Physical Assessment Sample

Thereafter body measurements include height and weight.

Physical assessment sample. Assessment can be called the base or foundation of the nursing process. This form is given to every person in order to check his or her recent health status. Physical assessment body part normal findings actual findings interpretation. Recording the physical assessment findings.

Mouth inspection breath smells no significant. Neck inspection symmetrical symmetrical no significant. The students have granted permission to have these h ps posted on the website as examples. Make sure your hands are clean and properly sanitized.

Changes in level of consciousness. Charting examples for physical assessment. Some hospitals have their own form for recording findings and other facilities a narrative or story form. 8 sample physical assessment forms in pdf word.

With a weak or incorrect assessment nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. She complains of resolving chest pain. As you read and review each system be aware of the possible abnormalities of the mental status examination. Hair brown shoulder length clean shiny.

Temperature 100 2 pulse 96 regular with occasional extra beat respiration 24 blood pressure 180 100 lying down 2. Conduct a hearing test. Take the radial pulse by placing your index and middle fingers on the inside of your wrist. Check the patient s ears.

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. Nose inspection symmetrical symmetrical and no significant. Body measurements include length or height weight and head circumference for children from birth to 36 months of age. Nursing assessment is an important step of the whole nursing process.

Take the patient s blood pressure. No lesions or excoriations noted. Skin pink warm dry and elastic. History and physical examination h p examples the links below are to actual h ps written by unc students during their inpatient clerkship rotations.

This guide for charting will present one method. The following topics are part of the routine daily assessment of most patients. As an introduction to charting it should be known that there are many different ways to record an assessment. Restlessness listlessness confusion disorientation others.

The assessment of hearing speech and vision are also measurements of an individual s function in these areas. Steps in performing a physical exam 1. Sprinkling of freckles noted across cheeks and nose. Skin hair and nails.

Generally a well developed slightly obese elderly black woman sitting up in bed breathing with slight difficulty.