Instructions Creating a Plan of Care Utilizing the information you have gathered over the last four weeks regarding the specific illness group you identified, this week, you will create a plan of care
Running Head: WEEK 4 PROJECT 0
Week 4 Project
Ralph Marrero
South University
May 24,2020
Head to Toe Assessment
In recent days, doctors and nurses have taken keen interest in patients’ health examination. This growing interest comes from the role these assessments play in the effective management of medical conditions. The assessment is crucial as it illuminates through the symptoms expressed by the patients thus assisting medical care providers to device a proper treatment and diagnosis plan. Mr. Lawlence, a seventy-eight year old Asian - American, has been brought in by her son, following a slip and fall accident within the vicinity of his home. He has a bleeding forehead and knee and is complaining of body pains. I have to carry out a head to toe assessment so that I can determine the full impact of the fall, to administer the correct treatment(Nelson, 2020).
Assessment of the patient
Integumentary assessment
I observed Mr. Lawrence's color of the skin, pigmentation, and distribution of hairs, fingers, and toes condition where I measured the skin turgor and the clubbing of fingernails. I also palpated the skin to see if there lumps or masses and conducted a lewis test.
Review of the system
The patient's skin was smooth, even-toned complexion with no lesions but had wrinkles as a result of age. The skin palpation revealed that Mr. Lawrence's upper and lower skin was warm, dry, and lacked edema. A pinch on the patient's hand indicated poor turgor as the skin slowly pulled back. He had clear, pinkish nails with no rigidity or swelling and a slight convex. His fingers and toes, however, revealed a 170֯ clubbing away from the usual 160 degrees(Belleza, 2017).
Neurological assessment
This assessment is essential in the determination of the patient's mental status, sensory functioning, and conscious levels. I applied the Glasgow Coma Scale (GSC) to assess the patient's opening of the eyes, motor, and oral responses. I requested Mr. Lawlence to elaborate on how he got to the center, to read the letters on a wall-mounted Snellen chart and directed light into his eyes to assess his sensitivity to light.
Review of the system
Mr. Lawrence could not account how he got to the clinic, had an impaired speech, and had a GSC score of 7 way below the recommended 15. He was unresponsive, looked restless, and had a Snellen test score of 17 out of 20. Mr. Lawrence had a reduced sensitivity to light. This assessment shows some signs of possible Alzheimers disorder(Moyle, 2018).
Cardiovascular assessment
This assessment entails the examination of how the blood is moving and circulating across the body. This circulation removes toxic waste materials like carbon iv oxide as well as nourishes the cell by availing food and oxygen. I inspected the patient's chest and thorax walls for symmetry and any heaves through palpation and the use of a stethoscope. I also used the stethoscope to assess the vigor and the rate of the heartbeat. Besides, I assessed Mr. Lawlence's blood pressure using a manometer.
Review of the system
The patients had a symmetrical chest and thorax with no heaves on his chest. His apical pulse rate and rhythm was irregular and had an 85% pulse oximeter reading way from the recommended 95-100%. He had a loudest S1 apex and a most vociferous S2 base with an abnormal blood pressure of 160/90 mmHg. The recommended pressure ranges from 90/60 mmHg to 120/80mmHg. The patients experienced chest pains when palpated. These reviews directly expose the hypertension condition.
Differential diagnosis
The above analysis accorded me the necessary information to determine the conditions the patient was suffering from. The two conditions detected include high blood pressure and Alzheimer's condition.
Alzheimer’s disease ( AD)
The general confusion and loss of memory among elderly persons are connected to dementia. AD is a condition related to the progressive and gradual decline in cognition and memory capacity. It starts like dementia but becomes worse with time. The performed examination of Mr. Lawrennce indicated that he has his memory capacity had declined, which can be connected to AD. A person's age is one of the predisposing factors of AD, with the elderly above 64 years of age having the highest risk of AD development. AD results in the degeneration and eventual death of brain cells leading to memory impairment, loss of nervous coordination, making the patient restless, deterioration of speech, and changes in behavior(Buchner & Larson, 2018).
Hypertension
Individual blood pressure is established from the quantity of blood that the heart pumps and the related blood vessel resistance. High blood pressure occurs if the pressure goes above 120/80mmHg. an individual with the condition can stay for a long time without realizing in case there are no accompanying symptoms. The patient had an abnormal blood pressure of 160/90 mmHg, a clear indication of hypertension.
A care plan
There is no single test used in the diagnosis of Alzheimer's disorder. AD is primarily identified through the observation of related signs and symptoms. Diagnostic strategies for AD include the assessment of the patient's nervous system, taking a CT or MRI scan (Mayo Clinic, 2018). Conversely, to diagnose high blood pressure, an inflatable cuff gets fastened on the arm, and the pressure of the blood is measured. The pressure of the blood can be grouped as normal when the reading ranges from 90/60 mmHg to 120/80mmHg or elevated when the reading is from 120/80to 129/80mmHg. The hypertension stage occurs when the systolic pressure of blood is ranging from 130 to 139 mmHg, and the diastole pressure 80 to 89mmHg. The stage two of high blood pressure has pressure from 140/90 mmHg upwards(Mayo Clinic, 2018).
There is no cure for the two conditions, and the treatment plan is only aimed at managing them. Whereas there exist no known medications used in the treatment of AD disorder, researchers have found the drug therapies to be effective in keeping in check of AD symptoms. Besides the drug therapies, a supportive and safe environment has been termed as helpful in making the patient's life easier. The role that engaging in social activities, performing guided physical workouts, and taking the recommended diet plays in the management of both conditions, cannot also be ignored.
Pharmacological interventions
As I have specified above, the high blood pressure and the AD do not have any cure, and as such, we can only manage the symptoms. Among the known medications that would help to manage and to improve AD symptoms in Mr. Lawlence includes donepezil, galantamine, Exelon, and memantine. Those to be used to manage hypertension includes calcium channel blockers, ACE inhibitors, and thiazide diuretics. Others may consist of alpha and beta-blockers, aldosterone antagonists, and renin inhibitors(Mayo Clinic, 2018).
Conclusion
The conducted HTT assessments show the critical role they can play in identifying underling medical conditions in patients. The assessments guide every process f the nursing care and assists nurses to come up with an effective, comprehensive, and correct diagnosis and treatment plan to achieve desired patients outcome.
References
Belleza, M. (2017, September 23). Integumentary system anatomy and physiology. Retrieved from https://nurseslabs.com/integumentary-system/
Buchner, D., & Larson, E. (2018). Falls and fractures in patients with Alzheimer-type dementia. Alzheimer Disease & Associated Disorders, 21(3), 270. doi:10.1018/00002093-198701040-0003
Mayo Clinic. (2018, December 8). Alzheimer's disease - Diagnosis and treatment - Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/diagnosis-treatment/drc-20350453
Mayo Clinic. (2018, May 12). High blood pressure (hypertension) - Diagnosis and treatment - Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417
Moyle, S. (2018, March 27). Neurological assessment and GCS. Retrieved from https://www.ausmed.com/cpd/articles/neurological-assessment-gcs
Nelson, L. (2020, April 7). How to conduct a head-to-toe assessment. Retrieved from https://nurse.org/articles/how-to-conduct-head-to-toe-assessment/
