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. Jarvis, C. (2019). Physical Examination and Health Assessment (8th Edition). Elsevier Health Sciences (US). OR ANY OTHER NURSING TEXTBOOK. Write a summary of the assessment (subjective & objective data in narrative note) and the skills utilized. Do not disclose any patient identifiers.

Summary of Assessment:

For this assessment, I conducted a comprehensive examination on a fellow student, John, utilizing the process described in the nursing textbook Physical Examination and Health Assessment by Jarvis (2019). The aim of the examination was to assess various body systems and gather subjective and objective data. Prior consent was obtained from John before proceeding with the assessment.

The assessment began with collecting John’s subjective data through an interview. During the interview, John reported a history of occasional shortness of breath and chest pain, which he attributed to stress. He also mentioned experiencing intermittent fatigue and difficulty sleeping. John denied any significant medical history or allergies. Additionally, he reported his current medications to include a daily multivitamin and occasional over-the-counter pain relievers.

Moving on to objective data, I began by assessing John’s general appearance and vital signs. John appeared alert and oriented, with no obvious signs of distress. His vital signs were within normal limits, with a blood pressure of 120/80 mmHg, heart rate of 72 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 98.6°F.

Next, I focused on the respiratory system assessment. I evaluated John’s breathing pattern, noting regular and unlabored respirations. Auscultation of the lungs revealed clear and equal breath sounds bilaterally, with no adventitious sounds such as wheezes or crackles. Percussion and palpation of the chest wall showed symmetrical expansion and no tenderness.

Moving on to the cardiovascular system, I inspected John’s chest for any abnormalities and observed no visible pulsations or heaves. Palpation of the precordium did not reveal any thrills or abnormal cardiac impulses. Auscultation of the heart showed normal S1 and S2 sounds, with no murmurs, clicks, or gallops present. Peripheral pulses were palpable and equal bilaterally.

Continuing with the abdominal assessment, I inspected John’s abdomen for any visible abnormalities, such as scars or distention. The abdomen appeared flat, with no visible masses or lesions. Upon palpation, the abdomen was soft, non-tender, and without guarding or rebound tenderness. Bowel sounds were present in all quadrants, indicating normal peristalsis.

Moving to the musculoskeletal system, I assessed John’s muscle strength and range of motion. He demonstrated full range of motion in all joints, without any limitations or signs of discomfort. Muscle strength was symmetric and graded as 5/5 for all major muscle groups tested.

Next, I performed a neurological assessment, starting with evaluating John’s cranial nerve function. Pupils were equal and round, with reactive responses to light. Extraocular movements were intact, and facial sensation and symmetry were normal. Motor function was assessed by instructing John to perform various movements, which he executed without difficulty or weakness. Sensory assessment showed intact touch, temperature, and proprioception in all extremities.

In terms of the integumentary system, I inspected John’s skin for any abnormalities. The skin was warm, dry, and without any rashes, lesions, or discoloration. Capillary refill was less than 2 seconds, indicating adequate peripheral circulation.

Lastly, I conducted a genitourinary assessment on John. He reported no symptoms related to the urinary system, such as pain, frequency, or urgency. Inspection of the genitalia showed normal appearance, without any lesions or discharge. No tenderness or masses were palpated in the inguinal area.

Skills utilized during the assessment included taking accurate vital signs, auscultation of body systems using a stethoscope, palpation of the abdomen and peripheral pulses, and assessing muscle strength and range of motion. Additionally, I employed effective communication skills to gather subjective data from John and provide clear instructions during the examination.

In conclusion, the assessment on John revealed normal findings in the respiratory, cardiovascular, abdominal, musculoskeletal, neurological, integumentary, and genitourinary systems. No significant abnormalities or concerns were identified. This comprehensive assessment allowed for a thorough evaluation of John’s overall health status and provided valuable subjective and objective data for further analysis and potential health intervention if needed.