NURS FPX 4015 Assessment 5

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

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

Introduction and Initial Observations

Hello, Ms. Jackson. My name is __, and today I will conduct a comprehensive head-to-toe assessment to evaluate your overall health. This assessment allows us to understand your current health status and develop a personalized care plan. If you feel discomfort at any point, please let me know, and we can pause as needed. Let’s begin.

As I observe you, I note your posture, facial expressions, and alertness. You appear slightly tense with mild signs of fatigue. To assess your mental status, I will ask a few questions to evaluate your cognitive function and orientation. Ms. Jackson, can you tell me your full name? Do you know today’s date and where we are? Thank you. Next, I want to understand how you have been feeling emotionally. Have you been experiencing any mood changes, trouble sleeping, or feelings of sadness or anxiety? Thank you for sharing. Mental health is as important as physical health, and together, we will create a supportive care plan.

Neurological and Cardiovascular Assessment

I will now conduct a neurological assessment, starting with your pupils’ response to light. Your pupils react equally, which is a positive sign. Please follow my finger with your eyes without moving your head—your eye movements are smooth. Now, I will assess your reflexes by tapping below your knee, and the response is normal. Let’s check your hand grip strength—can you squeeze my fingers as hard as possible? Strength is equal on both sides. Finally, for coordination, can you touch your nose with your finger and then reach out to touch my hand?

Moving on to cardiovascular health, I will listen to your heart sounds using a stethoscope. Please take a few deep breaths. Your heart sounds are clear, and your pulse is steady. Next, I will check your blood pressure, which is 145/90—slightly elevated. This could be due to stress, diet, or other factors, which we will discuss. I will also check your capillary refill by pressing on your fingertips; circulation appears normal.

Respiratory, Abdominal, and Musculoskeletal Assessment

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

Now, I will assess your musculoskeletal system and skin. I will check joint mobility by asking you to raise your arms and move them in a circular motion. Great. Next, let’s assess your leg strength—please push against my hands with your feet. Strength is equal on both sides. Your skin appears healthy, with no sores, rashes, or swelling, and your nails show no color changes or abnormalities.

Discussion of Diagnosis and Findings

Ms. Jackson, I have completed a comprehensive assessment and would like to discuss my findings. Your symptoms of anxiety and depression may be contributing to your fatigue and could be affecting your concentration, appetite, and sleep patterns. According to the Centers for Disease Control and Prevention (CDC, 2023), mental health conditions such as depression and anxiety can result in poor sleep, restlessness, and frustration. Your vital signs show mild fluctuations, likely linked to emotional health. Additionally, I observed muscle tension, which is commonly associated with stress and anxiety.

You shared that you often feel low, lack motivation, and feel overwhelmed—these symptoms align with major depressive disorder (CDC, 2023). You also reported excessive worry and restlessness, which could indicate an anxiety component. Mental health conditions like these are medical concerns that can be managed, similar to hypertension or diabetes. These findings help us create an individualized treatment plan to improve your quality of life. Do you have any questions about what I have discussed so far? It is important that you feel informed and comfortable with the next steps.

Table: Comprehensive Head-to-Toe Assessment Findings

Assessment Category	Findings	Comments
Mental Status	Oriented to name, date, and location.	No cognitive impairment detected. Emotional health concerns noted.
Neurological	Pupillary response equal, smooth eye movements, normal reflexes, strong grip, good coordination.	No abnormalities detected.
Cardiovascular	BP: 145/90 (slightly elevated), clear heart sounds, steady pulse.	Stress may contribute to elevated blood pressure.
Respiratory	Lungs clear with no abnormal sounds.	Respiratory function is normal.
Abdomen	Soft, non-tender, normal bowel sounds.	Normal abdominal findings.
Musculoskeletal and Skin	Joint mobility normal, leg strength equal, healthy skin.	No issues noted.

Understanding of Pharmacological Needs

Ms. Jackson, based on our assessment, you are experiencing 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 conditions (Chu & Wadhwa, 2023). These medications help balance brain chemicals that regulate mood. Another option is serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine, which are effective in treating depression and anxiety.

However, considering your elevated blood pressure, we must be cautious, as some medications—especially SNRIs—can raise blood pressure (Calvi et al., 2021). We will carefully evaluate your options before starting treatment. These medications typically take a few weeks to take full effect, and possible side effects include nausea, headaches, and appetite changes. If you experience significant side effects, we will reassess your treatment plan. Avoiding alcohol while taking these medications is essential, as it can interfere with their effectiveness. Does this information make sense to you? Please let me know if you have any concerns.

Understanding of Pathophysiology

Mental health conditions such as depression and anxiety affect both emotional and physical health. These disorders are linked to imbalances in neurotransmitters, particularly serotonin, dopamine, and norepinephrine, which regulate mood, sleep, hunger, and stress responses (Cleveland Clinic, 2022). A disruption in these neurotransmitters can result in persistent sadness, fatigue, poor concentration, and sleep disturbances.

Anxiety overstimulates the nervous system, causing restlessness and panic attacks, while depression can impact the endocrine system, affecting appetite, sleep, and energy levels. Prolonged stress and anxiety can also increase the risk of cardiovascular conditions, including hypertension and heart disease. Understanding these physiological impacts will help guide our treatment approach.

Critical Thinking and Clinical Reasoning

Based on my assessment, our priority is to develop a care plan that addresses both your emotional and physical health. Our goal is to stabilize your mood, manage symptoms, and consider SSRIs as a potential treatment, given their role in neurotransmitter regulation (Chu & Wadhwa, 2023). Additionally, improving sleep and energy levels is essential, as many individuals with depression experience fatigue and sleep disturbances.

Cognitive Behavioral Therapy (CBT) will be integrated to help manage stress and anxiety (Nakao et al., 2021). Monitoring cardiovascular health is also crucial, as stress can elevate blood pressure. Lifestyle modifications, including physical activity and mindfulness, will be incorporated to improve mental and physical well-being (Ghodeshwar et al., 2023). Mental health support through counseling and support groups will be an important part of your treatment plan. Regular follow-up visits will ensure we stay on track with your care.

Conclusion

Thank you, Ms. Jackson, for allowing me to conduct this assessment. Your health is my priority, and I am here to support you. Together, we will create a personalized care plan to improve your well-being. If you have any questions or concerns, please feel free to reach out.

References

Calvi, A., et al. (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