NURS FPX 4015 Assignment 5 Comprehensive Head-to-Toe Assessment

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 to Patient Evaluation

Hello, my name is ——-. I am conducting a full body assessment of Aiyana Tehanata based on the Sentinel U. case study. Aiyana’s chief complaints include tingling in the feet, moderate pain rated 5/10, and elevated blood sugar levels. This evaluation focuses on assessing major body systems, providing transparent communication with Aiyana, and ensuring she fully understands each component of her health evaluation.

Systematic and Detailed Physical Examination

The initial step is to make Aiyana feel at ease by explaining the process and purpose of the assessment. Emphasis is placed on the symptoms—foot tingling, pain, and hyperglycemia. Starting with a general physical exam, the affected foot area is palpated to detect any inflammation or nerve-related issues. Aiyana is asked to provide feedback on any exacerbated pain or numbness during palpation, which helps identify the extent of sensory nerve damage.

Next, pulse checks in both hands and feet are performed to assess vascular health. The skin’s color, texture, and temperature are evaluated for signs of poor perfusion or infection—important considerations given the link between diabetes and circulatory impairment. The cardiovascular assessment follows, including auscultation of the heart and lungs for abnormalities such as murmurs, irregular rhythms, or adventitious breath sounds. These are common in individuals with diabetes or suspected cardiac involvement (Eckel et al., 2021).

Blood pressure is measured using a cuff, which may feel tight but provides valuable insight into heart function. Each step of the examination is communicated clearly to Aiyana, with active encouragement for her to share any discomfort or unusual sensations. Educating the patient during evaluation is essential to improve engagement and outcomes.

Table 1: Key Physical Examination Components

System	Assessment Focus	Clinical Indicators
Peripheral Nervous	Palpation, sensory testing	Tingling, numbness, neuropathic pain
Circulatory	Pulses, skin texture/temp	Adequate perfusion or ischemic signs
Cardiovascular	Heart auscultation, BP measurement	Abnormal rhythms, hypertension
Respiratory	Lung auscultation	Crackles, wheezing (potential CHF indicators)

Analysis of Diagnosis and Clinical Findings

Differential Diagnosis and Interpretation

Upon reviewing Aiyana’s symptoms and test results, diabetic peripheral neuropathy is identified as a likely cause of the foot tingling and moderate pain. This condition results from chronic hyperglycemia damaging peripheral nerves, especially in the lower extremities. Sensory deficits identified during the exam reinforce the likelihood of this diagnosis.

No signs of circulatory obstruction (e.g., diminished pedal pulses) were detected, supporting neuropathy over peripheral arterial disease as the primary concern. However, Aiyana’s elevated lipid levels, shortness of breath, and exertional chest discomfort raise the suspicion of Coronary Artery Disease (CAD)—a serious and common diabetes-related complication (Mauricio et al., 2023).

Table 2: Diagnostic Considerations and Supporting Evidence

Diagnosis	Supporting Symptoms/Findings	Comments
Diabetic Neuropathy	Tingling, pain, abnormal foot sensation	Sensory testing positive
Coronary Artery Disease	Dyspnea, chest discomfort, elevated lipids	Requires further cardiac work-up

Chronic hyperglycemia disrupts the microvasculature responsible for nerve and cardiac function. Over time, this leads to progressive nerve injury and vascular inflammation, reinforcing the need for prompt medical intervention (Mauricio et al., 2023).

Patient Education and Management Strategy

Aiyana is advised that her symptoms are linked to unmanaged diabetes and its systemic consequences. Proactive steps, such as improved glucose control and cardiac risk reduction, can slow disease progression. Emphasis is placed on not feeling alone—many individuals face similar complications, and treatments exist to manage them effectively.

Pharmacological Management and Clinical Reasoning

Treatment of Diabetes and Neuropathy

Effective management begins with glucose regulation. Metformin remains a first-line therapy due to its ability to reduce hepatic glucose production and enhance insulin sensitivity (Baker et al., 2021). However, Aiyana may require adjunct medications if glycemic control remains suboptimal.

Table 3: Pharmacological Recommendations

Medication Class	Purpose	Examples	Side Effects
Antidiabetics	Glucose control	Metformin, GLP-1 agonists	GI upset, lactic acidosis (rare)
Neuropathic Pain Agents	Nerve pain relief	Gabapentin, Pregabalin	Drowsiness, dizziness
Antidepressants (TCA)	Alternative for neuropathy	Amitriptyline	Dry mouth, sedation
Lipid-lowering Agents	Cardiovascular protection	Statins (e.g., Atorvastatin)	Myalgia, liver enzyme elevation
Antiplatelets	Clot prevention	Aspirin	Bleeding, GI irritation

A combination of these medications is tailored based on Aiyana’s response and tolerance. For neuropathy, gabapentin is recommended for its efficacy in blocking aberrant pain signaling pathways (Baker et al., 2021). Additionally, CAD prevention may require statins and possibly ACE inhibitors or beta-blockers, especially if blood pressure or cholesterol is elevated.

Consideration of Comorbidities and Drug Interactions

Before initiating or adjusting medications, underlying kidney function must be evaluated. Metformin, for example, requires caution in patients with renal impairment. Likewise, combinations like ACE inhibitors with diuretics require electrolyte monitoring. Potential side effects and interaction risks should be reviewed regularly.

Non-Pharmacological Interventions

Lifestyle modification plays an indispensable role. Recommendations include adopting a low-sodium, heart-friendly diet (e.g., DASH), increasing physical activity, and avoiding tobacco. These changes, supported by resources from the American Heart Association (AHA, 2024), complement pharmacological treatment and reduce long-term complications.

Pathophysiological Mechanism and Disease Progression

Type 2 diabetes results from insulin resistance and inadequate insulin production, leading to sustained hyperglycemia. Over time, this damages endothelial cells, disrupts nerve transmission, and promotes atherosclerosis (Azmi et al., 2021). The nerve pain and tingling in Aiyana’s feet are due to peripheral neuropathy caused by small vessel disease. Kidney and eye involvement, though not currently symptomatic, remain risks due to similar pathophysiological mechanisms (Kropp et al., 2023).

Table 4: Complications of Poorly Controlled Diabetes

System Affected	Potential Complication
Nervous	Peripheral neuropathy
Cardiovascular	Atherosclerosis, CAD
Renal	Diabetic nephropathy
Ophthalmologic	Diabetic retinopathy

Clinical decision-making is based on symptom severity, lab findings, and the interconnected pathophysiological impact of diabetes. A focus is placed on glucose control (HbA1c < 7%) as a preventive measure against macrovascular and microvascular complications (Sinha & Ghosal, 2021).

Conclusion

In summary, Aiyana’s care plan should prioritize controlling blood sugar levels, managing diabetic neuropathy symptoms, and preventing cardiovascular complications. A comprehensive approach combining medications, lifestyle changes, and regular monitoring is key to improving her quality of life. With appropriate support and intervention, she can effectively manage her condition and prevent further deterioration.

References

AHA. (2024). American Heart Association. https://www.heart.org/en/

Azmi, N. A. S., Juliana, N., Azmani, S., Mohd Effendy, N., Abu, I. F., Mohd Fahmi Teng, N. I., & Das, S. (2021). Cortisol on circadian rhythm and its effect on the cardiovascular system. International Journal of Environmental Research and Public Health, 18(2), 676. https://doi.org/10.3390/ijerph18020676

NURS FPX 4015 Assignment 5 Comprehensive Head-to-Toe Assessment

Baker, C., Retzik-Stahr, C., Singh, V., Plomondon, R., Anderson, V., & Rasouli, N. (2021). Should metformin remain the first-line therapy for treatment of type 2 diabetes? Therapeutic Advances in Endocrinology and Metabolism, 12, 1–14. https://doi.org/10.1177/2042018820980225

Eckel, R. H., Bornfeldt, K. E., & Goldberg, I. J. (2021). Cardiovascular disease in diabetes, beyond glucose. Cell Metabolism, 33(8), 1519–1545. https://doi.org/10.1016/j.cmet.2021.07.001

Elmakki, E. (2024). The role of lifestyle modifications in preventing and managing systemic hypertension: Current guidelines and future directions. Annals of African Medicine, 24(1), 1–8. https://doi.org/10.4103/aam.aam_90_24

Kropp, M., Golubnitschaja, O., Mazurakova, A., et al. (2023). Diabetic retinopathy as the leading cause of blindness and early predictor of cascading complications—risks and mitigation. EPMA Journal, 14(1), 21–42. https://doi.org/10.1007/s13167-023-00314-8

Mauricio, D., Gratacòs, M., & Nadal, J. F. (2023). Diabetic microvascular disease in non-classical beds: The hidden impact beyond the retina, the kidney, and the peripheral nerves. Cardiovascular Diabetology, 22(1). https://doi.org/10.1186/s12933-023-02056-3

NURS FPX 4015 Assignment 5 Comprehensive Head-to-Toe Assessment

Sinha, B., & Ghosal, S. (2021). A target HbA1c between 7 and 7.7% reduces microvascular and macrovascular events in T2D regardless of duration of diabetes: A meta-analysis of randomized controlled trials. Diabetes Therapy, 14, 21–42. https://doi.org/10.1007/s13300-021-01062-6