, and mood instability. Additionally, muscle tension was observed, which is commonly associated with stress and anxiety.

You also reported feeling low, lacking motivation, and experiencing overwhelming emotions, which align with symptoms of major depressive disorder (CDC, 2023). The excessive worry and restlessness you described may indicate an anxiety component. Mental health conditions are treatable, similar to chronic physical conditions like hypertension. Addressing these findings will allow us to create a personalized treatment plan to improve your quality of life. Do you have any questions about my findings? It is important that you feel informed and comfortable with the next steps.

References

Calvi, A., et al. (2021). Antidepressant drugs effects on blood pressure. Frontiers in Cardiovascular Medicine, 8(8). https://doi.org/10.3389/fcvm.2021.704281

CDC. (2023). Mental health conditions: Depression and anxiety. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html

Chu, A., & Wadhwa, R. (2023). Selective serotonin reuptake inhibitors. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554406/

Cleveland Clinic. (2022). Neurotransmitters. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/22513-neurotransmitters

NURS FPX 4015 Assessment 5

Ghodeshwar, G. K., et al. (2023). Impact of lifestyle modifications on cardiovascular health. Cureus, 15(7). https://doi.org/10.7759/cureus.42616

Nakao, M., et al. (2021). Cognitive-behavioral therapy for mental health and stress. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w