Detailed Health and Physical Examination of Mr. Williams - Nursing

This nursing assignment provides a comprehensive health assessment of Mr. Andrew Williams, a 45-year-old patient with a history of gastro-esophageal reflux disease (GERD) and a past appendectomy. The assessment includes a review of his medical history, which reveals difficulties in swallowing, chest pain, and heartburn. The assignment outlines a head-to-toe assessment approach, considering both complete health assessments and focused assessments based on specific health issues, such as Mr. Williams' recent severe frontal headache. The importance of immunization assessment is also highlighted to ensure a holistic care approach. Ultimately, the assignment emphasizes the significance of thorough patient assessment in identifying health concerns and guiding appropriate interventions to improve patient health and wellbeing. Desklib offers a range of solved assignments and past papers for students.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student
Name of the University
Author note

1NURSING ASSIGNMENT
Complete health and physical examination and its documentation is an important step in
nursing practice that helps in identification of critical health situation in patient and application
of required intervention (Clarke, 2014). This assignment will carry out a complete health
assessment of Mr. Andrew Williams (45) and in the course of assessment will discuss his
medical history and will carry out a complete head to toe assessment with immunization
requirement so that holistic care approach could be implemented in the care of Mr. Williams.
The patient in the given scenario is Mr. Andrew Williams (45) who lives with his family
with his wife and two teenage kids. Mr. Williams used work as a college professor and did not
had any habit of smoking or drinking (Poggenborg et al., 2014). His last hospital admission was
due to the appendectomy 6 years ago and after that it has been 4 years he has visited any
healthcare physician or facility. His medical history includes critical gastro-esophageal reflux
disease or GERD due to which he suffered from difficulty in swallowing, presence of a lump in
the throat, chest pain and a burning sensation or heart burn after consuming food (Thrift et al.,
2013). Besides these, the patient did not had any allergic reaction due to any kind of drug.
Therefore, from this patient description and medical history it could be said that besides
appendectomy or GERD related health concern the patient did not had any other severe health
condition as well as did not had any issues of diabetes, blood pressure fluctuation and others.
Head to toe assessment is the process using which the nursing professionals can identify
the specific issues that could affect the patient’s health and wellbeing and while this assessment
besides the physical aspects, the mental and emotional aspect of healthcare should be analyzed
(Clarke, 2014). In this aspect of Mr. Williams, the two type of head to toe assessment could be
carried out. Firstly, a complete health assessment I which the professionals would carry out a

2NURSING ASSIGNMENT
detailed examination of patients health using medical history and comprehensive head to toe
assessment (Considine & Currey, 2015). Secondly, the head to toe assessment focusing on a
single health issue could also be carried out so that a specific health goal could be achieved. As
Mr. Williams recently faced severe frontal headache and was not able to relieve it with the use of
tylenol (Poggenborg et al., 2014). Therefore his head to toe assessment will include assessment
about his severe headache, CT scan and other physiological tests so that the reason behind his
headache could be obtained and specific medication and intervention could be provided. Further,
immunization assessment will also be carried out to understand the requirement of any specific
immunization to make the patient condition improved (Considine & Currey, 2015).
Therefore, in conclusion, it could be stated that conducting a full head to toe patient
assessment provides the healthcare professionals with an opportunity to identify the health
concerns that affects the patient’s health and wellbeing. In this assessment discussion about Mr.
Williams was carried out so that interventions for his health condition could be carried out.

3NURSING ASSIGNMENT
References
Clarke, C. (2014). Promoting the 6Cs of nursing in patient assessment. Nursing
Standard, 28(44), 52-59.
Considine, J., & Currey, J. (2015). Ensuring a proactive, evidence‐based, patient safety approach
to patient assessment. Journal of clinical nursing, 24(1-2), 300-307.
Poggenborg, R. P., Pedersen, S. J., Eshed, I., Sørensen, I. J., Møller, J. M., Madsen, O. R., ... &
Østergaard, M. (2014). Head-to-toe whole-body MRI in psoriatic arthritis, axial
spondyloarthritis and healthy subjects: first steps towards global inflammation and
damage scores of peripheral and axial joints. Rheumatology, 54(6), 1039-1049.
Thrift, A. P., Kramer, J. R., Qureshi, Z., Richardson, P. A., & El-Serag, H. B. (2013). Age at
onset of GERD symptoms predicts risk of Barrett's esophagus. The American journal of
gastroenterology, 108(6), 915.