Question

viewed the vidoes, I want you to perform a head to toe assessment on a family member. I want you to submit a word document synopsis of the head to toe you completed on your family member. You should start with the head portion and work your way down to include the abdomen and Peripheral vascular system. Include the age/sex/health history and head to toe synopsis of the family member you complete this on in the word document. Try to pick a person in your family who has a health issue if you have one available. Please reach out to me if you have

Answer 1

Ans) Nursing staff should discuss the history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status, implants and family and social history. Recent overseas travel should be discussed and documented.

For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, Apgar score, resuscitation required at delivery and Newborn Screening Tests

General Appearance:
Assessment of the patients’ overall physical, emotional and behavioral state. This should occur on admission and then continue to be observed throughout the patients stay in hospital.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

Neonate and Infant
Parent infant, infant parent interaction
Body symmetry, spontaneous position and movement
Symmetry and positioning of facial features
Strong cry
Young Child
Parent child, child parent interaction
Mood and affect
Gross and fine motor skills
Developmental milestones
Appropriate speech
Adolescent
Mood and affect
Personal hygiene
Communication
Vital signs:
Baseline observations are recorded as part of an admission assessment and documented on the patient’s observation flowsheet. Ongoing assessment of vital signs are completed as indicated for your patient. It is mandatory to review the ViCTOR graph at least every 2 hours or as patient condition dictates to observe trending of vital signs and to support your clinical decision making process.

Temperature: tympanic temperatures for children older than 6 months. Less than 6 months use digital thermometer per axilla.
Respiratory Rate: count the child’s breaths for one full minute. Assess any respiratory distress.
Heart Rate: Palpate brachial pulse (preferred in neonates) or femoral pulse in infant and radial pulse in older children. To ensure accuracy, count pulse for a full minute.
Blood Pressure: Baseline measurement should be obtained for every patient. Selection of the cuff size is an important consideration. A rough guide to appropriate cuff size is to ensure it fits a 2/3 width of upper arm. For neonates without previous hospital admissions do a blood pressure on all 4 limbs.
Oxygen Saturation: Monitor as clinically indicated. Note oxygen requirement and delivery mode.
Pain: Use FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool as appropriate to the age group. Areas such as PICU and NICU use specialised pain scales for intubated and sedated patients. E.g. Modified Pain Assessment Tool (MPAT), Comfort B. Review current pain relief medications/practices.
Additional Measurements:
Weight: on admission and/or weekly/daily as clinically indicated.
Height: as clinically indicated.
Head circumference: as clinically indicated.
Blood sugar level (BSL): as clinically indicated.
Physical assessment:
A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation/inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment information includes, but is not limited to:

Primary assessment (Airway, Breathing, Circulation and Disability) and Focussed systems assessment. Information regarding each assessment criteria is specified comprehensively in the “Shift assessment” section below.

Shift Assessment:
At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the patient care plan and further assessments or changes to be documented in the progress notes. Clinical judgment should be used to decide on the extent of assessment required.  
Patient assessment commences with assessing the general appearance of the patient. Use observation to identify the general appearance of the patient which includes level of interaction, looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Assessment information includes, but is not limited to:

Airway: noises, secretions, cough, any artificial airways
Breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing: - spontaneous/ laboured/supported/ ventilator dependent, oxygen requirement and delivery mode.
Circulation: pulses (location, rate, rhythm and strength); temperature (peripheral and central), skin colour and moisture, skin turgor, capillary refill time (central and Peripheral); skin, lip, oral mucosa and nail bed colour. ECG rate and rhythm if monitored.
Disability: use assessment tools such as, Alert Voice Pain Unconscious score (AVPU) or University Michigan Sedation Score (UMSS), Gross Motor Function Classification System (GMFCS. Identify any abnormal movement or gait and any aids required such as mobility aids, transfer requirements, glasses, hearing aids, prosthetics/orthotics required.
Observation of vital signs including Pain: use FLACC, Wong Baker Faces, numeric scale, Neonatal Pain assessment tool, Comfort B scale as appropriate to the age group. Review current pain relief medications/practices. For further information please see the Pain Assessment and Measurement clinical guideline
Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries.
Hydration/Nutrition: Assess hydration and nutrition status and check feeding type- oral, nasogastric, gastrostomy, jejunal, fasting, and breast fed, type of diet, IV fluids.
On admission, the paediatric nutrition screening tool* should be completed for all paediatric patients and is a requirement for compliance to accreditation standard 5. The screening tool comprises of 4 ‘yes/no’ questions used to identify those patients that require nutritional assessment and interventions. Information can be obtained from parents/carers, medical records and by examining the child. Children that do not require nutrition assessment should be rescreened every 7 days during their hospital stay. Rescreening should include regular weights and monitoring of nutritional intake.
*Adapted from Dietetics and Food Service, Lady Cilento Children’s hospital’s ‘Paediatric Nutrition Screening Tool Instructions for use’ information sheet.
Output: Assess Bowel and Bladder routine(s), incontinence management urine output, bowels, drains and total losses. Review fluid balance activity
Blood sugar levels as clinically indicated.
Focused Assessment: assessment of presenting problem(s) or other identified issues, e.g. cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
Risk Assessment: pressure injury risk assessment (link to pressure guideline), falls risk assessment (link to Falls guideline), ID bands.
Wellbeing: Assess for Mood, sleeping habits and outcome, coping strategies, reaction to admission, emotional state, comfort objects, support networks, reaction to admission and psychosocial assessments.
In the adolescent patient it is important to consider completing psychosocial assessments as physical, emotional and social well-being are closely interlinked. The HEADSS assessment is a psychosocial screening tool which can assist in building a rapport with the young person while gathering information about their family, peers, school and inner thoughts and feelings. The main goals of the HEADSS assessment are to screen for any specific risk taking behaviours and identify areas for intervention, prevention and health education. For more information see Engaging with and assessing the adolescent patient. It is important to note that you may need to establish a rapport with the young person and may require a few shifts to fully complete the HEADSS assessment.
Social: This may include discussing a wide range of factors including Parents/ carers/ guardian, siblings, living arrangements, visiting plans, transport, specific cultural requirements, schooling, discharge plan etc. Pertinent social assessment information such as court orders can also be documented in the FYI tab to alert all members of the health care team.
Review the history of the patient recorded in the medical record. It may be necessary to ask questions to add additional details to the history.