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

Student 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

Hello, Ms. Jackson. My name is __, and today I will be conducting a thorough head-to-toe assessment to evaluate your health. This assessment will provide us with valuable information regarding your current health status, which will help us create a personalized care plan. If you experience any discomfort during the examination, please let me know so that we can pause. Let’s begin.

Comprehensive and Professional Assessment

As I observe you, I note your posture, facial expressions, and overall level of alertness. You appear somewhat tense, with signs of fatigue. I will now assess your mental status, which is an essential part of your health. Ms. Jackson, I would like to ask you a few questions to assess your orientation and cognitive function. Can you please tell me your full name? Do you know today’s date and where we are currently? Thank you. Next, I will assess your emotional state. Have you noticed any changes in your mood, trouble sleeping, or feelings of sadness or anxiety? I appreciate your willingness to share this information. Mental health is just as important as physical health, and we will work together to develop a suitable support plan.

Next, I will perform a neurological assessment. I will shine a light in your eyes to check your pupils’ reaction. Your pupils react equally to the light, which is a positive sign. I will ask you to follow my finger with your eyes without moving your head. Your eye movements are smooth. I will also test your reflexes by gently tapping below your knee, and the response is normal. Let’s check your hand grip strength—can you squeeze my fingers as hard as you can? The strength is equal on both sides. Lastly, I will assess your coordination. Can you touch your nose with your finger and then reach out to touch my hand?

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

Now, I will assess your cardiovascular health by listening to your heart sounds with my stethoscope. Please take a few deep breaths. Your heart sounds are clear, and your pulse is steady. I will check your blood pressure next; your reading is 145/90, which is slightly elevated. This may be linked to stress, diet, or other factors, and we can discuss strategies for managing it. I will also check your capillary refill by pressing on your fingertips. Your circulation appears normal.

For the respiratory assessment, I will place my stethoscope on various areas of your chest and back to listen to your lungs. Please take a deep breath in and out. The sounds are normal with no wheezing or crackling, which is a positive sign. Moving on, I will examine your abdomen by gently pressing on different areas. Please let me know if you feel any pain or discomfort. Your abdomen is soft, and there are no unusual masses or tenderness. Your bowel sounds are normal.

Next, I will perform a musculoskeletal and skin assessment. I will check your joint mobility by asking you to raise your arms and move them in a circular motion. Great. Now, let’s assess your leg strength—push against my hands with your feet. The strength is equal on both sides. Your skin appears healthy, with no sores, rashes, or swelling. I’ve also checked your nails for any color changes or abnormalities, and everything looks good.

Discussion of Diagnosis and Findings

Ivy, I have completed a comprehensive head-to-toe assessment, and I want to discuss what I have observed. Your symptoms of anxiety and depression seem to be contributing to your fatigue and may be affecting your focus, eating, and sleeping patterns. According to the CDC (2023), mental health conditions like depression and anxiety can lead to poor sleep, feelings of restlessness, and frustration. Your vital signs show mild fluctuations, which may be related to stress or emotional health. I also observed muscle tension, which is commonly associated with anxiety or chronic stress.

You mentioned that you often experience a low mood, struggle with motivation, and feel overwhelmed, all of which are consistent with symptoms of major depressive disorder (CDC, 2023). Additionally, you mentioned moments of excessive worry and restlessness, suggesting a possible anxiety component. It is important to remember that mental health disorders, like depression and anxiety, are medical conditions that can be managed, just like physical conditions such as hypertension or diabetes. These findings are a starting point for developing a treatment plan aimed at improving your quality of life. Do you have any questions about what I’ve found so far? It is essential that you feel informed and comfortable with the next steps.

Table: Comprehensive Head-to-Toe Assessment Findings

Understanding of Pharmacological Needs

Ivy, based on our assessment, we have identified symptoms consistent with depression and anxiety. If medications become part of your treatment, I want to ensure you understand your options. Selective serotonin reuptake inhibitors (SSRIs), such as sertraline and fluoxetine, are commonly prescribed for both conditions (Chu & Wadhwa, 2023). These medications help balance chemicals in the brain that regulate mood. Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine are another option, effective for treating both depression and anxiety. If there are concerns about side effects, we may consider alternatives such as bupropion or mirtazapine.

However, we must be mindful of your history of high blood pressure. Some medications, especially SNRIs, can raise blood pressure (Calvi et al., 2021). We will carefully consider this when choosing your medication. These medications can take weeks to show full effects, and possible side effects include nausea, headaches, or changes in appetite. If you experience severe side effects, we will reassess your treatment plan. It is also important to avoid alcohol while on these medications, as it can interfere with their effectiveness. Does this make sense to you? Please let me know if you have any questions.

Understanding of Pathophysiology

Ivy, mental health conditions like depression and anxiety affect both your emotional and physical health. These conditions are linked to imbalances in brain chemicals, particularly serotonin, dopamine, and norepinephrine, which regulate mood, sleep, hunger, and stress responses (Cleveland Clinic, 2022). An imbalance in these neurotransmitters can lead to persistent sadness, fatigue, difficulty concentrating, and disrupted sleep patterns.

Anxiety overstimulates the nervous system, causing feelings of restlessness and panic attacks, while depression can affect the endocrine system, leading to changes in appetite, sleep patterns, and energy levels. Over time, chronic stress and anxiety can increase the risk of cardiovascular problems, including heart disease. Understanding these physiological impacts will help guide our treatment plan.

Critical Thinking and Clinical Reasoning

Ivy, based on my assessment, our priority is to create a care plan that addresses both your emotional and physical health. We will work to stabilize your mood, manage symptoms, and consider SSRIs as potential treatment options, given their role in regulating neurotransmitter levels (Chu & Wadhwa, 2023). Improving sleep and energy levels is also important, as many individuals with depression experience fatigue and sleep disturbances.

We will integrate Cognitive Behavioral Therapy (CBT) to help you manage stress and anxiety (Nakao et al., 2021). Monitoring your cardiovascular health is crucial, as stress can increase blood pressure. Lifestyle changes, such as physical activity and mindfulness, will also be incorporated to improve both mental and physical well-being (Ghodeshwar et al., 2023). Support from mental health resources, such as counseling and support groups, is vital to your treatment plan. Regular follow-up appointments will help ensure we are on track with your care.

Conclusion

Thank you for allowing me to conduct this assessment today. Your health is important to me, and I am here to support you. Together, we will work on a care plan to ensure the best possible outcome for your well-being. Please feel free to reach out if you need anything.

References

Calvi, A., Fischetti, I., Verzicco, I., Belvederi Murri, M., Zanetidou, S., Volpi, R., Coghi, P., Tedeschi, S., Amore, M., & Cabassi, A. (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 Comprehensive Head-to-Toe Assessment

Ghodeshwar, G. K., Dube, A., & Khobragade, D. (2023). Impact of lifestyle modifications on cardiovascular health: A narrative review. Cureus, 15(7). https://doi.org/10.7759/cureus.42616

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w

NAMI. (2022). NAMI: National Alliance on Mental Illness. https://www.nami.org/