Journal of Adolescent Health Essay

Head-to-Toe Assessment: For this assignment, perform a complete head-to-toe assessment on someone of your choice or a hypothetical person who has at least two (2) systems issues. Use the head-to-toe template here to document your assessment (add more lines as needed). In a Microsoft Word document of 4-5 pages (in addition to the template) formatted in APA style, discuss the remaining criteria for the assignment. Please note that the title and reference pages should not be included in the total page count of your paper. In your paper, address each of the following criteria: Use the template and include: -System being assessed. -Detailed review of each system with normal and abnormal findings. -For any system for which you do not have equipment, explain how you would do the assessment. -Normal laboratory findings for client age. -An analysis of age-specific risk reduction health screening and immunizations. -Two differential diagnoses (diseases) associated with possible abnormal findings. -A plan of care (including two priority-nursing diagnoses, interventions, evaluation). -Pharmacological treatments that can be used to address health issues for this client. -Client and age appropriate evidenced-based practice strategies for health promotion. On a separate references page, cite all sources using APA format. Journal of Adolescent Health Essay.

Introduction

This paper describes the head to toe assessment of a 14-year-old boy. It discusses the normal and abnormal findings of the assessed systems, the laboratory findings, and presents two differential diagnoses associated with the abnormal findings. The author will also provide a care plan, pharmacological treatments, and health promotion strategies appropriate for the patient’s age. A head to toe assessment helps to identify the abnormal and normal findings in all patient age groups by applying critical thinking to obtain, validate, analyze and synthesize information collected to make sound judgments and informed decisions on a patient’s health status.

Patient

The Patient is a 14-year-old boy (Ray) who came to the clinic for an annual checkup.

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Vital Signs

Height 6’2, weight 165 pounds, BP-130/65(right arm), 130/65(left arm), PR-72bpm, RR-16breaths per minute, temp-97.0F, SPO2-99%, not in pain. Ray’s vital signs are within normal limits. His height is in the 95th percentile while in the 78^th percentile for weight. Ray’s BMI is 21.77, which is healthy (CDC, n.d).

Appearance: Well-groomed 14-year-old with blue eyes, short black hair, has a steady gait, shows no signs of anxiety or distress.

Orientation: AOX4spheres. Responds appropriately to verbal commands, well-spoken with a clear speech, GCS findings- verbal response-oriented (5pts), spontaneous eye-opening (4pts), and motor response-obeys commands (6pts).

Head: round and symmetrical. No lesions, depressions, or masses on inspection and palpation. He has short black hair, evenly distributed with no signs of brittleness or thinning.         

Face symmetrical face, no lesions or discoloration. Intact, clean, dry, and warm skin with no masses, and non-tender lymph nodes on inspection and palpation. Journal of Adolescent Health Essay. All cranial nerves are intact.

Eyes and Vision:  Symmetrical and evenly spaced blue eyes, no discharge, PEBRL. Vision 20/20 both eyes.

Nose: midline nasal septum and nose. No discharge, pink nasal mucosa, no masses, intact sense of smell,            

Mouth and Throat: moist oral mucosa. Uses teeth braces and rubber bands. Has mildly puffy gums with food residue. Midline uvula, no dysphagia, and has a strong gag-reflex. No masses or pain over the neck on palpation, and can easily swallow both solids and liquids,

Ears: symmetrical with intact skin. No lesions, masses, or pain on palpation. No ear discharge, well visualized tympanic membrane, hearing is intact.

Chest and Back: no lesions or masses. A small amount of hair was noted over his chest. No tender region palpated on the back and chest. Can easily shrug shoulders. The chest is resonant on percussion, has no signs of spine curvatures. No lesions, masses, or drainage from the breasts, and there is minimal axillae hair. On auscultation, the lungs are clear, chest moves with respiration, no dyspnea, orthopnea, or shortness of breath noted. Ray denies having a cough or difficulty in breathing.

Heart: no distension of the jugular vein, S1, and S2 heard, no added heart sounds, equal pulses on all extremities, capillary refill less than two seconds, no edema, no finger clubbing.

Abdomen: flat and symmetrical, with no lesions. Active bowel sounds on all four abdominal quadrants. On percussion, dullness was noted over the spleen and liver (Ferguson, 2020). Light and deep palpation reveal no tenderness, ascites, or masses.  Denies vomiting and nausea, and acknowledges having normal bowel movements every day.

Genitourinary: dark pubic hair. The patient denies dysuria, oliguria, and polyuria Patient informs that he is not sexually active.

Musculoskeletal: no lesions, deformities, or masses noted over the skin in both upper and lower extremities. Sensation intact in all extremities, he has a steady and fast gait, the full length of movement in all joints, equal grip strength. Journal of Adolescent Health Essay.

Risk Reduction

Since Ray is a teenager (14 years old), his most significant risk reduction should focus on abstinence from using and abusing drugs, depression, practicing safe sex, and observing vehicle safety. Although he has admitted that he is not sexually active, he received handouts discussing STIs and safe sex. He admitted to tasting alcohol some months ago but did not like the taste and in their household, no one uses drugs, smokes tobacco, or takes alcohol. As recommended by Das et al (2016), he was also educated and given a handout about alcohol, tobacco smoking, and drugs. Ray drives safely, does not use the cell phone while driving, and always uses a seatbelt. He also underwent a driers safety course thus has the required driving skills. However, he received a handout that emphasized on vehicle safety. Ray also admitted to having depressive thoughts about his declining grades in school at a time when he was taking very difficult classes in junior high school so that he could secure admission to a good college. He sees a therapist to modify his behaviors and thought patterns (Gautam et al., 2020). He also discusses this issue freely with teachers and close family members and denies having thoughts of harming himself or committing suicide.

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Health Promotion

Ray goes for his annual health visits and is encouraged to continue doing so. During the last visit, the physician advised that he should engage in regular physical activity. In the past month, Ray began exercising daily in a local gym with a team of friends. Ray has also reduced the intake of calories, sweetened sugars, and fats. Today, he informs that he has lost six pounds and still has high energy levels. He is therefore encouraged to continue with this health practice. He should also check to ascertain that he is up to date with all his immunizations.

Plan of Care

Nursing Diagnosis 1

Impaired oral mucosa linked to lack of hygiene as evidenced by mildly puffy gums and food residue on teeth.

Intervention

• Encourage Ray to brush his teeth after every meal using the timer that the orthodontist provided.
• Each morning, Ray will floss his teeth and continuously use the special floss that his orthodontist provided.

Evaluation

Although he feels better, Ray did not realize the puffiness of his gums. He plans to continue with the earlier interventions.

Nursing Diagnosis 2

Depression related to poor grades in school as evidenced by verbal acknowledgment.

Intervention

• Ray will visit a therapist to help him reduce his anxiety and depression through therapy
• Ray will discuss with teachers, peers, and family his fears, listen to their inputs, and write a journal of what he considers the most appropriate actions.

Evaluation

            Ray stated that therapy was very helpful in relieving depression and will continue with all the sessions as planned. He expressed his fears about talking to peers but looked forward to doing it. He started journaling and working towards some of the actions he thought will be the most beneficial.

Conclusion

Ray’s head to toe assessment revealed that he had a good health status and was determined to improve his health status through lifestyle modification (healthy diets, regular physical exercise). Health promotion initiatives focus on reducing the risks of depression and improving overall hygiene. Ahead to toe assessment is integral to identifying a patient’s health needs and implementing intervention strategies to address the identified needs. Journal of Adolescent Health Essay.

References

CDC (n.d). Data Table of Weight-for-age Charts. Retrieved from https://www.cdc.gov/growthcharts/html_charts/wtage.htm#males

CDC (n.d). Adolescents and STDs. Retrieved September 12, 2020, from https://www.cdc.gov/std/life-stages-populations/stdfact-teens.htm

Das, J. K., Salam, R. A., Arshad, A., Finkelstein, Y., & Bhutta, Z. A. (2016). Interventions for adolescent substance abuse: An overview of systematic reviews. Journal of Adolescent Health, 59(4), S61-S75.

Ferguson C. M. (2020). Inspection, Auscultation, Palpation, and Percussion of the Abdomen. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. Third edition. Boston: Butterworths- Chapter 93. Retrieved September 12, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK420/

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian journal of psychiatry, 62(Suppl 2), S223. Journal of Adolescent Health Essay.