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

Hello, my name is________. Today, I will perform a comprehensive head-to-toe assessment on my patient, Aiyana Tehanata, from the Sentinel U case study. Her major complaint is tingling in her feet, with a pain level of 5/10 and high blood sugar. This assessment will cover all major body systems and identify key findings related to the patient’s condition. I will verbally describe what I am doing and explain my findings. This will help ensure clarity while also providing important patient education. Let’s begin the assessment.

Comprehensive and Professional Assessment

As my first step, I am examining your overall condition. Your current appearance shows fatigue alongside heavy breathing, particularly upon exertion, while maintaining a tripod position. This position may indicate an increased effort to breathe due to decreased heart oxygen supply, temperature, and pale skin tone, suggesting that your blood circulation is likely faulty. Swelling in your lower legs is mild, but peripheral edema, which is swelling in the lower legs/hands, can sometimes manifest in Coronary Heart Disease (CHD) patients due to venous congestion (Alevroudis et al., 2024).

• Vital Signs: I will proceed with taking your vital sign measurements. Your temperature matches the normal range at 98.4 degrees Fahrenheit. Your heart works harder to distribute blood throughout your body because your heart rate currently reaches 96 beats per minute. The blood pressure reading of 140/88 mmHg points to increased pressure commonly associated with CHD and hypertension, which increase cardiovascular strain. The 22 breaths per minute you take constitute an increased respiratory rate because shortness of breath means poor cardiac output or a condition called Ischemia-dyspnea. In this condition, blood flow to the heart muscle is reduced. Your oxygen saturation level is 94% while breathing in room air, which is in a low but safe range. The monitoring for worsening hypoxic conditions is essential to see signs of worsening ischemia.

• Neurological Assessment: Now, my focus is on your neurological condition. Please provide me with your identity, present location, and current date. You show proper awareness about your identity, current location, and the present day. The examination with a penlight shows equal round pupils that show a proper light reaction. No focal neurological deficits are noted, and no signs of transient ischemic attack (TIA) or stroke, which could be potential concerns in CHD patients, are observed. The slowness in your speech pattern appears linked to your heart needing to work extra hard. You do not show evidence of coordination dysfunction during finger-to-nose movement tests and alternating movement tasks.

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

• • Head, Eyes, Ears, Nose, and Throat (HEENT): The top of your head displays a normal shape with no detectable irregularities. Your white part of the eye shows mild pallor that signals anemia, a common comorbidity in CHD that contributes to reduced oxygen delivery, as shown in a study by Siddiqui et al. (2022)—no signs of jaundice. Examining your ears reveals no observable issues, together with normal hearing function. The interior of your nose displays no signs of congestion and operates without nasal flaring. Your dry mucous membranes indicate mild dehydration, which could be exacerbated by medication use, such as diuretics often prescribed for CHD management—no visible lesions in the oral cavity.
  • Cardiovascular Assessment: Let us see how your heart sounds. An S4 heart sound emerges during my examination, which is characteristic of CHD due to left ventricular hypertrophy and decreased compliance (Pechetty & Nemani, 2020). Possible atrial fibrillation appears to be present through your irregular apical pulse, which is a common irregular heartbeat in CHD caused by reduced blood flow to the heart. Your radial (near thumb) and dorsalis pedis (upper foot) pulses show weak and slightly reduced strength because blood flow is restricted to your extremities. Atherosclerosis (which is a plaque on arteries) in patients with CHD can develop into peripheral arterial disease (PAD), which is the reason for tingling in the feet (NHLBI, 2024). The jugular veins in your body do not experience major expansion when placed at a 45-degree angle, thus distinguishing this situation from right-sided heart failure. The test of your lower legs for edema takes place at this instant. The low-grade dependent edema affects you, but vessel damage produces this swelling rather than fluid accumulation.
  • Respiratory Assessment: The following assessment of your lungs is about to begin. Another minimal stethoscope breathing through will help me identify your lung sounds. Your breathing sounds show no crackles, and no wheezing was noted. Your breaths appear quicker, probably due to shortness of breath caused by physical exertion, caused by decreased cardiac blood flow. You currently experience an orthopneic condition that allows better breathing while sitting upright than lying on your bed (Mukerji, n.d.).

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

• Abdominal Assessment: The next step will be an abdominal examination. No swelling is visible during the visual assessment of your abdomen. During bowel sound examination, you should hear sounds covering the entire testing area, divided into four sections. You experience mild pain while I do right upper quadrant palpation, yet there is no marked liver congestion; therefore, this case is distinct from right-sided CHF. Examination reveals neither hepatomegaly nor ascites because these clinical signs are more frequent in patients with heart failure.

• Musculoskeletal Assessment: Let us begin with a musculoskeletal assessment. Your hand squeeze shows weakened strength, which seems to be caused by tiredness. Your ability to push against my hands using your feet shows the mild weakness of lower limb muscles, which signifies inadequate blood circulation and physical inactivity rather than water retention. It could be the reason for feet ‘tingling sensation as there is poor oxygen circulation and nutrients delivery to the lower limb. The joints show no signs of deformities or no contractures in your body. Chronic illness and decreased mobility explain the mild muscle wasting within your lower extremities. 

• Skin Assessment: I am conducting a skin examination now. Light-colored and slightly cool skin provides evidence of circulatory problems. No rashes or lesions are visible in my eyes. The lower legs of your skin display a shiny stretch that often happens in people with prolonged edema, but the stretch does not leave any dimples. The procedure of capillary refill testing involves temporary skin whitening before observing the color recovery speed, according to McGuire et al. (2023). The test demonstrates light blood flow limitations that match arterial insufficiency symptoms in patients with CHD.

Discussion of Diagnosis and Findings

Aiyana, your heart receives insufficient blood flow, according to my evaluation, because of coronary heart disease (CHD). Your history of struggle with high blood pressure, along with high cholesterol, puts you at higher risk for this condition. Your heart operates at an elevated rate with disordered heartbeat patterns when there is insufficient oxygen supply to the heart, as determined during my examination. Your dizziness and foot tingling may result from circulatory problems that frequently appearing in CHD.

The combination of elevated blood pressure and heart rate indicates an overworked heart and sections of your blood vessels become restricted, causing a reduction in heart pumping efficiency. Your doctor may change medications combined with heart-healthy dietary and activity recommendations to enhance your heart function because CHD raises heart complication risks (Gaudel et al., 2022). Your physician will get a summary of my findings to develop an optimal treatment strategy for your care. Please feel free to share any doubts you have regarding our conversation today.

Understanding of Pharmacological Needs

Aiyana! In coronary heart disease treatment, you need medicine to increase the heart’s pumping performance and prevent fluid accumulation. Your doctor will choose a medication based on your medical condition from a list that includes Furosemide (Lasix) and Methotrexate, among others. 

• The beta-blocker medications in the metoprolol series reduce heart rate and control heart strain. According to Marti et al. (2020), initial tiredness from medication consumption tends to resolve itself over time. 
• Lisinopril’s blood pressure-management properties and vessel relaxation capability facilitate heart pumping effectiveness while lowering pressure levels. Please keep us informed about dry cough symptoms because they represent a known side effect of this medication (Marti et al., 2020).

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

People using Spironolactone benefit from aldosterone antagonist medications because this treatment stabilizes fluids while reducing blood pressure. Close blood sugar monitoring is essential since your diabetes status makes beta-blockers potentially impact your glucose control (Marti et al., 2020). The use of NSAIDs, including ibuprofen, should be avoided because they increase fluid retention, which will worsen your symptoms (Bindu et al., 2020). Monitor all treatment side effects, including dizziness, swelling, and any unusual symptoms, and immediately report to me for proper assessment. Do you have inquiries about the medications I have prescribed for diabetes and heart conditions nowadays, and how they control your sickness?

Understanding of Pathophysiology

Discussing body processes will help you understand coronary heart disease (CHD). The distribution of blood across your entire body depends entirely on your heart. CHD manifests when atherosclerosis causes plaque accumulation to block or narrow the heart supply arteries, lowering heart tissue oxygenation and nutrient deprivation. Coronary heart disease mostly affects heart structures and blood vessels, but simultaneously disrupts liver circulation, resulting in inadequate oxygen delivery. A fallen oxygen supply to the heart muscle leads to angina, chest pain, and shortness of breath.

Eventually, it leads to heart attacks when the oxygen supply becomes critically reduced, and reduced blood circulation results in dizziness, fatigue, and intermittent heart rhythm problems. An accumulation of fluids in your lungs challenges normal breathing, particularly when active (Shahjehan & Bhutta, 2024). Worsening of CHD can result in the development of secondary health issues that may create heart failure or arrhythmias (abnormal heart rhythm). Blood pressure monitoring, together with cholesterol level tracking and symptom assessment, needs to be done daily to manage CHD effectively. Let your doctor know immediately if you notice your chest pain worsening or develop unexpected breathlessness or dizziness alongside leg or body swelling. The awareness of early indicators facilitates quick response, which improves heart health management practices.

Critical Thinking and Clinical Reasoning

Care Priorities for the Patient with CHF

• Improving Blood Flow to the Heart: The reduced oxygen flow to the heart caused by blocked arterial passageways increases heart attack risk and creates conditions for chest pain (angina) or feet tingling sensation. People receive aspirin or clopidogrel medications that stop blood clotting, and atorvastatin or similar statins control artery plaque formation by reducing cholesterol. Doctors provide nitroglycerin as an angina-relieving drug that expands blood vessels. A healthy diet and exercise frequency form essential lifestyle components that aid blood flow together, improving symptoms like tingling. 
• Optimizing Heart Function: Beta-blockers such as metoprolol benefit the heart by controlling blood pressure while slowing the heart rate. ACE inhibitors, including lisinopril, direct blood vessels to relax, thus improving circulation. Monitoring blood pressure and heart rate helps to check the effectiveness of these medicines and safeguard against potential complications. The treatment protocol requires changes when patients show different responses to their medication. 

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

• Preventing Complications: CHD creates a high risk for patients to develop heart attacks, arrhythmias, and stroke complications. People who have advanced artery blockages need more treatment, like angioplasty or bypass surgery, to establish proper blood flow. Doctors may prescribe blood-thinning drugs to minimize clots within the bloodstream. Medical testing for cholesterol and blood pressure levels, as well as laboratory tests, serve to identify heart conditions at their earliest stages. 
• Lifestyle and Self-Care Education: Medical professionals must teach patients about lifestyle modifications since these changes help patients control their CHD and stop the disease from worsening. Preventing additional artery blockage depends on consuming dietary nutrients with low saturated fats and minimal cholesterol and sodium levels. Regular physical exercise and the act of stopping smoking practice help protect the heart from attacks effectively. Patients need to detect chest pain alongside shortness of breath or dizziness and immediately report these symptoms to their healthcare provider (Gaudel et al., 2022).

Evidence-Based Practices Supporting These Priorities

The American Heart Association (AHA) and the American College of Cardiology (ACC) endorse treatments that combine medications with lifestyle changes and regular checks as the basis for managing CHD effectively. Studies demonstrate that maintaining proper blood pressure, blood sugar, and cholesterol control reduces heart attack incidents while delivering better long-term health achievements (Heidenreich et al., 2022). Combining patient evaluation data with current CHD management guidelines allows the development of a personalized care strategy that protects patient well-being and avoids complications.

Conclusion

Through the complete assessment, we gained important details about Aiyana Tehanata’s medical circumstances, especially regarding her coronary heart disease. I conducted thorough evaluations to spot major healthcare issues affecting her circulation and breathing, along with medication-related challenges. Proper management, lifestyle changes, and active patient monitoring are necessary to enhance her health status. Your support enabled the redevelopment of this assessment, and I thank you for the opportunity provided.

References

Alevroudis, I., Kotoulas, S.-C., Tzikas, S., & Vassilikos, V. (2024). Congestion in heart failure: From the secret of a mummy to today’s novel diagnostic and therapeutic approaches: A comprehensive review. Journal of Clinical Medicine, 13(1), 12. https://doi.org/10.3390/jcm13010012 

Bindu, S., Mazumder, S., & Bandyopadhyay, U. (2020). Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochemical Pharmacology, 180(1), 114147. https://doi.org/10.1016/j.bcp.2020.114147 

Gaudel, P., Neupane, S., Koivisto, A., Kaunonen, M., & Rantanen, A. (2022). Effects of Intervention on Lifestyle Changes among Coronary Artery Disease Patients: A 6‐month Follow‐up Study. Nursing Open, 9(4). https://doi.org/10.1002/nop2.1212 

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., & Milano, C. A. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063 

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

Marti, C. N., Fonarow, G. C., Anker, S. D., Yancy, C., Vaduganathan, M., Greene, S. J., Ahmed, A., Januzzi, J. L., Gheorghiade, M., Filippatos, G., & Butler, J. (2020). Medication dosing for heart failure with reduced ejection fraction — opportunities and challenges. European Journal of Heart Failure, 21(3), 286–296. https://doi.org/10.1002/ejhf.1351 

McGuire, D., Gotlib, A., & King, J. (2023). Capillary Refill Time. PubMed Central. https://www.ncbi.nlm.nih.gov/books/NBK557753/ 

Mukerji, V. (n.d.). Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea. Nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK213/ 

NHLBI. (2024, October 28). Atherosclerosis – What Is Atherosclerosis? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/atherosclerosis 

Pechetty, R., & Nemani, L. (2020). Additional Heart Sounds—Part 1 (Third and Fourth Heart Sounds). Indian Journal of Cardiovascular Disease in Women WINCARS, 5(02), 155–164. https://doi.org/10.1055/s-0040-1713828 

Shahjehan, R. D., & Bhutta, B. S. (2024, October 9). Coronary artery disease. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK564304/ 

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

Siddiqui, S. W., Ashok, T., Patni, N., Fatima, M., Lamis, A., & Anne, K. K. (2022). Anemia and heart failure: A narrative review. Cureus, 14(7). https://doi.org/10.7759/cureus.27167