NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment – Step-by-Step Guide With Example Answer
The first step before starting to write the NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment is to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment.
It is also important to identify the paper’s audience and purpose, as this will help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, review its use, including writing citations and referencing the resources used. You should also review the formatting requirements for the title page and headings in the paper, as outlined by Capella University.
How to Research and Prepare for NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment
The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify a list of keywords related to your topic using various combinations. The first step is to visit the Capella University library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from the Capella University Library, PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last 5 years and go through each to check for credibility. Ensure that you obtain the references in the required format, such as APA, so that you can save time when creating the final reference list.
You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next, create a detailed outline of the paper to help you develop headings and subheadings for the content. Ensure that you plan what point will go into each paragraph.
How to Write the Introduction for NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment
The introduction of the paper is the most crucial part, as it helps provide the context of your work and determines whether the reader will be interested in reading through to the end. Begin with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.
How to Write the Body for NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment
The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence collected from the research, and ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance, as well as how it relates to the thesis statement. You should maintain a logical flow between paragraphs by using transition words and a flow of ideas.
How to Write the In-text Citations for NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment
In-text citations help readers give credit to the authors of the references they have used in their work. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:
“The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Morelli et al. (2024), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Alawiye (2024) highlights that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.”
How to Write the Conclusion for NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment
When writing the conclusion of the paper, start by restating your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper by restating them. Discuss the implications of your findings and your arguments. Conclude with a call to action that leaves a lasting impression on the reader or offers recommendations.
How to Format the Reference List for NURS-FPX4000 Assessment 2 Applying Research Skills
The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded. The references should be organized in an ascending order alphabetically, and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication.
Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:
References
Morelli, S., Daniele, C., D’Avenio, G., Grigioni, M., & Giansanti, D. (2024). Optimizing telehealth: Leveraging Key Performance Indicators for enhanced telehealth and digital healthcare outcomes (Telemechron Study). Healthcare, 12(13), 1319. https://doi.org/10.3390/healthcare12131319
Alawiye, T. (2024). The impact of digital technology on healthcare delivery and patient outcomes. E-Health Telecommunication Systems and Networks, 13, 13-22. 10.4236/etsn.2024.132002.
NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment Instructions
Create a 10 to 15 minute video recording of yourself performing a head-to-toe assessment on a volunteer who will be acting like one of the patients from the scenario case studies in this course.
Introduction
Click to view the NURS-FPX4015 Course Wrap-Up Video.
As you grow as a nurse, the ability to conduct a comprehensive and precise physical assessment of a patient is paramount, serving as the foundation for all subsequent healthcare decisions. This skill is closely tied to the crucial task of formulating an accurate differential diagnosis, which guides the course of treatment and significantly impacts patient outcomes. Incorporating an understanding of pathophysiology and pharmacology not only aids in the diagnostic process but also informs the development of an effective treatment plan. Lastly, the nurse’s role extends beyond these technical aspects, encompassing the vital responsibility of communicating these findings and plans to the patient, thereby fostering a collaborative and informed approach to healthcare.
This assessment must be completed on camera. You should use Kaltura to make your recording.
If you need more information on how to create and submit your video, please refer to Using Kaltura.
Instructions
Remember, your assessment submission will not be graded if you have not completed and submitted the Comprehensive Head-to-Toe Assessment Waiver. If you have not, complete and submit the waiver for Assessment 1.
The purpose of this assessment is to allow you the opportunity to demonstrate your ability to conduct an accurate and thorough examination of a patient, which is a critical skill for nurse practitioners. Patient assessments that are either inaccurate or not thorough can lead to misdiagnoses or suboptimal health outcomes for patients.
For this assessment, you will submit a video of yourself conducting a head-to-toe assessment on a volunteer based on one of the Sentinel U case studies presented in this course. Your head-to-toe assessment should include a detailed analysis of the underlying pathophysiology of the selected disease process, the expected assessment findings, and the patient’s pharmacological needs. Additionally, you should discuss nursing implications for the selected disease process, from a pathophysiology, pharmacology, and physical assessment perspective.
Your video submission will be assessed on the following:
- Comprehensive and Professional Assessment: Perform a comprehensive, thorough, and accurate assessment of a patient based on a selected disease process.
- Remember, that the person standing in as your patient should be acting out one of the diagnoses from the Sentinel U case studies in the course.
- Be careful and thorough in your assessment, make sure the camera can see what you are doing or make sure you are describing what you are doing to the patient.
- Discussion of Diagnosis and Findings: Explain the diagnosis and findings of the physical assessment with the patient.
- What did you find in your assessment?
- How did the findings help you arrive at your diagnosis?
- Are you communicating the findings to the patient in a way that provides context and helps the patient understand your findings?
- Understanding of Pharmacological Needs: Discuss the pharmacological needs of the patient within the context of their disease process and current best practices.
- What are the standard pharmacological treatments for the patient’s diagnosis?
- How does the patient’s health history, other conditions, and other medications impact the decision making process related to pharmacological treatment options?
- What other information does the patient need to know related to potential side effects or things to avoid related to any new pharmacological treatments for their condition?
- Understanding of Pathophysiology: Explain the underlying pathophysiology of the disease process to the patient.
- How does the disease process work in the body? Which systems does it impact?
- How is the patient likely to feel if the disease process progresses?
- How might symptoms of the disease process look or sound like to the patient?
- Critical Thinking and Clinical Reasoning: Synthesize assessment findings with knowledge of the disease process, pharmacology, and pathophysiology to establish care priorities for the patient.
- What are the care priorities for the patient?
- How have you used your assessment findings, combined with what you know about the pharmacology and pathophysiology to arrive at these priorities?
- What evidence-based or best-practices support these priorities?
- Communication and Professionalism: The nurse displays professionalism and communicates clearly and effectively with the appropriate use of terminology with the patient throughout the assessment.
Additional Requirements
- Total Length of Submission: Your video assessment must be 10 to 15 minutes in length.
- Captions: Make sure that your Kaltura has been auto-captioned by the system before turning it in. This helps to support accessibility best practices and can help faculty more effectively assess your video.
- Kaltura captions are automatically generated within 24 hours of you uploading the video recording to your Kaltura library. So, make sure you are not making your recording at the last minute.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
- Competency 1: Explain how pathophysiology, pharmacology, and physical assessment comprise a holistic approach to nursing care.
- Synthesize assessment findings with knowledge of the disease process, pharmacology, and pathophysiology to establish care priorities for the patient.
- Competency 3: Educate individuals on prevention and management of health conditions, across the life span and including special populations, based on pathophysiology, pharmacology, and physical assessment knowledge.
- Discuss the pharmacological needs of the patient within the context of their disease process and current best practices.
- Explain the underlying pathophysiology of the disease process to the patient.
- Competency 4: Perform comprehensive and focused physical assessments using appropriate techniques and tools.
- Perform a comprehensive, thorough, and accurate assessment of a patient based on a selected disease process.
- Explain the diagnosis and findings of the physical assessment with the patient.
- Competency 5: Apply scholarly writing standards to communicate evidence based strategies that support safe and effective patient care.
- The nurse displays professionalism and communicates clearly and effectively with the appropriate use of terminology with the patient throughout the assessment.
NURS-FPX4015 Assessment 5 Comprehensive Head-to-Toe Assessment Example Brief
Assessment 5 Comprehensive Head-to-toe Assessment- Video Transcript
Nurse: “Good morning, my name is _, and I am a registered nurse. Today, I will comprehensively assess my patient, Ms. Ivy Jackson. Good morning, Ms. Jackson. I’ll be your nurse today. Can you kindly introduce yourself?”
Ms. Jackson: “Hello. My name is Ms. Ivy Jackson. I am 61 years old. I am here to get medical assistance.”
Nurse: “How can I help you today?”
Patient (Ivy Jackson): “I’m tired and don’t want to do anything.”
Nurse: “When did this fatigue begin?”
Patient: “A couple of months ago, after my husband mentioned that he needed a divorce and that he had a girlfriend.”
Nurse: “I’m sorry to hear about that. I understand that such changes can negatively impact your life.”
Patient: “Thank you.”
Nurse: “Have you noticed any changes in your sleep patterns? Are you sleeping too much or having trouble falling asleep?”
Patient: “I sleep a lot but still wake up feeling exhausted.”
Nurse: “That sounds frustrating. What about your appetite? Have you been eating more or less than usual?”
Patient: “I barely eat. I don’t feel hungry most of the time.”
Nurse: “Have you had any significant weight loss or gain recently?”
Patient: “I lost 10 pounds in the last few weeks.”
Nurse: “What about your mood? Have you been feeling down or hopeless or having difficulty finding joy in things you used to enjoy?”
Patient: “Yes. I don’t really enjoy anything anymore. I feel sad and unmotivated.”
Nurse: “I’m sorry to hear that, Ms. Jackson. Have you ever had thoughts of harming yourself or that life isn’t worth living?”
Patient: “I wouldn’t say I want to hurt myself, but I do feel like things won’t get better.”
Nurse: “Thank you for sharing that with me. You’re not alone, and we’re here to support you. Do you have any conditions, and are you taking any medications?”
Patient: “I have hypertension, and I take lisinopril 20 mg and hydrochlorothiazide 25mg every morning.”
Nurse: “Have you ever been hospitalized in the past or undergone surgery?”
Patient: “No.”
Nurse: “Do you have any known food, drugs, or environmental allergies?”
Patient: “No.”
Nurse: “Tell me more about your family: parents, grandparents, siblings, and children, and their health.”
Patient: “Well, my mother died at 73 years. She had depression and high blood pressure, which ended up giving her a stroke. My father died at 85 years old and had high blood pressure. My brother suffers from high blood pressure and depression, while my sister suffers from high blood pressure and diabetes.”
Nurse: “Do you smoke, drink alcohol, or use other drugs?”
Patient: No
Nurse: “How strong is the social connection at home?”
Patient: “We are pretty close. My parents were married till my mother died. The family is very close, and we have a get-together for dinner every Sunday.”
Nurse: “What are your hobbies, and what do you do to maintain your health?”
Patient: “I normally walk around the block but have done nothing in the past few weeks. I have no hobbies.”
Nurse: “Are you sexually active?”
Patient: “No.”
Nurse: When was your last annual physical?”
Patient: “3 years ago.”
Nurse: When was your last pap smear?”
Patient: “That was 3 years ago.”
Review Of Systems
Nurse: “Ms. Jackson, I’d like to review your body systems quickly to check for any other concerns you might have. I’ll ask about different areas of your health, and you can let me know if you’ve noticed any issues, okay?”
Patient: “Okay.”
General
Nurse: “Have you noticed any recent changes in your weight?”
Patient: “Yes, I’ve lost about 10 pounds over the past few months.”
Nurse: “Was this intentional, or were you not trying to lose weight?”
Patient: “No, I wasn’t trying.”
Nurse: “Okay. Any fever, chills, or night sweats?”
Patient: “No.”
Skin:
Nurse: “Have you noted any new rashes, itching, or changes in your skin?”
Patient: “No.”
HEENT:
Nurse: “Have you experienced any headaches, vision changes, hearing problems, or sore throat?”
Patient: “No.”
Cardiovascular
Nurse: “Have you experienced any chest pain, palpitations, or swelling in your legs?”
Patient: “No.”
Respiratory
Nurse: ” Have you experienced any shortness of breath, wheezing, or cough?”
Patient: “No.”
Gastrointestinal
Nurse: “Any nausea, vomiting, constipation, or diarrhea?”
Patient: “No.”
Genitourinary
Nurse: “Have you experienced any pain with urination, frequent urination, or changes in urine color?”
Patient: “No.”
Musculoskeletal
Nurse: “Any muscle weakness, joint pain, or swelling?”
Patient: “No.”
Neurological
Nurse: “Any dizziness, numbness, tingling, or memory problems?”
Patient: “No.”
Psychiatric
Nurse: “Besides what we discussed about your mood, have you had any anxiety, panic attacks, or feelings of paranoia?”
Patient: “No, just the fatigue and sadness.”
Nurse: “Alright, I appreciate your answers. The only notable concern is the unintentional weight loss, which we will monitor closely. Otherwise, everything else appears unremarkable.”
Physical Assessment
Nurse: “Now, I will conduct a basic physical assessment to check for any physical signs associated with Ms. Jackson’s condition. I will describe all the steps and their significance.”
General Appearance
Nurse: “Ms. Jackson, you appear fatigued but well-hydrated, developed, and nourished, and you appear to be the stated age. You have been answering questions appropriately and are a good historian.“
Vitals: “I am now taking Ms. Jackson’s vital signs. The Blood pressure is 128/76 mmHg, Heart rate: 78 bpm, regular, Respiratory rate: 16 breaths per minute, Temperature: 98.2°F (36.8°C), SpO2 98% on room air. The vitals are stable. There are no immediate concerns. The fatigue could be related to her underlying depression.”
Head, Eyes, Ears, Nose, Throat (HEENT)
“I am inspecting Ms. Jackson’s head, facial symmetry, and neck. There are no visible abnormalities. Her scalp is intact, and there are no signs of trauma. Eyes: No conjunctival pallor or jaundice. Pupils are equal, round, and reactive to light. Ears: No hearing deficits, no signs of ear infections. Nose: No congestion, septum is midline. Throat: Oral mucosa is moist, no lesions, teeth are intact. No signs of infection or inflammation.”
Neurological Examination
Nurse: “Can you tell me where you are and who I am. Can you tell the time right now?”
Patient: “I am at the medical clinic and came due to fatigue. You are the nurse attending to me. It is around midday.”
Nurse: “The patient is alert and oriented to person, place, and time. The speech is clear.”
Nurse: “I am assessing the sense of smell. I am now assessing eye movements. I am now assessing her gait and balance. Ms. Jackson, kindly walk across the room with your arms spread out. Spread the right arm, touch the nose with the index finger of the left arm and alternate the arms.” “Cranial nerves II-XII are intact. No deficits in motor function or coordination. No tremors; gait is steady.”
Cardiovascular System
Nurse: “I am auscultating Ms. Jackson’s heart sounds.” Regular S1 and S2, no murmurs, rubs, or gallops. Capillary refill is less than 2 seconds, indicating good perfusion. I am assessing swelling in the extremities. No peripheral edema. The cardiovascular assessment rules out immediate cardiac causes for her fatigue.”
Respiratory System
“I am now assessing Ms. Jackson’s respiratory function. The breath is warm and moist, and the chest rises symmetrically with breathing. The breath sounds are clear bilaterally, with no wheezing, crackles, or diminished sounds. Her respiratory assessment is unremarkable. There are no signs of respiratory illness contributing to her fatigue.”
Gastrointestinal System
Nurse: “I am assessing Ms. Jackson’s abdomen for any abnormalities. Normoactive bowel sounds are present in all quadrants. No tenderness, masses, or organomegaly noted. The gastrointestinal assessment is normal, and she has no current problems.
Musculoskeletal System
“I am assessing Ms. Jackson’s musculoskeletal system. No joint swelling, tenderness, or muscle weakness noted. She reports generalized fatigue but no focal muscle weakness. Gait is steady, with no signs of instability. Her musculoskeletal function is intact, but her decreased activity levels due to depression may contribute to muscle deconditioning.
Genitourinary system
Nurse: “I am assessing the genitourinary system. Normal external genitalia and no rashes, lesions, masses, or discharge noted.”
Skin
“I am inspecting Ms. Jackson’s skin for any abnormalities.” The skin is warm and dry, with no rashes or lesions. There are no signs of dehydration or poor hygiene. Her skin assessment is unremarkable. No physical signs of neglect or dermatologic conditions.”
Discussion of Assessment Findings
Nurse: “Ms. Jackson, I have completed your physical assessment. Your vital signs are stable, and there are no immediate physical abnormalities. However, you admit feeling fatigued, being sad, having low energy, and having a history of recent traumatic events, which align with depressive symptoms. Additionally, you have lost 10 pounds in the past few weeks. This is concerning because nutrition significantly affects mental and physical health.”
Patient: “So, this is all because of my depression?”
Nurse: “Yes, depression affects both the mind and body. It can lead to changes in sleep, appetite, energy levels, and overall motivation. Since you have a history of depression, your symptoms, and their persistence for more than two weeks indicate a possible major depressive episode, based on the DSM-5 diagnostic criteria for major depressive disorder.”
Nurse: “Antidepressants can take several weeks to show their full effect, so kindly take them faithfully, and you will see results in about 6 weeks. One of the standard treatments for Major Depressive Disorder includes Selective Serotonin Reuptake Inhibitors (SSRIs), such as sertraline or fluoxetine. These medications help balance brain chemicals that regulate mood. There are other classes for major depressive disorder: Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) such as Effexor, Tricyclic antidepressants such as amitriptyline, Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) such as Wellbutrin, and monoamine oxidase inhibitors such as parnate. The choice of medications is based on the expected outcomes and responses to the SSRIs, which are the first-line treatment interventions. In addition, if you had complications such as suicidal ideations or medical conditions, adjusting your medications could be paramount.”
Patient: “Are there side effects?”
Nurse: “Some people experience nausea, dizziness, or headaches initially, but these usually go away. Since you have hypertension, we would need to choose a medication that does not interfere with your blood pressure treatment. Regular follow-ups will be important to monitor your response to the medication.”
Understanding Pathophysiology
Nurse: “Ms. Jackson, depression results from imbalanced neurotransmitters like serotonin, dopamine, and norepinephrine in the brain and biological, genetic, environmental, and psychological factors (such as current stress from the divorce). Stressors can lead to neurotransmitter imbalance. These neurotransmitters are responsible for regulating mood, sleep, and appetite.
When there is an imbalance, it can lead to persistent sadness, fatigue, and lack of motivation. Without treatment, depression can lead to worsening symptoms, cognitive decline, and even physical health complications like high blood pressure and weakened immunity. Other symptoms of worsening depression include thoughts of death, suicidal ideations and attempts, changes in sleep patterns, significant weight loss or gain, unexplained aches and pains, and irritability. The goal is to manage it effectively before it progresses.”
Patient: “Oh, okay.”
Critical Thinking and Clinical Reasoning
Nurse: “Ms. Jackson, based on your symptoms and medical history, our care priorities are starting antidepressant therapy, referring you to a therapist or support group for additional coping strategies, educating you on lifestyle modifications, such as light exercise and balanced meals, and scheduling follow-ups to monitor progress and adjust treatment if needed.
Patient: “That sounds like a good plan, but I’m just not sure I have the energy for all of this.”
Nurse: “I understand. Taking small steps is the key. We will support you in this journey, and you are not alone.”
Communication and Professionalism
Nurse: “Throughout this session, I used a patient-centered approach to assess Ms. Jackson’s condition. I have also used clinical management guidelines and diagnostic tools such as the DSM-5 to diagnose and manage patients accurately. I actively listened to her concerns, validated her experiences, and provided education in a way that was clear and supportive. I formulated an appropriate care plan that prioritizes her mental and physical well-being by integrating clinical reasoning. This concludes the assessment. Thank you for watching.”