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Health Assessment Resources, Techniques, and Forms

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Ok, I need pointers I am in my first semester nursing and we have evals on health assessment head to toe UGH! 🤮 I am freaking I was very sick 😷 🤒 the morning we had lecture on this and am in need of some kind of checklist or video to show me more of what to do anyone out there have any hints for me please. Thank you all!

Hugs

This is a GREAT form my clinical instructor made for to us to use during an assessment....just remember you can get a neuro on your patient just by talking to them (LOC = how is your greeting with them, and their response to you?...their facial muscles during speech, etc.) Skin assessment while listening to heart and lungs...

A lot of the assessment gets incorporated altogether, you will see this as you go! I remember being stressed out too during my first focused patient assessment, and now I do them on real patients in the hospital with ease.

opt toolAssessment guide[1].doc

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

Assessment and description of pain includes the following:

  • Where the pain is located?
  • How long it lasts?
  • How often it occurs?
  • A description of it (sharp, dull, stabbing, aching, burning, throbbing)
    • Have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
  • What triggers the pain?
  • What relieves the pain?
  • Observe their physical responses
    • Behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
    • Sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
    • Parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

Mave said:

I was wondering...

In one of the links that was posted here, it said that to check for pt orientation, and to make sure that the pt is oriented, that it has to be alert and oriented x4. Why four? I thought it was x3?

"Orientation is checked by determining if the patient can state their name, the day or date, where they are, and the purpose. This is documented as oriented times 4."

VickyRN, MSN, DNP, RN

Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

Assessment Using Functional Health Patterns - Includes sample concept map and careplan, along with sample health history ("Client Assessment According to Functional Health Pattern") 🙂

Sample Head-to-Toe Assessment

Using the Body Systems Model

Assessment According to Human Needs Approach

Assessment According to Human Response Patterns

The Complete Health History and Physical Assessment (Power Point download)

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

Get Body Smart - This is Get Body Smart and online examination of human anatomy and physiology. Book mark this for your studies. Click on the respiratory system. Then keep clicking on the individual items on the list that comes up for an explanation of the anatomy of the various structures of the lung. My notes indicate that there are quizzes in this group of tutorials, but I didn't happen to access them this evening when I was verifying that the link was still good.

How a Bronchoscopy is Performed - Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during the treatment of some lung conditions.

COPD (chronic obstructive pulmonary disease) makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it.

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air.

Cystic Fibrosis (CF) is an inherited disease of the mucus and sweat glands. It affects mostly your lungs, pancreas, liver, intestines, sinuses, and sex organs. CF causes your mucus to be thick and sticky. The mucus clogs the lungs, causing breathing problems and making it easy for bacteria to grow. This can lead to repeated lung infections and lung damage.

Getting a Breathing Test (Spirometry) - Your Lungs & Respiratory System

Our next assessment is in vital signs. The first couple of assessments were breezy for me basically but this one I am afraid that I am going to have problems with. A lot of my classmates (including my lab partners) are CNAs and already know how to check vitals and they keep saying "oh, this assessment is going to be the easiest one," so I feel like I'm an idiot because I can't seem to hear the heartbeat when I try to check the blood pressure. I don't know if I'm supposed to count the first thump when I check pulse or the thump-thump as two thumps instead of one. I just feel overwhelmed because everyone else seems to know what they are doing. My clinical instructor is really helpful and says that she will be available anytime I need her for help but my concern is also that even if I am able to hear my instructor's beat when I am checking her pulse, I won't be able to hear my partner's. I am really worried and I don't want an U for this assessment. Does anyone have any advice on how to make this vitals assessment a little easier?

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

This is a form I've been tinkering around with to develop as a tool to help with critical thinking and the nursing process. It hasn't been going the way I wanted it to, but I'm posting it anyway because there are some redeeming qualities to it. If you have any suggestions and additions you think might improve it, please PM me and let me know your thoughts. In the meantime, feel free to download and use it. It was meant to be printed on both sides of one sheet of paper.

Critical Thinking Flow Sheet for Nursing Students.doc