NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care Comprehensive Head-to-Toe Assessment Introduction Hello, Ms. Jackson. My name is Brianna, and today, I will conduct a head-to-toe assessment to evaluate your health and well-being.

? Do you know what day it is and where we are right now? Thank you. Now, I would like to understand how you have been feeling emotionally. Have you been experiencing changes in mood, difficulty sleeping, or feelings of sadness or anxiety? I appreciate you sharing that with me. We will collaborate to establish a suitable support strategy because mental wellness deserves equal recognition as physical wellness.

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The next step is a neurological assessment. I will check your pupils’ response by shining a light into your eyes. Your pupils react equally to light, which is a good sign of neurological function. Now, I will have you follow my finger with your eyes without moving your head. Good, your eye movement is smooth. I will test your reflexes by gently tapping below your knee. That response is normal. I will also check your hand grip strength. Can you squeeze my fingers as hard as you can? That feels even 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?

Cardiovascular and Respiratory Assessment

I will now perform a cardiovascular assessment. I will listen to your heart sounds using my stethoscope. Please take a few deep breaths while I listen. Your heart sounds are clear, and your pulse is steady. Now, I will check your blood pressure. Let me place the cuff around your arm. Your reading is 145/90, which is slightly elevated. This could be linked to stress, diet, or other factors, and we will discuss ways to manage it. I will also check your capillary refill by pressing on your fingertips. Your circulation appears normal.

Now, I am doing a respiratory assessment. Let’s check your lungs. I will place my stethoscope on different areas of your chest and back. Please take a deep breath in and out. The examination of your lungs detects no abnormal sounds, wheezing, or crackling noises, which is positive for your health.

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Musculoskeletal and Skin Assessment

I will check your joint mobility. Can you raise your arms and move them in a circle? Great. Now, let’s check your leg strength. Push against my hands with your feet. That strength is even on both sides. Your skin looks healthy, with no visible sores, rashes, or swelling. I also checked your nails for color changes or abnormalities; everything looks good.

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Discussion of Diagnosis and Findings

Ms. Jackson, I have completed a thorough head-to-toe assessment, and based on my findings, I would like to discuss my observations. Your symptoms of anxiety and depression seem to explain your tiredness and affect your ability to focus, eating, and sleeping routines. According to the CDC (2023), mental illnesses such as depression and anxiety lead to improper sleep, restlessness, and frustration. Your vital signs show mild fluctuations, often linked to stress and emotional health. I also noticed signs of muscle tension, which can be associated with anxiety or chronic stress.

Mental disorders, including depression and anxiety, should be understood as medical illnesses like hypertension or diabetes. They are not a sign of weakness and can be managed with the right treatment and support. I want to ensure you understand that these findings are not a judgment but a starting point for a treatment plan that can help improve your quality of life.

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