Capella FPX 4015 Assessment 5

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

Introduction and Initial Observations

Good day, Ms. Jackson. My name is __, and I will be conducting a full head-to-toe assessment to evaluate your overall physical and emotional health. The purpose of this evaluation is to detect any potential health concerns and tailor a care plan specific to your needs. If at any point during the process you experience discomfort or need a break, please let me know immediately.

On initial observation, your posture suggests mild fatigue, and there appears to be some emotional tension based on your facial expressions and body language. To assess your mental clarity, I’ll ask you a few questions: Can you please tell me your full name, the current date, and your present location? Thank you. Additionally, I’d like to inquire about your emotional well-being—have you recently experienced trouble sleeping, mood fluctuations, or persistent anxiety or sadness? It’s important to address emotional and mental health alongside physical well-being so we can create a supportive and effective care plan.

Neurological and Cardiovascular Assessment

We’ll begin with a brief neurological examination. Your pupils are equal in size and react appropriately to light stimuli, which is a positive sign of neurological function. Your extraocular movements were assessed by tracking my finger, and your eye movements appeared coordinated and smooth. I then evaluated your reflexes with a patellar tap, which yielded a normal response. Your grip strength is balanced on both sides, and your coordination appears intact when performing the finger-to-nose test followed by reaching toward my hand.

Moving forward to the cardiovascular evaluation, I auscultated your heart sounds, which were regular and clear. Your pulse rhythm was steady. Upon measuring your blood pressure, the reading was 145/90 mmHg, which is mildly elevated. This may be related to recent stress, dietary habits, or underlying health conditions. Your peripheral circulation, evaluated through capillary refill time, is within normal limits.

Respiratory, Abdominal, and Musculoskeletal Assessment

The respiratory assessment involved listening to lung sounds at various locations on your chest and back. The breath sounds were clear, without wheezes, rales, or crackles, indicating healthy pulmonary function. I then palpated your abdomen, which was soft and non-tender, with no detectable masses. Your bowel sounds were active and regular, suggesting normal gastrointestinal activity.

In evaluating your musculoskeletal system, you demonstrated full joint range of motion when asked to move your arms in circles. Your leg strength was symmetrical when pressing against resistance. A brief skin examination revealed healthy, intact skin without signs of lesions, edema, or rashes. Your nails also appeared healthy, with no abnormalities such as discoloration or brittleness.

Table: Comprehensive Head-to-Toe Assessment Findings

Assessment Category	Findings	Comments
Mental Status	Oriented to person, place, and time.	No signs of confusion; emotional distress noted.
Neurological	Pupils equal/reactive; smooth eye tracking; intact reflexes; good strength.	Neurological findings within normal limits.
Cardiovascular	BP: 145/90 mmHg; heart sounds clear; regular pulse.	Slight hypertension possibly linked to stress or diet.
Respiratory	Breath sounds clear in all lung fields.	Respiratory system appears healthy.
Abdominal	Abdomen soft, non-tender; normal bowel activity.	No GI concerns noted.
Musculoskeletal and Skin	Joint movement normal; symmetrical leg strength; skin intact.	No dermatological or musculoskeletal issues observed.

Discussion of Diagnosis and Findings

Following the comprehensive assessment, it appears that Ms. Jackson may be experiencing symptoms commonly associated with anxiety and depression. Fatigue, difficulty concentrating, disturbed sleep, and feelings of hopelessness are all indicative of underlying mental health conditions. As the CDC (2023) highlights, conditions such as anxiety and depression can significantly affect one’s physical health, often presenting with symptoms like muscle tightness, restlessness, and mood instability.

Ms. Jackson also expressed feelings of low motivation, sadness, and emotional overwhelm—symptoms that may align with major depressive disorder. These emotional health conditions are treatable and should be addressed with the same level of attention as chronic conditions such as hypertension (CDC, 2023). It’s important that we proceed with a tailored treatment strategy that may include therapy, lifestyle modifications, and possibly pharmacological support, all of which can improve her quality of life. Ms. Jackson, do you have any concerns or questions regarding today’s findings? Your comfort and understanding are essential as we move forward.

References

Calvi, A., et al. (2021). Antidepressant drugs effects on blood pressure. Frontiers in Cardiovascular Medicine, 8(8). https://doi.org/10.3389/fcvm.2021.704281

Centers for Disease Control and Prevention (CDC). (2023). Mental health conditions: Depression and anxiety. https://www.cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html

Chu, A., & Wadhwa, R. (2023). Selective serotonin reuptake inhibitors. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554406/

Cleveland Clinic. (2022). Neurotransmitters. https://my.clevelandclinic.org/health/articles/22513-neurotransmitters