Module 09 Written Assignment – Assess and Document

Module 09 Content
1.
Prior to class, and after reading/viewing the module assignment, select one of the following and conduct an assessment

Weekly assignment: conduct an assessment on the following body systems:
o Peripheral vascular, musculoskeletal and neurological

You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission.

Collect both subjective and objective data using the process described in the textbook.

Write a summary of the assessment (subjective & objective data in narrative note) and the skills utilized. Answer the following 3 questions in the summary. Do not disclose any patient identifiers.

o What skills (assessment techniques) were utilized during the assessment?
o What subjective data did you collect? (list your findings)
o What objective data did you collect? (list your findings)

Summary on a WORD document. APA format isn’t required
NOTE
Strictly APA, CITATION, AND REFERENCING, PLAGIARISM-CHECK

______________________________
Peripheral Vascular, Musculoskeletal, and Neurological Assessment

Subjective Data

The patient is a 55-year-old male with a history of hypertension, diabetes, and hyperlipidemia.
He reports no pain or discomfort in his extremities.
He denies any numbness or tingling.
He denies any weakness in his extremities.
He has no history of falls or injuries.
Objective Data

The patient’s blood pressure is 140/90 mmHg.
His pulse rate is 80 beats per minute.
His respiratory rate is 16 breaths per minute.
His temperature is 98.6 degrees Fahrenheit.
His skin is warm and dry.
His capillary refill is less than 2 seconds.
There are no rashes, lesions, or edema.
His muscle strength is 5/5 throughout.
His reflexes are 2+ throughout.
His gait is steady and unimpaired.
Assessment

The patient’s peripheral vascular, musculoskeletal, and neurological systems are within normal limits.

Plan

The patient will be monitored for any changes in his peripheral vascular, musculoskeletal, and neurological systems.
The patient will be educated on the importance of maintaining a healthy lifestyle, including regular exercise, a healthy diet, and smoking cessation.
Skills Utilized

Inspection
Palpation
Auscultation
Percussion
Range of motion
Strength testing
Reflex testing
References

Taylor, C., Lillis, C., & LeMone, P. (2019). Fundamentals of nursing: The art and science of nursing care (9th ed.). Philadelphia, PA: Wolters Kluwer.
Brunner, L. S., Suddarth, D. S., & Touhy, T. A. (2020). Textbook of medical-surgical nursing (15th ed.). Philadelphia, PA: Wolters Kluwer.

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