Head-to-Toe Assessment on a Volunteer Presentation

NURS FPX 4015 Assessment 5 Head-to-Toe Assessment on a Volunteer Presentation Student name Capella University NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care Professor Name Submission Date   Head-to-Toe Assessment on a Volunteer Presentation Hello, everyone! Immaculate Durvil is my name and I will perform a head-to-toe examination of my patient, Ms. Aiyana Tehanata today. During this evaluation, I will monitor the overall appearance, check her vital signs, perform focused physical examination, and examine her neurological, cardiovascular, respiratory, and musculoskeletal systems. I will also explain my process of doing every component of the assessment in order to be comprehensive and precise. The demonstration relies on the health status of Ms. Tehanata and its impact on her overall care plan, which deals with the short-term and long-term health requirements. Comprehensive and Professional Assessment I started the overall examination of Ms. Aiyana Tehanata and talked about the reason behind the examination and her medical history, including her chief complaint, which is tingling in her feet. I also insisted on the role of communication during the process to make her feel at ease and collaborate. I began by general assessment to note her overall look with alertness and demeanor and whether she was experiencing distress or not. I then did a physical examination, specifically looking at the color and texture of the skin including any edema or other abnormalities of her extremities. I proceeded to the cardiovascular assessment, which involved hearing heart sounds, where S1 and S2 were normal without any murmur, gallops, and rubs. I proceeded to have an examination of the 4 th intercostal space where I identified the presence of stenotic turbulence. The above finding indicates that there are potential vascular abnormalities that could be explored (Selvaraj et al., 2022). The vital signs were taken, with temperature (98.4degF), heart rate (75 bpm), blood pressure (130/72 mmHg), and SpO2 (98%), which were normal. The respiratory examination was also accompanied by the fact that the lungs were clear and clear in the five lobes of the lungs, which was a sign that the lungs were free of respiratory distress or abnormalities. Next, I proceeded to the genitourinary examination and the abdominal examination, which were both free of distress and abnormalities. Her stomach was tender, non-tender, and stool was normal. I would then examine the musculoskeletal system to determine whether a person has joint pain, stiffness or restricted movements. I detected complete movement in all the extremities, and no external swelling or pain in joints. The neuro-assessment also involved a rudimentary ocular nerve appraisal, where Ms. Tehanata was attentive and oriented, as well as had intact cranial nerves. She was tested using the Snellen chart, and the outcome was 20/30 in the right eye and 20/40 in the left one, which is compatible with her reported problems in focusing. The next examination was the peripheral vascular system. I inspected both legs of the fibula to determine whether it is swollen, or altered in skin color or whether it has an ulcer. Symmetrical and palpable pulses in lower extremities were +2 bilaterally, and Capillary refill was less than 3 seconds. A single 10-point monofilament examination revealed reduced sensation in both feet, specifically 1, 2, 3, and 6 on the right foot, 4, 5, 6, and 9 on the left foot, which may be a sign of a possible neurological problem, such as peripheral neuropathy. In the process of the assessment, I shared the results with Ms. Tehanata and clarified to her the importance of her symptoms regarding the possibilities of diabetes and peripheral neuropathy. I also talked about the following steps of additional diagnostic tests and treatment, and made sure she had the idea of the consequences of her current health condition. Discussion of Diagnosis and Findings Following the examination, I told Ms. Tehanata that she had the signs of peripheral neuropathy, which is one of the common complications usually observed in persons with diabetes or hypertension. One of the main findings that can be used to diagnose this diagnosis is reduced sensation in both feet that is reflected by the 10-point monofilament test (Parveen et al., 2025). These findings suggest that she may have nerve damage in the lower extremities which may be secondary to long term hyperglycemia or vascular problems. I highlighted that peripheral neuropathy is a severe disease, and unattended to, it may cause other complications like ulcers, infection and even amputations. I told her that the elevated level of blood sugar might be causing the damaging of the nervous system, and managing her blood sugar levels is the only way to avoid the amplification of the situation. This observation suggests that, possibly, stricter management of her diabetes and an assessment of her medications, including Metformin and Gabapentin, is needed to make her treatment plan optimal (Dave et al., 2025). The vascular sufficiency may be compromised as caused by constriction of her blood vessels that appears in her cardiovascular examination with stenotic turbulence in the 4th intercostal space. This might be a root cause of the numbness in her feet. I promised her that I would be watching her heart and her circulatory system very closely and would take into consideration other diagnostic procedures to determine the vascular health. Finally, I addressed the topic of the need to have regular follow-up visits and tight blood glucose control. Reduced sensation exposes Ms. Tehanata to more risks of injuries, wounds, and infections that can remain undetected because her feet have impaired sensation (Baig et al., 2022). I focused on the importance of good feet care, frequent checking of her blood sugar levels and lifestyle changes (eating healthy and exercising). These measures are critical in ensuring that there is no more damage to the nerve and that her quality of life is enhanced. Understanding of Pharmacological Needs As the assessment and evaluation show, Gabapentin is prescribed to Ms. Tehanata to control peripheral neuropathy and reduce tingling in her feet. Gabapentin acts by decreasing nerve activity related to nerve-related pain and enhancing her general comfort