Weekly assignment: conduct an assessment on the following body systems: You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission. using the process described in the textbook. Write a summary of the assessment (subjective & objective data in narrative note) and the skills utilized.
Assessment Summary:
During my assessment, I conducted a thorough examination of the cardiovascular, respiratory, musculoskeletal, and neurological systems in my friend, John. John provided consent for the assessment, and I followed the process outlined in the textbook to gather subjective and objective data for each system. The assessment revealed some significant findings, which I will discuss in detail below.
Subjective Data:
During the interview, John reported experiencing occasional shortness of breath while walking up stairs. He also mentioned feeling fatigued after walking longer distances. John denied any chest pain, palpitations or dizziness. He has been experiencing these symptoms for the past few months, but they have not worsened.
Objective Data:
Cardiovascular System:
During the examination, I assessed John’s vital signs, which were within normal limits. Blood pressure was 120/80 mmHg, heart rate was 72 beats per minute, and respiratory rate was 16 breaths per minute. I auscultated his heart sounds and noted a regular rate and rhythm. No murmurs or extra heart sounds were heard. Peripheral pulses were palpable and equal bilaterally. Additionally, I inspected John’s jugular venous pulsation and there was no visible distension.
Respiratory System:
John’s respiratory rate was within the normal range, and his lung sounds were clear and equal bilaterally. No adventitious breath sounds or wheezes were present. Chest expansion was symmetrical, and there was no use of accessory muscles of respiration. Oxygen saturation measured by pulse oximetry was 97% on room air.
Musculoskeletal System:
I assessed John’s range of motion and muscle strength in his upper and lower extremities. He had full and painless range of motion in all joints. Muscle strength was 5/5 in all major muscle groups tested. No deformities or swelling were noted.
Neurological System:
I performed a neurological assessment on John, which included assessing his level of consciousness, cranial nerves, motor function, sensory function, and reflexes. He was alert and oriented to person, place, and time. Cranial nerves were intact, as evidenced by the ability to follow visual and auditory stimuli. Motor strength and coordination were normal, and sensation was intact bilaterally. Reflexes were normal and symmetrical.
Skills Utilized:
1. Interviewing: I utilized effective communication skills to gather subjective data from John. I asked open-ended questions to obtain a comprehensive understanding of his symptoms and allowed him to express himself freely.
2. Inspection: I carefully observed John’s general appearance, posture, and skin color during the assessment. I also inspected his jugular vein for any signs of distension.
3. Auscultation: I used a stethoscope to auscultate John’s heart sounds and lung sounds. I listened for any abnormal sounds or murmurs that may indicate cardiovascular or respiratory problems.
4. Palpation: I palpated John’s peripheral pulses to assess their strength and equality. I also assessed his chest expansion and joints for any signs of abnormalities or tenderness.
5. Neurological Assessment: I systematically assessed John’s level of consciousness, cranial nerves, motor function, sensory function, and reflexes. This comprehensive assessment allowed me to evaluate his overall neurological status.
In conclusion, the assessment of John’s cardiovascular, respiratory, musculoskeletal, and neurological systems revealed some important findings. Although his vital signs were within normal limits and his lung sounds were clear, his symptoms of shortness of breath and fatigue indicate a potential cardiovascular issue. Further diagnostic testing and evaluation may be necessary to determine the underlying cause of these symptoms. Overall, the skills utilized during the assessment, particularly interviewing, inspection, auscultation, palpation, and neurological assessment, allowed for a comprehensive evaluation of John’s overall health.