Head To Toe Assessment Essay.

Head To Toe Assessment Essay.



The purpose of the assignment is to provide a comprehensive head to toe assessment of the chosen participant, patient X, 32 years of male. A head-to-toe assessment is defined as a physical examination or health assessment of a patient which becomes one of the most fundamental components of the health care sector which further provides the understanding of a patient’s needs and problems. This paper will provide a summative overview of the head to toe assessment of 9 components of health which will provide an idea of the abnormal and normal health status. Head To Toe Assessment Essay.



Eye assessment:

  1. Visual acuity: visual acuity is defined as a condition where the eye can detect fine details, the especially in-focus image at a certain distance. The standard optimum range of vision to see is 6/ 6. It is often measured with a Snellen chart or with a logMAR base Velorum Visual Acuity System (Suetsugu, Ohki &Kaku, 2016).
  2. Refraction: The refraction of vision is usually measured for identifying a refractive error of the patient such as myopia and hyperopia (Suetsugu, Ohki &Kaku, 2016). The objective refraction is measured by retinoscope and subjective refraction is measured by phoropter.
  3. Pupil function: An examination of the pupil includes inspecting the pupils for equal size, the standard shape of the pupil, reactivity, direct accommodation. The slit lamp is used to measure all these factors mentioned above. Head To Toe Assessment Essay.
  4. Intraocular pressure: Intraocular pressure (IOP) is required measured by Tonometry devices which are used to measure the internal pressure of the eye. Tonometry is a method of measuring this pressure using various instruments. The normal range is 10-21 mmHg.
  5. Retinal examination: The retinal examination is a crucial part of the general eye assessment. The dilating the pupil using eye drops greatly enhances the view as well as permits the extensive examination of the periphery (Currie et al., 2016). An ophthalmoscope is an instrument that is used to do the retinal examination.Head To Toe Assessment Essay.

Ear assessment:

The assessment of the ear focuses on the activity of the auditory system of the person. Hence, the audibility of the person would be assessed in this assessment. The assessment also includes any kind of lesion or protrusion observation on the ear by palpating the auricle. Looking inside the ear in order to observe the condition and the exudates of the ear would also be considered. Moreover, the tuning fork test of Weber should also be implemented along with whisper test for the audibility and the range of audibility by the range of sounds would be assessed. The measurement of the audibility of the person would be done by audiometer and the process is termed as the audiometry (Govender & Mars, 2018).

Head and Face assessment:

Assessment of head and face will be helpful in the identification of the orientation and other pain or sensation issues of the person. Hence, checking the distribution and condition of the hair would be required. Moreover, checking the scalp for identifying any bump or lesion would be done as well. Palpating the scalp for the tenderness and any kind of pain in the scalp would also be done. Furthermore, observation for the assessment of the symmetrical facial movement would be required. Other than these palpating the face for any kind of pain or dull sensation should be assessed (Marmura, Silberstein & Schwedt, 2015). On this context it can be stated that the dull sensation should be considered as and treated as it can be caused by neurological disorder.Head To Toe Assessment Essay.

Mouth and Throat assessment:

This assessment helps in the identification of the hydration condition, functionality of the mouth and teeth, infection identification in the mouth and other factors. This assessment is dependent on the observation process and focuses on the colour and moistness of the lips, inspect the teeth and gums by observing any colour or infection identification, examining the tongue colour and looking into the tonsils. Furthermore, the palpating of jaw joints would also be considered for identification of any kind of displacement as well (Epstein et al., 2017).Head To Toe Assessment Essay.

 Vital sign assessment:

  1. Assessment temperature: Assessing body temperature is considered a nursing procedure that provides baseline data for subsequent evaluation for the proper homeostasis of the individuals. The normal range of body temperature is in between 35 to 38 degrees (Cardona-Morrell et al., 2016). The thermometer is used to measure body temperature.
  2. Blood pressure assessment: blood pressure assessment is one of the most common vital sign assessments which provides the idea of the vital signs. An optimal blood pressure level is reading under 120/80 mmHg (Cardona-Morrell et al., 2016). The sphygmomanometer is used to assess the blood pressure of the patient.Head To Toe Assessment Essay.
  3. Heart rate assessment: Heart rate assessment should be considered as one of the most important factors of physical assessment. It provides the idea of circulatory and the functionality of the body. Normal heart rate of an adult is 60 to 100 beats per minute. The stethoscope and the automatic vital sign record are the tools used to assess the heart rate of a person (McCraty & Shaffer, 2015).Head To Toe Assessment Essay.
  4. Respiratory rate: Respiratory rate provides the idea of breathing rate of a person and also the functionality of the lungs of the person along with the idea about cardiac function. Optimal respiratory rate of an adult is 12 to 16 per minute. Respiratory rate can be measured through the observation process with the stop watch implementation (Bergese et al., 2017).Head To Toe Assessment Essay.

Circulatory system assessment:

  1. Palpate temporal artery: This one of the assessment which identifies the pulse rate and the heart rate of the person and the blood flow rate to the brain. The normal measurement is 20 to 40 mm/hr for an adult. The measurement would be done through placing finger on the upper neck and calculating the rate of flow by pulse rate (Chase & Ramsey, 2018).
  2. Heart beat assessment: This is to examine the rate of the blood flow in the body or the pumping functionality of the heart of a person. Normal heart beat of an adult is 60 to 100 beats per minute and lower than this rate or over this rate a chance of cardiac arrest would occur. The measurement can be done by listening to different pulses of the body and the heart beat directly through the stethoscope (Herry et al., 2017).

Gastrointestinal assessment:

This assessment focuses on the inspection of the metabolic function of a person. Hence, the bowel movement of the person should be questioned at the time of the assessment that is if there is any kind of problem identified by the patient should be considered with priority. Moreover, the inspection of the abdomen by listening to the bowel sounds of the four quadrates of abdomen. Other than this palpating the abdomen or assessing the pain or tenderness of the abdomen should also be done (Cunningham et al., 2016). Hence, the assessment is done through observation.Head To Toe Assessment Essay.

Leg and feet assessment:

This assessment focuses on the range of motion and the strengths of the ankles, muscles and joints as well. The measurement of the range of motion would be conducted by implementing goniometer (Meir et al., 2017). Moreover, the cap refills of the toenails and the pulses of the legs should be done by palpating the feet and other portions of the leg. Furthermore, pressing the leg muscles to identify any sharp or dull sensation of the leg muscles should also be done. On this context it can be stated that the dull sensation should be considered as and treated as it can be caused by neurological disorder. Other than all these the gait assessment should be done by the observation of the movement and the orientation of the feet during the walking process of the person.Head To Toe Assessment Essay.

Neck and Shoulder assessment:

The assessment of neck and should would also be focused on the range of motion measurement by the goniometer. The shoulder assessment can also be done through the providing resistance and observing the functionality of the shoulder against range of resistance. Moreover, palpating the lymph nodes of head, face, neck and underarms would be conducted for the assessment of the pain and sensations along with functionality (Habibi, Mohammadi & Sartang, 2016). Neck and the trachea would also be palpated for the same assessment.

Plan of care

Plan of care for the person would include the consideration of the abnormal conditions found by the head to toe assessment. On this context it can be stated that the observation of the patient and the evaluation of the issues play a crucial role in the care plan development. Firstly, the focus should be on the improvement of the abnormal condition and reverting to the normal state. For this process the health care professional would be prescribing medicines such as diuretics, beta blockers or ACE inhibitors for blood pressure issues; beta blockers for heart rate control; anti microbial or anti fungal medicines for any kind of infection on skin or eye or any other portion identified during head to toe assessment; loperamide or bismuth subsalicylate for stomach pain, lactulose, linaclotide and lubiprostone for proper bowel movement; non-steroidal anti-inflammatory drug for the muscle pain; vitamin B medicines for the nerve damage control (Corden et al., 2016). For eye treatment medication such as eye drops and vitamins, eye exercises and if needed operation would be prescribed. Secondly, the neurological issues such as the movement issue and also the issues regarding other musculoskeletal problems should be diagnosed properly through different electromagnetic test (MRI, CT scan, EEG, EMG, NCV) implementation (Naro et al., 2016). Based on the test result the health care professional should prescribe regular physiotherapy, exercises and muscle strengthening exercises as well. Other than these the intervention process would also focusing on the education of the patient and also motivating the patient to develop self management skills such as medication administration on time and with specific dose, proper diet following and proper routine following for other works (Collins et al., 2017).Head To Toe Assessment Essay. The education should be about healthy habits, hygiene maintenance, daily exercises. Hence, regarding the motivation and knowledge development of the patient the health care professionals can develop health promotion plans for improving health literacy and reducing disease rates among adult people such as obesity, cardiovascular disease, gastrointestinal diseases and also the physiological disorders (Brisbois & Asselin, 2016). Moreover, any kind of specialised chronic illness such diabetes, obesity, cancer and others should be referred to the specialist carer and health promotion for these issues should be considered with priority.Head To Toe Assessment Essay.


Based on the above discussion it can be concluded that the head to toe assessment is a crucial factor in terms of the primary diagnosis of a person. Moreover, the process helps in identification of any kind of abnormality and done by observation or other instrument implementation. Based on the assessment the intervention, medication and health promotion or education of the individual patient or a community would be done.Head To Toe Assessment Essay.