Rasmussen College Peripheral Vascular System Assessment Report

Part 1

You will perform a history of a peripheral vascular problem that your instructor has provided you or one that you have experienced and perform a peripheral vascular assessment. You will document your subjective and objective findings, identify actual or potential risks.

part 2

you completed your full head-to-toe assessment skills demonstration last week and now will document your results. Continue to document only the objective findings for this section without bias or explanation. Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief.

Documentation of Peripheral Vascular System Assessment
Examiner:
Patient:
Date:
Reason for Visit:
Health History
1. Are you having any leg pain or cramps?
2. Any skin changes in arms or legs?
3. Any swelling in legs?
4. Any swollen glands? Where?
5. What medications are you taking?
6. Do you smoke cigarettes?
a. How many per day?
b. For how long?
Physical Assessment
1. Inspection
a. Inspect Arms
i. Color of skin and nail beds (clubbing?)
ii. Symmetry
iii. Any lesions?
b. Inspect legs
i. Color of skin
ii. Hair distribution
iii. Lesions or ulcers?
iv. Varicose veins?
2. Palpate
a. Palpate arms and legs for edema, temperature, and texture
b. Palpate pulses and grade
i. Brachial
ii. Radial
iii. Popliteal
iv. Dorsalis pedis
v. Posterior tibial
Regional Write-Up
1. Subjective
2. Objective
3. Assessment of risks and plan (include two risks)
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Documentation of Assessment of the Neurological System
Examiner: Pehsehlyn
Date:5/22 2021
Patient:Linet
Date of Birth:
Reason for Visit: : blurred vision
Health History
2
Subjective
The patient, a 34-year-old black woman called Linet, comes to the hospital for assessment.
She states that she developed blurred vision a few days ago after operating her computer for about
30 minutes. The computer began looking fuzzy, and when she stared around the room, everything
appeared unclear. At the same time, she felt a strong sensation in the right eyelid. She slept and
woke up in the morning, unable to open the right eye. She also noted she was experiencing
diplopia when she tried lifting the right eyelid.
The patient further indicated that for the last one week, she had been experiencing
headaches on the frontal part of the head, and these occurred when she was either coughing or
having a bowel movement. She has also experienced migraines about 5 times in the last 6 months
and when they occur, she sees some ‘shimmering shiny stars’ moving across her visual field. She
has used ibuprofen to treat her headaches.
Objective
The patient is overweight. Her body temperature is 37.5, a blood pressure of 129/79, and a
pulse of 86. There is no proptosis, conjunctival edema, or lid swelling. The patient is alert and has
clear speech.
An analysis of all the cranial nerves indicated the following:
CN II: Visual fields are full and normal, and her visual acuity is 20/20 bilaterally.
CN III, IV, VI: The patient’s right eye does not adduct when looking left and both eyes do not
move up when the patient is looking up. The patient experiences horizontal diplopia when gazing
to the left. The right eye is drooping.
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CN V: Facial sensation is normal.
CN VII: The face shows normal symmetry with a normal smile and normal eye closure.
CN VIII: Hearing is normal.
CN IX, X: Palate elevates symmetrically.
CN XI: Head-turning intact and patient can shrug the shoulder normally.
CN XII: Tongue shows normal movements and has no atrophy.
Her proprioception and light touch senses are intact in fingers and toes and the MRI scan
showed no notable abnormalities in the brain stem or in the corpus callosum.
The patient has an isolated CN III palsy because of the affected eye muscles (i.e., superior
and medial recti and levator palpebrae). There is are involvement of other cranial nerves; thus, the
lesion is located on the oculomotor nerve. The MRI does not show any sign of a mass lesion. The
third nerve palsy could result from meningitis, but this is unlikely as the patient has no meningeal
signs.
Risks:
Hypertension causes ischemic changes that affect the nerves’ normal functioning. The
nerve’s nutrient and oxygen supply are cut off. Consequently, it increases the chances of
developing CN III palsy.
Diabetes mellitus also increases the chance of developing CN III palsy in a similar way to
hypertension. It affects the nerves’ vasa vasora causing ischemic changes that hamper its normal
functioning. Since the vasa vasora supply it with nutrients and oxygen, it experiences hypoxic
damage and adverse metabolic changes.
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