Head-to-Toe Assessment-Essay Example
For this purpose, a disposable, electronic or tympanic thermometer is required (Amugi-crouch& Meurier, 2011). Since temperature of the patient is within such a narrow range and is required to take accurately, the presence of a thermometer is essential, as it cannot be measured without it.
Pulse is measured directly by the monitor that is used to measure other vital signs. However, if the machine is not available, it can be felt by palpating the pads of the first three fingers against the patient’s wrist and counting the pulse beats in one minute, starting from zero.
Normal Findings: Temperature of the patient is between 36-37.5°C.Normal pulse rate is 60-100 (mean of 70) beats per minute. The systolic blood pressure normally ranges from 100-140mmHg. The diastolic blood pressure, on the other hand normally ranges from 60-90 mmHg.
Abnormal Findings: Hyperthermia, pyrexia or fever occurs when the temperature exceeds 38°C. An excessively high temperature- such as above 40°C is known as hyperpyrexia. Hypothermia where in the temperature of the patient is below 35°C A pulse rate of under 60 beats per minute is termed bradycardia and may occur in hypoxia, ischemic heart disease etc. A pulse rate of over 100 beats per minute is termed as tachycardia. It may occur in stress, anxiety, pyrexia and pain (Amugi-crouch & Meurier, 2011).Hypertension occurs when the blood pressure readings remain consistently over 140mmHg for systolic and 90mmHg for diastolic blood pressure. It may result from the excess consumption of caffeine and in excessively cold environments. Hypotension occurs when the blood pressure readings fall below 100mmHg for systolic and 60mmHg for diastolic blood pressure (Talley & O’Connor, 2009). It may result because of shock, pulmonary embolus and cardiac failure (LeMone et al 2012).
Nursing Plan in abnormal findings: The plan taken will be primarily to …Download file to see next pagesRead More
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| Assignment 2 Grading Criteria | Maximum Points |
| Performed a complete head-to-toe assessment and incorporated topical headings to delineate systems. | 20 |
| Analyzed and described how portions of the assessment would be conducted without certain equipment. | 20 |
| Provided a detailed review of each system with normal and abnormal findings, and included normal laboratory findings for client age. | 16 |
| Analyzed and explained age-specific risk reduction health screen and immunizations. | 16 |
| Provided expectations as normal findings and indicated abnormal findings in review of systems. | 16 |
| Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. | 16 |
| Designed a plan of care including nursing diagnosis, interventions, evaluation. | 16 |
| Discussed pharmacological treatments that can be used to address health issues for this client. | 20 |
| Included evidenced based practice strategies for health promotion. | 20 |
| Used correct spelling, grammar, and professional vocabulary. Cited all sources using APA format. | 20 |
| Total: nursing head to toe assessment form | 180 |
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