Physical assessment checklist -wanted

  1. 2
    I'd like to find a checklist for doing my physical assessment. I get most of the data from the patient, but when I start to write my narrative chart I leave things out. I'd like to find something with each area (ie Head) then what to look for (pupils, sclera, exudate) with each of those broken down into further check boxes (pupils: Pin-point, PEARRLA, dilated, etc) (sclera: white, yellow, injections, etc.)
    Has anyone seen anthing this in depth, or have a link or copy they could post?
    Any help would be greatly appreciated.
    Thanks
    Pat_Pat
    fagan and Proud 2b Me like this.
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  4. 4
    Head To Toe Assessment Checklist Client Initials
    Vital Signs
    Time
    T
    P
    R
    B/P
    Manual/Electric
    Location
    Body Position

    Upper Extremities
    Skin Color
    Skin Temp
    Turgor(Chest)
    Radial Pulses
    Capillary refill
    Handgrip
    Movement
    ROM

    Lower Extremities
    Skin Color
    Skin Temp

    Pedal Pulses
    Capillary refill

    Movement
    ROM
    Hohman’s Sign

    Oxygen
    Oximetry
    Liters/Minute
    Room Air
    Nasal Cannula
    Mask

    IV/Saline Loc
    Solution
    Rate
    Site
    Redness
    Irritation
    Edema

    Pain
    Pain
    Location
    Duration
    Scale (1 – 10)
    Intervention
    Evaluation
    (within 30 minutes)

    Mental Status
    Alert
    Person
    Place
    Time

    Apical Pulse
    Rate
    Regular
    Regular Irregularity
    Irregular Irregularity

    Elimination
    Voiding freely
    Continent/incontinent
    Foley
    Patent
    Color
    Clarity

    BM
    Continent/incontinent
    Color
    Consistency
    Amount

    Pupils
    Left Right
    P
    E
    R
    R
    L
    A


    Breath Sounds
    Anterior/Posterior
    L Upper
    Middle
    Lower
    Inspiratory/Expiratory

    Dressing
    Location
    Clean
    Dry
    Intact
    Drainage
    Color
    Amount
    Odor
    Consistency

    Mucous Membranes
    Moist
    Pink

    Abdomen
    Soft
    Round
    Non Tender
    LUQ RUQ
    LLQ RLQ

    Miscellaneous
    Pt in bed
    Low position
    Siderails up
    Call light within reach
    Special equipment
    Last edit by catlover13 on Apr 5, '07 : Reason: Tweaked
    jrgab05, CHaley88, gracielou1, and 1 other like this.
  5. 0
    The above was a combination of several different types of head to toe checklists. This format will fit into 3 columns, with boxes for each section. This is meant to be more of a check list, with ____ next to each entry. I think I even had it set up so you could do a couple of assessments for the same patient, but at different times on the same page.

    I printed out one for each patient I had, stapled them together, so I worked with a sheaf of papers, just had to flip to the patient I wanted to see.

    There was room at the bottom for info from report, or on the back if you needed extra room.

    When I wrote the narrative, I just began at the beginning, and went section by section. Added any other comments as needed, or at the end.

    You should be able to copy and paste it, then tweak it into boxes. There will be extra room to write special findings in the boxes too!!!

    The formatting did not translate when I copied and pasted.

    This form worked well for me, but you'll have to find the one that works best for you.
    Last edit by catlover13 on Apr 5, '07 : Reason: Tweaked
  6. 2
    pat_pat. . .you are pretty much going to have to make up your own or 5-finger discount one from the various clinical facilities you visit as a student. most facilities are very stingy about sharing the ones they have with others. you can find some of these assessment forms in different care plan books. carpenito's books have them. so do some of the doenges/moorhouse books. there may be others i'm not aware of.

    you should check out the weblinks on this thread:
    http://allnurses.com/forums/f205/hea...ms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum). if i'm not mistaken, some of them have assessment forms on them.

    this is a clinical worksheet i've put together for nursing students. the review of systems which takes up 2/3 of the lower page runs through all the major body systems but doesn't list everything you are looking for.
    tingler0 and berquj like this.


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