NURS FPX 4015 Assessment 5

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 perform a thorough head-to-toe assessment to evaluate your health. This assessment will help us understand your current health status and guide us in developing a personalized care plan. If you experience any discomfort during the process, please let me know, and we can pause at any time. Let’s begin.

Comprehensive and Professional Assessment

As I observe you, I note your posture, facial expressions, and overall alertness. You appear somewhat tense and fatigued. I will now assess your mental status, which is essential for understanding your overall health. Ms. Jackson, I will 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? Thank you. Next, I will ask about your emotional health. Have you experienced any changes in mood, trouble sleeping, or feelings of sadness or anxiety? Mental health is as important as physical health, and we will work together to create a suitable support plan.

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

Now, I will assess your cardiovascular health by listening to your heart sounds using my stethoscope. Please take a few deep breaths. Your heart sounds are clear, and your pulse is steady. I will also check your blood pressure, which reads 145/90—slightly elevated. This could be due to stress, diet, or other factors, and we will discuss ways to manage it. Your capillary refill looks 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 discomfort. Your abdomen is soft, with 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 check your leg strength—push against my hands with your feet. The strength is equal on both sides. Your skin looks healthy, with no sores, rashes, or swelling. I’ve also checked your nails for any color changes or abnormalities, and everything appears normal.

Discussion of Diagnosis and Findings

Ivy, I have completed a comprehensive head-to-toe assessment, and based on my findings, I would like 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, restlessness, and frustration. Your vital signs show mild fluctuations, often linked to stress or emotional health. I also observed muscle tension, commonly associated with anxiety or chronic stress.

You mentioned feeling low most days, struggling with motivation, and feeling overwhelmed, all of which align with symptoms of major depressive disorder (CDC, 2023). You also mentioned excessive worry and restlessness, which suggests a possible anxiety component. It’s important to understand that mental health disorders, such as depression and anxiety, are medical conditions that can be managed, much like physical conditions such as hypertension or diabetes. These findings are the starting point for a treatment plan aimed at improving your quality of life. Do you have any questions about what I have found so far? It is essential that you feel informed and comfortable with the next steps.

Table: Comprehensive Head-to-Toe Assessment Findings

Assessment Category	Findings	Comments
Mental Status	Orientation questions: Full name, date, and place recognized.	No cognitive impairment noted. Emotional health concerns identified (depression, anxiety).
Neurological	Pupillary response: Equal, smooth eye movements, normal reflexes, strong hand grip, good coordination.	No abnormalities detected.
Cardiovascular	Blood pressure: 145/90 (slightly elevated), clear heart sounds, steady pulse.	Stress may be a contributing factor to elevated blood pressure.
Respiratory	Lungs clear with no abnormal sounds.	Respiratory function is normal.
Abdomen	Soft, no tenderness or unusual masses. Bowel sounds normal.	Normal abdominal findings.
Musculoskeletal and Skin	Joint mobility: normal. Leg strength: equal. Skin: no rashes or swelling.	Musculoskeletal and skin assessments show no issues.

Understanding of Pharmacological Needs

Ivy, based on our assessment, we have identified symptoms consistent with depression and anxiety. If medications are considered as 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 depression and anxiety (Chu & Wadhwa, 2023). These medications help balance brain chemicals that regulate mood. Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine are another option, effective for both depression and anxiety. If you have concerns about side effects, we may consider alternatives like bupropion or mirtazapine.

However, we must consider 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 may take weeks to show full effects, and possible side effects include nausea, headaches, or appetite changes. If you experience severe side effects, we will reassess your treatment plan. Additionally, it’s 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 such as 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 restlessness and panic attacks, while depression affects the endocrine system, leading to changes in appetite, sleep, and energy levels. Chronic stress and anxiety can also increase the risk of cardiovascular issues, including heart disease. Understanding these physiological impacts will 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 people 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 essential, as stress can elevate blood pressure. Lifestyle changes, such as physical activity and mindfulness, will also be incorporated to improve both mental and physical health (Ghodeshwar et al., 2023). Support from mental health resources, such as counseling and support groups, will be a vital part of your treatment plan. Regular follow-up appointments will 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