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

Specializes in med/surg, telemetry, IV therapy, mgmt.

Important information about the patient that you need to collect from your patient's chart is listed on post #5 in this topic...

Help Preparing for Clinical Day!

  • Assume you may end up having to write a care plan on the patient. after your clinical is over and the patient has been discharged, the information is no longer going to be easily available to you, so it is up to you to get the important facts.
  • Getting information about a patient is part of the assessment process (data collection). the more you know, the more you'll understand about what is going on with the patient and the better you are able to make decisions about their care.
  • No one can ever know the entire patient's medical history, even if you think you do. sometimes even the patient can't remember everything.

According to one author (Pamela Schuster, Concept Mapping: A Critical-Thinking Approach to Care Planning), 99% of assessment data comes from documentation that is in the medical record and obtaining it can be time-consuming. The other 1% is obtained when you are face-to-face with the patient and perform your own interview and physical assessment. Now, I've known that for years, but this was the first author that I've found who actually wrote it down in a book. That said, here's where to look and what data you might need:

The Patient's Chart

Face Sheet (typically one of the first pages in the chart)

  • Patient's age (you need to know the normal growth and developmental tasks for the patient's age and how illness may/may not have affected that)
  • Gender
  • Marital status
  • Occupation
  • Admission date
  • Reason for admission (may be called the admission diagnosis, may include any planned surgical procedures)
  • Past medical diagnoses

Doctor's Order Sheets/Physician's Orders

  • Any DNR (do not resuscitate) order
  • Diet
  • Activity allowed
  • Orders for lab and diagnostic procedures
  • Medication orders
  • IV orders
  • Other treatments (i.e., oxygen, catheters, ng tubes, dressing changes)
  • Support services (i.e., physical therapy, occupational therapy, speech therapy, respiratory therapy, social worker)
  • Consultations by other physicians, usually specialists

Physician's Progress Notes

  • The patient's progress and response to medical treatment
  • Changes in the patient's condition
  • Medical and surgical procedures that have been performed and findings
  • Results of tests and procedures

Doctor's History and Physical Exam

Physician Consultations

  • The patients h&p by the admitting physician that includes a review of systems and past medical, family and social history
  • Any consultation reports that may also have some review of systems and past medical history
  • The consultation section may contain consults by other ancillary services that don't have their own section in the chart

Surgical Consents

  • The name of the exact procedure(s) the patient has had or is to undergo (a surgical consent must have the complete name of the surgical procedure written out with no abbreviations)

Operative Report

Pathology Report

  • Date and name of surgical procedures done by physicians
  • Medical diagnoses
  • Findings
  • Full description of the procedure and any materials/prostheses placed in the patient's body
  • Report on any tissue biopsied or removed during a surgical procedure

Laboratory and Diagnostic Procedures

  • Date and time of collection and analysis/examination of blood, urine, stool and other body substances
  • Blood bank records (if the patient has had blood/blood products transfusions)
  • X-Ray reports
  • EKG tracings and reports
  • EEG tracings and reports

Nursing Admission Assessment

  • Past medical diagnoses
  • Past illnesses, injuries and surgeries
  • If the patient has an advanced directive (living will, healthcare power of attorney)
  • Height and weight
  • Allergies
  • Medications taken at home
  • Home caregiver
  • A nursing review of systems
  • A nursing assessment of the patient's ability to perform adls

Nurses Notes / Flow Sheets Graphic Sheet

  • Graphic information (vital signs)
  • I&O information (may indicate ivs and catheters)
  • BM monitoring
  • Activity performed

Other Resources on the Nursing Unit

Medication Cart

  • Medication Sheet/Record
  • IV therapy record
    • Allergies
    • Drugs/dosages/routes/times
    • IV solutions to be infused and rates
  • Double check the generic and/or brand names of the drugs listed on the medication sheet/record by looking at the labels on the drugs in the patient's bin.

The Nurses Station

Kardex

  • Allergies (food and drug)
  • Age, gender, admission date
  • Diet
  • Activity allowed
  • IV orders
  • Surgical procedures
  • DNR orders
  • Diagnostic tests to be done
  • Ordered treatments (i.e., oxygen, catheters, ng tubes, dressing changes)
  • Support services (i.e., physical therapy, occupational therapy, speech therapy, respiratory therapy, social worker, discharge planning)
  • Consultations by other physician specialists
  • Blank copies of forms you are going to have to document on the next day to become familiar with what information goes on them and where. these forms can include:
  • Assessment forms
  • Fall risk assessment form
  • Standardized pre-written care plans/clinical pathways
  • Printed copies of standing orders
  • Educational materials that might apply to your patient

The nurses who work on the unit, preferably the one assigned to your patient

  • Anything you can't find on your own

To help you organize your clinical day, print out a copy of the student clinical report sheet for one patient to help you. The critical thinking flow sheet for nursing students was developed to help include all the elements needed in writing a care plan, but there are some items on it that may help you determine the assessment data you want to collect.

Once you get this information then start looking up information about the medical diagnoses, procedures, lab tests, drugs and their side effects.

Note: I forgot to add that when you are looking at any of the physician history & physicals or consultation reports read through them and look for reference to any symptoms the patient might be having. these same symptoms can be helpful to you later in determining nursing diagnoses if you have to construct a care plan. Also, on some of these different chart documents you may find evidence that the patient has a tube, drain or other medical device in them that wasn't mentioned anywhere else in the record (some people are just real good at observation and documenting these things!)

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daytonite said:
These are a couple of the links I have on physical assessment guidelines. I think that you are mostly going to find that you are either going to have to pick one from a facility or make up your own.
You might try posting your question on the critical care forum and see if any of the nurses who hang out there are willing to share anything with you. you usually will never go wrong with the old head to toe assessment and then a review of all the tubes and equipment hanging off the patient.

Thanks for all the websites you noted daytonite. I am making a list for future reference when I start school in the fall.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

You all need to understand that articles come and go on the internet. What was there yesterday could very well be removed from public access today. This is one of the frustrations about using internet resources. A good book on physical assessment is still one of your best assets on how to do a head to toe assessment. the only way it will disappear is if you lose it, someone steals it, or it somehow gets destroyed. I have the following books here at home that i use for reference:

If you can't afford a book that specifically addresses this subject then spend an afternoon or two in a library and look this information up for yourself. Learn where your medical libraries are in the town where you live. they are not only in your college libraries, but in hospitals as well. you may need to ask each hospital. they will generally allow student nurses to use their medical library facility. Those of you who are in college nursing programs are expected to perform college level work and learning how to find references is certainly part of student college work for any subject you are studying.

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Specializes in Gerontological, cardiac, med-surg, peds.

Skills Checklists

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Newborn Assessment

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Sensorium, Mental Grasp and Capacity:

Consciousness: alert, clouded, fluctuating, stuporous
Orientation: normal, mild, moderate, severe, disorientation to (time, place, person, situation)

Memory: intact, mild, moderate, severe, memory deficits (immediate, recent, remote)

Digit Span: forward (good, poor), backward (good, poor)

Disorders Of: counting, calculation, reading, writing, attention, concentration, comprehension

General Knowledge: good, poor, consistent with education, inconsistent with education, personalized, superficial, pseudoabstraction

Intelligence: normal, below normal, above normal

Insight: good, fair, poor, none

Judgment: good, fair, poor, none, feelings of worthlessness or guilt, diurnal mood variation

Emotional State/Reaction:

Affect: unremarkable, indifferent, fearful, angry, euphoric, anxious, sad

Range: normal, labile, constricted
Depth: normal, shallow, increased
Vegetative Symptoms of Depression: depressed mood, loss of interest of pleasure, appetite disturbance, sleep disturbance, psychomotor agitation or retardation, fatigue of loss of energy, decreased concentration
Suicidal/Homicidal: denies, ideation, plan, attempt

General Attitude and Behavior:

Behavior: cooperative, passive, domineering, withdrawn, restless, dramatic, hostile, intimidating, suspicious, uncooperative, other

Appearance: unkempt, disheveled, clean, neat, unusual
Attire: appropriate, seductive, loud, meticulous, untidy, atypical
Facial Expression: unremarkable, sad, angry, perplexed, fearful, elated, immobile, grimacing, atypical
Gait: normal, parkinsonian, ataxic, shuffling, unusual, other
Motor Activity: unremarkable, agitated, hypoactive, tremor, tic, hyperactive, pacing, handwringing, mannerisms

Stream of Mental Activity:

Productivity: spontaneous, verbose, pressured, slow, soft, mute, atypical

Progression: logical, association, loose association
Circumstantiality: perseveration, halting, incoherent, fragmented, tangential, flight of ideas, ruminations, confabulation, neologism
Language: normal, childlike, peculiar, stilted

Mental Trend and Thought Content:

Perception: unremarkable, depersonalization, derealization, dissociation

Hallucinations: auditory, visual, tactile, olfactory, gustatory
Cognitive Style: obsessive, self deprecatory, intellectualized, autistic, global (histrionic), other
Cognitive Content: obsessions, phobias, compulsive rituals, religiosity, ideas of reference, bizarre ideas, self depreciations, delusions, nihilistic, somatic, grandiose, paranoid, guilt
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Specializes in Gerontological, cardiac, med-surg, peds.

Health Assessment and Physical Examination - Expanded Glossary

Excellent resource! ?

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Specializes in clinic and rural ER.

Hi i am looking for a assessment sheet to use in a private care setting. Pt has Spina Bifida and G/T ACE malone and problems with decub on coccyx d/t sitting in w/c. Also has a trach and is on a vent at night. I can't seem to find anything and think it would be helpful to chart daily so when Pt has appt's i can send copies. Can anyone please help. Pt. is very active goes to college. Thanks sooo much

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Specializes in med/surg, telemetry, IV therapy, mgmt.
reefwoman said:
Hi i am looking for a assessment sheet to use in a private care setting. Pt has Spina Bifida and G/T ACE malone and problems with decub on coccyx d/t sitting in w/c. Also has a trach and is on a vent at night. I can't seem to find anything and think it would be helpful to chart daily so when Pt has appt's i can send copies. Can anyone please help. Pt. is very active goes to college. Thanks sooo much

It's not likely to exist. It's sounds like something that would need to be very customized. You will probably have to create it. In all the years I've been a nurse that has been what I have found to be true--had to create my own.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

How to do a process recording:

Assertiveness:

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Specializes in psych,and detox,and Ltc.
Angelwings2007 said:
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 pleaseeeeeeeeee Thank you all!

Hugs

You'll be fine.......I just got my skin assessment back,and got 99%...I'm turning in my mobility assessment this Friday........They are not hard to do....They just make you think. ?

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Specializes in Med-Surg.

This link was EXACTLY what I was looking for:

http://www.hospitalsoup.com/public/Admissi3rev2.pdf (attached below)

I don't think I'll miss anything on an assessment again!

Thanks!

nursing-admission-assessment.pdf

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