Nursing

Thank you for receiving my order, this assignment is going to be a full head-to-toe assessment, please review the order instructions and the grading rubric to make sure which headings to include and expectations.

ANSWER

Documentation of the complete head to toe physical assessment.

Objective Findings

The patient has a good level of consciousness and orientation to place, person and time. The patient shows an erect posture and general hygiene. The speech is clear and fluent thus a high quality and appropriateness of speech. When assessing the heading, there are no lesions, lumps, parasites or hair distribution. The patient can feel the difference between dull and sharp sensation on the face. The eyes have no discharge or redness, with the eyes symmetrical and eye lashes evenly distribution and curved outwards. The patient has normal extra ocular movements and a positive field of vision. Gross hearing is intact with the rub fingers together by ear. There is no concern with shoulder shrug for resistance. The patient’s lymph nodes were non palpable.

The patient has normal respiratory rate and rhythm with a depth, presence of accessory muscle use. The bowel sounds are present and normal in all four quadrants. The client has costovertebal angle tenderness. The patient had no extremities for tenderness, edema, deformities, temperature and lesions. The capillary fill of the toes and fingers is less than 5 seconds. The client has normal gait and balance thus negative Romberg test. The patient has strength in all extremities.

Actual or Potential Risks

Costovertebal angle tenderness is a symptom of both polycystic kidney disease and acute pyelonephritis. The tenderness is felt in the area between the ribs and hipbone. Costovertebal angle tenderness is caused by the inflammation of the kidneys (Bergmann et al., 2018). Polycystic kidney disease is a condition where the kidneys are enlarged and contain multiple cysts. The cysts are filled with fluid and can cause the kidneys to become enlarged. Polycystic kidney disease can also lead to kidney failure. Acute pyelonephritis is a bacterial infection of the kidney that can cause the kidneys to become inflamed (Johnson and Russo, 2018). The condition is often caused by a urinary tract infection. Costovertebral angle tenderness is present in acute pyelonephritis especially among those with kidney stone, kidney abscess, ureter pelvic junction obstructions and urinary tract infection.

fgReferences

Bergmann, C., Guay-Woodford, L. M., Harris, P. C., Horie, S., Peters, D. J., & Torres, V. E. (2018). Polycystic kidney disease. Nature reviews Disease primers, 4(1), 1-24.

Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. New England Journal of Medicine, 378(1), 48-59.