Physical Assessment Sample

This form is given to every person in order to check his or her recent health status.

Physical assessment sample. Old appendectomy scar right lower abdomen 4 inches long thin and white. Nursing assessment is an important step of the whole nursing process. Changes in level of consciousness. She complains of resolving chest pain.

Hair brown shoulder length clean shiny. Charting examples for physical assessment. Thereafter body measurements include height and weight. Restlessness listlessness confusion disorientation others.

Sprinkling of freckles noted across cheeks and nose. Body measurements include length or height weight and head circumference for children from birth to 36 months of age. The following topics are part of the routine daily assessment of most patients. Take the patient s blood pressure.

Generally a well developed slightly obese elderly black woman sitting up in bed breathing with slight difficulty. Abdomen inspection abdominal abdominal no. Assessment can be called the base or foundation of the nursing process. Skin hair and nails.

Take the radial pulse by placing your index and middle fingers on the inside of your wrist. A physical assessment form is a type of a form which helps in determining the various physical attributes of an individual. To prevent those kind of scenarios we have created a cheat sheet that you can print and use to guide you throughout the first step of the nursing process. History and physical examination h p examples the links below are to actual h ps written by unc students during their inpatient clerkship rotations.

No lesions or excoriations noted. As an introduction to charting it should be known that there are many different ways to record an assessment. Skin pink warm dry and elastic. The students have granted permission to have these h ps posted on the website as examples.

Conduct a hearing test. With a weak or incorrect assessment nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. Nose inspection symmetrical symmetrical and no significant. Mouth inspection breath smells no significant.

Temperature 100 2 pulse 96 regular with occasional extra beat respiration 24 blood pressure 180 100 lying down 2. Recording the physical assessment findings. 8 sample physical assessment forms in pdf word. This guide for charting will present one method.

Make sure your hands are clean and properly sanitized. As you read and review each system be aware of the possible abnormalities of the mental status examination. Check the patient s ears. Neck inspection symmetrical symmetrical no significant.

The assessment of hearing speech and vision are also measurements of an individual s function in these areas.