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

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• NURS FPX 4015 Assessment 5 Comprehensive Head-to-Toe Assessment.

Comprehensive Head-to-Toe Assessment

Student Name

Capella University

NURS-FPX4015

Instructor Name

Submission Date

Comprehensive Head-to-Toe Assessment

Hello, everyone. This is Name. The complete head-to-toe assessment is a simple clinical practice in the assessment of a patient. It offers an orderly system to facilitate the identification of small alterations in health status and advanced comprehensive nursing care. Inspection, palpation, percussion, and auscultation are methods used by clinicians to assess objective and subjective data points. It is a thorough examination of the body that checks the functioning of all significant systems to develop physiological baselines and find deviations to inform the development of a unique care plan.

Thorough Disease Process Patient Assessment

Ivy Jackson, a 61-year-old woman, possesses all the typical signs of a major depressive disorder: continuous low mood, anhedonia, sleep disturbances, changes in appetite, and weight loss. She mentions one of the major life events, separation from her husband after 38 years of marriage, as the primary reason for her distress, which has contributed to her emotional distress. In the assessment, Ivy exhibited hopelessness, loneliness, and heightened anxiety in most aspects, meeting the requirements to be classified with MDD (Harrington et al., 2021). She denies suicidal thoughts, but admits to severe emotional disturbances, disturbed sleep, and loss of motivation, which is a reason to conduct a detailed psychiatric examination and follow up.

Besides her emotional problems, Ivy also has a history of high blood pressure and a previous hysterectomy. She is under antihypertensives and was under venlafaxine, which she stopped because of side effects. Her lab tests, such as Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Vitamin D, and thyroid panel, were all normal; this obviously eliminates the possibility of medical conditions, such as hypothyroidism or vitamin D deficiency, as the explanation behind her depressive symptoms, which confirms the major cause to be psychiatric. The fact that a family history is characterized by depression and stroke, and Ivy has had depressive episodes in the past, only increases her risk (Khan et al., 2023). Interestingly, she has a good support network in the form of family and church, and there are no issues of substance use that can be classified as protective factors.

The symptoms’ persistence and severity, as well as her clinical history, provide support for the diagnosis of MDD instead of situational depression as assessed. Escitalopram has been prescribed and tolerated with few side effects. She said she slept a little better but had little improvement in mood or motivation. They should prescribe adjunctive therapy in the form of cognitive behavioral therapy (CBT) to assist Ivy in processing her loss, reframing negative thought patterns, and developing coping skills (Nakao et al., 2021). Assessment of medication adherence, engagement in therapy, and suicide risk should be ongoing so that a holistic and patient-centered plan of care is provided.

Diagnostic Findings Explained For Patient

In my evaluation, I observed that you have been experiencing low moods, a lack of interest in doing things you enjoyed before, and you can barely sleep or sustain sleep. You have reported an unwanted 10-pound weight loss during the last few weeks and anorexia. Your tone was monotonal, and you would hesitate or shed tears when discussing your divorce. During the mental status exam, you had slo,w logical thinking, and you had recurrent negative self-judgments. It is important to note that you denied having a thought of harming yourself or other individuals. Your vital signs, thorough labs, CBC, metabolic panel, vitamin D, and thyroid functions were all within normal range, which further excludes the physical cause of the problem, i.e., thyroid imbalance or deficiencies in nutrients. These results give a clear picture of the current interconnection between your body and your mood.

These test results are very consistent with an MDD diagnosis. It is stated that the diagnosis of MDD should include at least five symptoms (depressed mood, sleep difficulties, change in appetite, and loss of interest), which should last at least two weeks (Bains & Abdijadid, 2025). You fit these criteria because you have had your symptoms for several weeks, and your symptoms are affecting you badly in terms of your daily functioning. Normal lab tests assist in further confirming that there is no pre-existing medical condition that is causing these mood shifts, and further support the fact that we are, in fact, dealing with a primary depressive condition. The significance of this difference is that it helps us to refer to valid psychiatric and therapeutic courses of action instead of further medical screening.

I want you to know what this diagnosis is all about and why we are suggesting some treatments. Think of the depression as a chemical imbalance in the brain, and the emotional burden, like in your case, the loss of a long marriage, to make it hard to start feeling positive. With the help of escitalopram administration, we will be able to bring balance to chemicals in the brain, which govern the mood (Cui et al., 2024). Counseling will be included, including CBT, and will offer you the means to deal with negative thoughts and develop coping skills (Nakao et al., 2021). I am interested in working with you: we will monitor your progress, change treatments according to your needs, and make sure that you will not feel alone in the process.

Pharmacological Needs, Benefits, And Drawbacks

The treatment of MDD is most frequently carried out with the help of antidepressant medications, and selective serotonin reuptake inhibitors (SSRIs), such as escitalopram, sertraline, and fluoxetine, have become the first-line treatment option because of their high level of safety and tolerability. They are also commonly prescribed serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine or duloxetine, especially in cases where patients have comorbid pain syndromes (Jaime et al., 2022). In treatment-resistant cases or in cases where a quick symptom relief is required, augmentation with atypical antipsychotics (e.g., aripiprazole) or addition of bupropion may be effective. Irrespective of the agent that is selected, best current practice considers the use of low doses, titration, and continuation of therapy at least six to twelve months following remission to minimize recurrence.

Her pharmacologic plan must consider her current health history in Ivy, where she has hypertension treated with lisinopril and hydrochlorothiazide, and her past experience with decreasing venlafaxine. Even though SSRIs are associated with minimal cardiovascular effects, some of them (e.g., citalopram) are associated with the threat of QT-interval prolongation at high doses, and, therefore, the low cardiotoxic potential of escitalopram preconditions its reasonable selection (Gundugurti et al., 2022). The possibility of hyponatremia is also increased by age and use of diuretics, especially during initiation of SSRI treatment, and therefore, the monitoring of the serum sodium and fluid status is important. Since she has had a successful experience with venlafaxine and discontinuation symptoms that are distressing, follow-up will be close when changing her doses to expect withdrawal symptoms and promote compliance.

The patients should also be advised on the common adverse effects of SSRIs, such as nausea, headache, insomnia or drowsiness, sexual dysfunction, and the possible early anxiety, and should be assured that most of these effects wear off after two to four weeks. The sudden withdrawal is not to be used because it can lead to the so-called discontinuation syndrome (as the flu syndrome, light-headedness, or alternating moods). Consumption of alcohol may worsen depression symptoms and improve sedation. They also advise them to notify their antidepressant to every provider of their antidepressant in order to prevent interactions (e.g., over-the-counter decongestants or St. John’s Wort) (Czigle et al., 2023). Effective communication in regard to the expected schedules, symptom tracking, and reporting adverse effects will enable Ivy to take an active role in her treatment and maximize the results.

Underlying Pathophysiology and Impact Explanation

Depression has its basis in alterations in the chemicals in your brain and stress-regulating mechanisms. The nerve cells are usually associated with chemical messengers, which are known as serotonin, norepinephrine, and dopamine, in order to regulate mood, energy, and motivation. The levels of these neurotransmitters between the brain cells are low in MDD, and therefore, your feel-good signals are low. In the meantime, you might be experiencing an overactive hypothalamic-pituitary-adrenal (HPA) axis, the reaction of your body to stress, which makes your body loaded with stress hormones, including cortisol (Jiao et al., 2025). This chemical imbalance and hormone overload can later influence the parts of the brain that govern emotion and memory, and may hinder the capacity to enjoy or reason straight.

When the depression is worse, you can see how the energy can drop even lower, and it can become even more difficult to perform the simple things. You might not sleep well, lie awake struggling with worries, or sleep so deeply that you do not easily wake up (Solelhac et al., 2024). The weight and appetite may continue dropping, and you will be physically weak. It is also possible to become emotionally more engrossed in sadness as you are more likely to isolate yourself and turn away from your friends and family, as you believe yourself to be a burden. The physical effects can be headaches, body pain, or stomach pain since depression can cause more pain sensations and dysfunction of the digestive system.

Symptoms are likely to manifest in your actual life: you may have a lower tone or a slower speech when discussing things you previously considered to be exciting; you may be hesitating in the middle of a sentence more frequently because your mind feels confused. You can stare into the screen of a television or a computer in blankness and fail to follow the plot, or you can even start crying when you are triggered to recall hard memories. Activities such as paying bills or showering are insurmountable. Being aware of these patterns allows us to understand that depression is not merely a feeling of sadness; it is a systemic alteration in the way your brain and body talk to each other, and it is an issue we can work on together using specific treatments.

Critical Thinking and Clinical Reasoning

The top priorities in the primary care of Ivy Jackson are the maintenance of safety and stabilization of mood, optimizing pharmacologic care, and initiating psychotherapeutic care. To start with, the most important thing is to keep a safe environment and watch over the emergent suicidal ideation, although she now denies self-harm. Second, we need to maintain a therapeutic concentration of escitalopram and observe its efficacy and side effects, and increase the dosage according to the protocol in case of minimal improvement after 6-8 weeks (Cui et al., 2024). Third, timely connection to evidence-based interventions, including CBT, will help to correct maladaptive thinking and psychosocial stress factors, including her recent divorce (Nakao et al., 2021). Overall, these priorities create a broad, data-driven plan to facilitate the recovery of Ivy and enhance her overall mental health outcomes.

The priorities are founded on the assessment of Ivy and what we know about the MDD pathophysiology and pharmacology. The serotonergic transmission and HPA axis maladaptation are characterized by her severe anhedonia, sleep disturbance, and reduced cognition (Jiao et al., 2025).

Treatment of the deficiency of serotonin in the synaptic clefts is initiated with escitalopram, and her age and comorbid hypertension are considered through monitoring hyponatremia and QT prolongation. At the same time, her negative belief restructuring, which is in line with neurotransmitter normalization, will be possible through identifying her emotional triggers, divorce-related grief, or linking her with CBT. This is supported by a follow-up that is conducted on a regular basis and consists of a re-evaluation of the severity of depression (using standardized scales, e.g., PHQ-9), side effect burden, and tracking the adherence to therapy, which results in an adaptive, evidence-based care plan.

Professional best practices advocate these care priorities. The Practice Guideline for the Treatment of MDD, suggested by the American Psychiatric Association, proposed to use SSRIs as first-line pharmacotherapy and a continuation therapy of at least six months after the remission of the disease to avoid relapse (Van Leeuwen et al., 2021). They also supported the use of pharmacotherapy and psychotherapy as an alternative to moderate to severe MDD. Tudorancea et al. (2025) also recommended continuous risk assessment, dose titration according to response, and organized psychotherapies according to patient preferences. Combining the clinical presentation of Ivy with these evidence-based frameworks will allow us to provide a full, patient-centered plan that will foster a safe, symptom-reducing, and long-term recovery.

Conclusion

Ivy Jackson reports chronic sadness, lack of pleasure, sleep disturbance, and psychosocial stresses, and all her labs are normal; this confirms the initial diagnosis of major depressive disorder. Escitalopram and cognitive behavioral therapy are used to treat the imbalance of neurotransmitters and maladaptive thought patterns. She has comorbid hypertension, and the reason is that she should be carefully monitored because of hyponatremia and QT prolongation. Monitoring and support will improve her recovery.

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References

Bains, N., & Abdijadid, S. (2025). Major depressive disorder. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559078/

Cui, L., Li, S., Wang, S., Wu, X., Liu, Y., Yu, W., Wang, Y., Tang, Y., Xia, M., & Li, B. (2024). Major depressive disorder: Hypothesis, mechanism, prevention and treatment. Signal Transduction and Targeted Therapy, 9, 30. https://doi.org/10.1038/s41392-024-01738-y

Czigle, S., Nagy, M., Mladěnka, P., & Tóth, J. (2023). Pharmacokinetic and pharmacodynamic herb-drug interactions—Part I. Herbal medicines of the central nervous system. PeerJ, 11. https://doi.org/10.7717/peerj.16149

Gundugurti, P. R., Bhattacharyya, R., & Koneru, A. (2022). Management of psychiatric disorders in patients with cardiovascular diseases. Indian Journal of Psychiatry, 64(2), 355–365. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_42_22

Harrington, B. J., Klyn, L. L., Ruegsegger, L. M., Thom, A., Jumbe, A. N., Maliwichi, M., Stockton, M. A., Akiba, C. F., Go, V., Pence, B. W., Maselko, J., Gaynes, B. N., Miller, W. C., & Hosseinipour, M. C. (2021). Locally contextualizing understandings of depression, the EPDS, and PHQ-9 among a sample of postpartum women living with HIV in Malawi. Journal of Affective Disorders, 281, 958–966. https://doi.org/10.1016/j.jad.2020.10.063

Jaime, H. B., Salcedo, J. A. S., Cabrera, M. M. E., Jiménez, T. M.., Altamirano, J. L. C., & Rodríguez, A. A. (2022). Depression and pain: Use of antidepressants. Current Neuropharmacology, 20(2), 384–402. https://doi.org/10.2174/1570159X19666210609161447

Jiao, W., Lin, J., Deng, Y., Ji, Y., Liang, C., Wei, S., Jing, X., & Yan, F. (2025). The immunological perspective of major depressive disorder: Unveiling the interactions between central and peripheral immune mechanisms. Journal of Neuroinflammation, 22, 10. https://doi.org/10.1186/s12974-024-03312-3

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

Khan, A. I., Abuzainah, B., Gutlapalli, S. D., Chaudhuri, D., Khan, K. I., Al Shouli, R., Allakky, A., Ferguson, A. A., & Hamid, P. (2023). Effect of major depressive disorder on stroke risk and mortality: A systematic review. Cureus, 15(6). https://doi.org/10.7759/cureus.40475

Leeuwen, E. V., Driel, M. L., Horowitz, M. A., Kendrick, T., Donald, M., De Sutter, A. I., Robertson, L., & Christiaens, T. (2021). Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults. The Cochrane Database of Systematic Reviews, 2021(4). https://doi.org/10.1002/14651858.CD013495.pub2

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine, 15, 16. https://doi.org/10.1186/s13030-021-00219-w

Solelhac, G., Imler, T., Strippoli, M.P. F., Marchi, N. A., Berger, M., Rubio, J. H., Raffray, T., Bayon, V., Lombardi, A. S., Ranjbar, S., Siclari, F., Vollenweider, P., Vidal, P. M., Geoffroy, P.-A., Léger, D., Stephan, A., Preisig, M., & Heinzer, R. (2024). Sleep disturbances and incident risk of major depressive disorder in a population-based cohort. Psychiatry Research, 338. https://doi.org/10.1016/j.psychres.2024.115934

Tudorancea, I.M., Stanciu, G.-D., Torrent, C., Madero, S., Hritcu, L., & Tamba, B.-I. (2025). Psychedelic interventions for major depressive disorder in the elderly: Exploring novel therapies, promise and potential. Dialogues in Clinical Neuroscience, 27(1), 98–111. https://doi.org/10.1080/19585969.2025.2499458