The assessment of the patient's neurologic, musculoskeletal, and peripheral vascular systems should not be delegated to assistive personnel (AP). Some items may be noticed while providing care and noted by the AP. The nurse must then validate, analyze, document, communicate, and act on these findings, as appropriate. Depending on the state's nurse practice act and the organization's policies and procedures, the licensed practical/vocational nurses (LPN/LVNs) may perform some or all the parts of assessment of the patient's neurologic, musculoskeletal, and peripheral vascular systems. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

• PPE, as indicated
• Bath blanket or other drape
• Tongue depressor
• Examination gown
• Gloves
• Containers of odorous materials (e.g., coffee or chocolate), as indicated
• Miscellaneous items (e.g., pin, cotton, paper clip)
• Cotton-tipped applicators

Complete a health history, focusing on the neurologic, musculoskeletal, and peripheral vascular systems. Identify risk factors for altered health by asking about the following:

• History of numbness, tingling, or tremors
• History of seizures
• History of headaches or dizziness
• History of trauma to the head or spine
• History of high blood pressure or stroke
• Changes in the ability to hear, see, taste, or smell
• Loss of ability to control bladder and bowel
• History of smoking
• History of chronic alcohol use
• History of diabetes mellitus or cardiovascular disease
• Use of prescription and over-the-counter medications
• Frequency of blood cholesterol tests and results
• History of trauma, arthritis, or neurologic disorder
• History of pain or swelling in the joints or muscles
• Frequency and type of usual exercise
• Dietary intake of calcium
• Changes in color or temperature of the extremities
• History of pain in the legs when sleeping or pain that worsens by walking
• History of blood clots or sores on the legs that do not heal

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Close the curtains around the bed and close the door to the room, if possible. Explain the purpose of the neurologic, musculoskeletal, and peripheral vascular examinations and what you are going to do. Answer any questions.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation.
4. Help the patient undress, if needed, and provide a patient gown. Assist the patient to a supine position, if possible. Use the bath blanket to cover any exposed area other than the one being assessed.	Having the patient wear a gown facilitates examination of the neurologic, musculoskeletal, and peripheral vascular systems. Use of a bath blanket provides for comfort and warmth.
5. Begin with a survey of the patient's overall hygiene and physical appearance.	This provides initial impressions of the patient. Hygiene and appearance can provide clues about the patient's mental state and comfort level.
6. Assess the patient's mental status.
a. Evaluate level of consciousness. Refer to Chapter 17 for standardized assessment tools to assess level of consciousness.	This helps identify the patient's level of awareness.
b. Evaluate the patient's orientation to person, place, and time.	The patient should be awake and alert. Patients with altered level of consciousness may be lethargic, stuporous, or comatose.
c. Assess memory (immediate recall and past memory).	Memory problems may indicate neurologic impairment.
d. Evaluate the patient's ability to understand spoken and written word.	Evaluation of the patient's ability to understand spoken and written word helps assess for aphasia.
7. Test cranial nerve (CN) function, as indicated.	It is not necessary to assess every cranial nerve for every patient. Assessment should be individualized based on the patient's needs and health care setting and circumstances (Jensen, 2019).
a. Ask the patient to close the eyes, occlude one nostril, and then identify the smell of different substances, such as coffee, chocolate, or alcohol. Repeat with the other nostril.	This action tests the function of CN I (olfactory nerve).
b. Test visual acuity and pupillary constriction. Refer to previous discussion in the assessment of the head and neck.	This tests function of CN II and CN III (optic and oculomotor nerves).
c. Move the patient's eyes through the six cardinal positions of gaze. Refer to previous discussion in the assessment of the head and neck.	This testing evaluates the function of tests CN III, CN IV, and CN VI (oculomotor, trochlear, and abducens nerves).
d. Ask the patient to smile, frown, wrinkle the forehead, and puff out cheeks (Figure 1).	This maneuver evaluates the motor function of CN VII (facial nerve).
e. Ask the patient to protrude tongue and push against the cheek with the tongue.	This evaluates function of CN XII (hypoglossal nerve).
f. Palpate the jaw muscles. Ask the patient to open and clench jaws. Stroke the patient's face with a cotton ball.	This evaluates function of CN V (trigeminal nerve).
g. Test hearing with the whispered voice test. Refer to previous discussion in the assessment of the head and neck.	This evaluates function of CN VIII (acoustic nerve).
h. Put on gloves. Ask patient to open mouth. While observing soft palate, ask patient to say “ah”; observe upward movement of the soft palate. Test the gag reflex by touching the posterior pharynx with the tongue depressor. Explain to patient that this may be uncomfortable. Ask the patient to swallow. Remove gloves.	Gloves prevent contact with blood and body fluids. An intact gag reflex and swallowing indicate normal functioning of CNs IX and X (glossopharyngeal and vagus nerves).
i. Place your hands on the patient's shoulders (Figure 2) while they shrug against resistance. Then place your hand on the patient's left cheek, then the right cheek, and have the patient push against it.	These actions check CN XI (spinal accessory nerve) function and trapezius and sternocleidomastoid muscle strength.
8. Check the patient's ability to move their neck. Ask the patient to touch their chin to the chest and to each shoulder, then move each ear to the corresponding shoulder (Figure 3), and then tip the head back as far as possible.	These actions assess neck ROM, which is normally smooth and controlled.
9. Inspect the upper extremities. Observe for skin color, presence of lesions, rashes, and muscle mass. Palpate for skin temperature, texture, and presence of masses.	Examination of the upper extremities provides information about the circulatory, integumentary, and musculoskeletal systems.
10. Ask the patient to extend arms forward and then rapidly turn palms up and down.	This maneuver tests proprioception and cerebellar function.
11. Ask the patient to flex upper arm and to resist examiner's opposing force (Figure 4).	This technique assesses the muscle strength of the upper extremities.
12. Inspect and palpate the hands, fingers, wrists (Figure 5), and elbow joints.	Inspection and palpation provide information about abnormalities, tenderness, and ROM.
13. Ask the patient to bend and straighten the elbow, and flex and extend the wrists and hands.	Tests ROM of elbow joint and wrists.
14. Palpate the skin and the radial and brachial pulses. Assess the pulse rate, quality or amplitude, and rhythm. Test capillary refill (Refer to “Pallor” in Box 3-2).	Pulse palpation and capillary refill evaluate the peripheral vascular status of the upper extremities.
15. Cross your index and middle fingers. Have the patient squeeze your index and middle fingers (Figure 6).	This maneuver tests the muscle strength of the hands.
16. Assist the patient to a supine position. Palpate (Figure 7A) and then use the bell of the stethoscope to auscultate the femoral pulses in the groin (Figure 7B), if not done during assessment of the abdomen. Note the strength of the pulse and grade it as with peripheral pulses.	This technique assesses flow of blood through the arteries. Auscultation can detect a bruit.
17. Examine the lower extremities. Inspect the legs and feet for color, lesions, varicosities, hair growth, nail growth, edema, and muscle mass.	Inspection provides information about peripheral vascular function.
18. Assess for pitting edema in the lower extremities by pressing fingers into the skin at the pretibial area and dorsum of the foot (Figure 8A). If an indentation remains in the skin after the fingers have been lifted, pitting edema is present (Figure 8B).	This technique reveals information about excess interstitial fluid. Refer to an edema scale in assessing the amount of edema: 1+ about 2 mm deep to 4+ about 8 mm deep.
19. Palpate for pulses and skin temperature at the posterior tibial, dorsalis pedis, and popliteal areas. Assess the pulse rate, quality or amplitude, and rhythm. Test capillary refill (Refer to “Pallor” in Box 3-2).	Pulses, skin temperature, and capillary refill provide information about the patient's peripheral vascular status.
20. Ask the patient to move one leg laterally with the knee straight to test abduction of the hip. Keeping knee straight, move leg medially to test adduction of the hip. Repeat with other leg.	This maneuver assesses ROM and provides information about joint problems.
21. Ask the patient to raise the thigh against the resistance of your hand (Figure 9); next have the patient push outward against the resistance of your hand; then have the patient pull backward against the resistance of your hand. Repeat on the opposite side.	These measures assess motor strength of the upper and lower legs.
22. Ask the patient to dorsiflex and then plantarflex both feet against opposing resistance (Figure 10).	These measure ankle flexion and dorsiflexion.
23. As needed, assist the patient to a standing position. Observe the patient as they walk with a regular gait, on the toes, on the heels, and then heel to toe (Figure 11).	This procedure evaluates cerebellar and motor function.
24. Perform the Romberg's test; ask the patient to stand straight with feet together, both eyes closed with arms at side (Figure 12). Wait 20 seconds and observe for patient swaying and ability to maintain balance. Be alert to prevent a patient fall or injury related to losing balance during this assessment.	This test checks cerebellar functioning and evaluates balance, equilibrium, and coordination. Slight swaying is normal, but patient should be able to maintain balance.
25. Assist the patient to a comfortable position.	This ensures the patient's comfort.
26. Remove PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems, as appropriate, or indicated. Initiate appropriate referral to other health care providers for further evaluation, as indicated.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Additional assessments should be completed, as indicated, to evaluate the patient's health status. Intervention by other health care providers may be indicated to evaluate and treat the patient's health status.