Head To Toe Assessment Essay

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In this essay I will be discussing the steps required to successfully complete a head to toe assessment on a 78-year-old male post operatively. The patient was admitted with a severe abdominal pain and was diagnosed with volvulus. I will be using a body systems approach to complete the head to toe assessment as well as discussing 2 immediate post-operative complications that may arise form his surgery and the nursing interventions required to manage it. I will also be covering the pathophysiological changes that occur during anaphylactic shock; hypovolemic shock, cardiogenic shock and septic shock.

To successfully complete a head to toe assessment we need to cover the following systems; CNS (central nervous system); CVS (cardiovascular system); Respiratory, Renal, GIT (Gastrointestinal Tract) and Integumentary. In the case of our post-operative patient who has been treated for volvulus, which is the rotation of loops of bowel around each other (Medical-Surgical Nursing, 2014), we will be going into more detail when assessing the GIT.
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This is where we auscultate the 5 sites listening for any murmurs, rubs or additional sounds as well as the heart rhythm, is it regular or irregular? We need to listen for at least one minute to get an accurate reading. The first site is the aortic, we can locate this on the 2nd intercostal space and the right sternum border; next we have the pulmonic site which is located between the 2nd intercostal space and the left sternum border; third site is the erb’s point located at the 3rd intercostal space and left sternum border; fourth site is the tricuspid located at the 4th intercostal space and left lower sternum border and the fifth site is the Mitral (or Apex) which is located at the 5th intercostal space and mid-clavicle line. Once this is completed we move on to the
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