NURS FPX 4015 Assessment 1 Comprehensive Head-to-Toe Assessment Transcript

Student Name

Capella University

FPX4015

Professor Name

Submission Date

Introduction and Patient Consent

Nurse: Good morning, Mr. Mancini. My name is Shazia, and I will be performing a comprehensive head-to-toe physical assessment today. I understand you have been experiencing sleep disturbances and anxiety. Before we begin, is it okay if I proceed with the assessment?

Client: Yes, that’s fine.

Nurse: Thank you. During the assessment, please let me know if you feel uncomfortable or need a break at any time.

Vital Signs and Anthropometric Measurements

• Temperature: 98.6°F (37°C)
• Heart Rate: 82 beats per minute, regular
• Respiratory Rate: 16 breaths per minute, unlabored
• Blood Pressure: 148/92 mmHg (elevated)
• Oxygen Saturation: 98% on room air
• Height: 5’10”
• Weight: 175 lbs
• BMI: 25.1 (overweight range borderline)

Clinical Interpretation:
Blood pressure is elevated and consistent with a history of hypertension, requiring ongoing monitoring and medication adherence.

General Appearance

Mr. Mancini appears stated age, well-groomed, and appropriately dressed for the setting. Eye contact is maintained throughout the interaction. The patient appears mildly anxious but cooperative. Speech is clear and coherent, although occasional pauses are noted when discussing emotionally distressing topics.

Nurse: I can see that you seem a bit tense. You are doing well—please take your time when answering.

Neurological and Cognitive Assessment

• Level of consciousness: Alert and oriented ×4 (person, place, time, situation)
• Cognition: Mild difficulty with concentration under emotional stress
• Memory: Intact short- and long-term memory
• Cranial nerves II–XII: Grossly intact
• Motor response: Appropriate and coordinated

Cognitive Screening Observation:
Nurse: Please count backward from 100 by sevens.
Client: 93… 86… 79… umm… 72…

Interpretation:
Mild slowing in cognitive processing is noted, though effort and engagement remain appropriate.

Head, Eyes, Ears, Nose, and Throat (HEENT)

• Head: Normocephalic, atraumatic
• Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA), no nystagmus
• Ears: Tympanic membranes intact and clear bilaterally
• Nose: Mucosa pink, no congestion or discharge
• Mouth/Throat: Moist mucous membranes, no lesions, dentition intact

Skin Assessment

• Color: Appropriate for ethnicity
• Temperature: Warm and dry
• Turgor: Elastic, within normal limits
• Lesions: No rashes, bruising, or abnormal findings
• Integrity: No evidence of self-harm or scarring

Cardiovascular System

• Heart sounds: S1 and S2 present, no murmurs
• Rhythm: Regular
• Peripheral pulses: 2+ bilaterally
• Capillary refill: Less than 2 seconds

Interpretation:
No acute cardiovascular abnormalities identified aside from elevated blood pressure.

Respiratory System

• Breath sounds: Clear bilaterally on auscultation
• Respiratory effort: Even and non-labored
• Chest expansion: Symmetrical
• Oxygenation: Adequate on room air

Gastrointestinal System

• Abdomen: Soft, non-distended, non-tender
• Bowel sounds: Present in all four quadrants
• No hepatosplenomegaly noted
• Subjective report: No nausea, vomiting, or appetite changes

Genitourinary System (Subjective Assessment)

• Denies dysuria, hematuria, or urinary frequency
• Denies sexual dysfunction
• No reported history of sexually transmitted infections

Musculoskeletal System

• Gait: Steady and balanced
• Range of motion: Full active ROM in all extremities
• Muscle strength: 5/5 bilaterally
• No joint swelling, tenderness, or deformities noted

Psychosocial and Mental Health Assessment

• Mood: “Some days I feel guilty… I get scared easily.”
• Affect: Constricted but appropriate to context
• Thought process: Logical and goal-directed
• Insight and judgment: Fair
• Suicidal ideation: Denies current or past suicidal or homicidal ideation
• Sleep: Disturbed due to nightmares and flashbacks
• Coping mechanisms: Avoidance behaviors (e.g., media avoidance, social withdrawal)

Nurse: Thank you for sharing that with me, Mr. Mancini. It is important for us to understand how these experiences affect your daily life. You are not alone, and we will work together to support your recovery.

Clinical Impression and Plan of Care

Based on assessment findings, the following plan of care is recommended:

Medical Management

• Continue lisinopril for hypertension management
• Citalopram 20 mg daily for anxiety/depression symptoms
• Prazosin 1 mg at bedtime for nightmares
• Monitor for orthostatic hypotension and medication interactions

Psychiatric and Behavioral Health Interventions

• Referral for Cognitive Behavioral Therapy (CBT)
• Psychoeducation regarding PTSD, anxiety, and medication adherence
• Education on crisis intervention and suicide prevention resources

Follow-Up Plan

• Psychiatric nurse practitioner follow-up in 3 weeks
• Weekly nursing check-ins to monitor symptoms and medication response

Closing Statement

Nurse: Thank you for your cooperation today, Mr. Mancini. Your openness helps us develop an effective care plan tailored to your needs. We will continue working together to support your recovery and overall well-being. Follow-up appointments will be scheduled to ensure continuity of care and ongoing evaluation.

Conclusion

This comprehensive head-to-toe assessment identifies both physiological and psychosocial health needs. Findings suggest controlled physical status with elevated blood pressure and significant psychosocial stressors related to anxiety and sleep disturbance. A coordinated, patient-centered care plan involving pharmacologic management, psychotherapy, and ongoing follow-up is essential to promote recovery, stability, and improved quality of life.