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about nursing process and physical health assessment

help guys,, any sites (websites) about how to make nursing process and physical health assessment?? sample documents and forms are a real help,,, have to make one for our assignment,,,have already a person to interview with,, just need a guide to be exact :)

Daytonite, BSN, RN

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

i've read your post over several times trying to figure out exactly what it is you are looking for. i'm getting that you are supposed to develop a physical health assessment form that you will be able to merge into your nursing process, is that correct? i have a couple of links for you on what the nursing process is.



a health assessment guide would follow the same general setup of a physician's history and review of systems. do a search of this site as i remember seeing several students who posted examples of assessment sheets they had been given. i've also seen documents like these at various nursing school sites, but i've never bookmarked them. i would recommend that you do a web search for a nursing physical assessment. i often find these kinds of documents in the web pages of specific nursing instructors in the various nursing schools. they have them on the internet for their students to access and print them out.

also, i recommend that you post this kind of question on the student nurse forums at this site (you will find them by using the drop down menu under "nursing discussions" at the very top of this page). the students will be more apt to telling you how to get this information. most of us older nurses have this stuff burned into our memories and don't use the school forms anymore.

Hmm...your instructors never gave you a packet that had a guide for a head to toe assessment? When we first started assessments we had a really detailed guide for that sort of thing.

I found this for you: http://nursing.about.com/od/assessmentskills/ht/headtotoeassess.htm

It's easier if you go into Word and make yourself a little chart. Is this for clinical? Or is it just a practice assessment? What we would do is something like this:

Make a space at the top for Vitals. A little box for 0800 and 1200. Then another box for essential things to know. DNR/Full code, diet type, whether or not they are on O2 (type, Liters, blahblah), IV (what type of fluid, ML/hr, site). I'm sure I'm forgetting some other things...

Then make another box for your Input and Output. You need to check this Q2H. So put little lines for 0800 and so on.

Then you just need to make more spots for heart sounds, lung sounds, bowel sounds, peripheral pulses...am I forgetting anything? You will also need to check the color of the patient's urine, mucous membranes, skin integrity, etc.

Someone please add whatever you feel needed!

I'm really sorry if this is confusing to read lol, I'm not always the best at explaining things. I wish I had a chart saved so that I could just send it to you and you could print it up for yourself cuz they are SO helpful. But hopefully you can make a spiffy one for yourself. Hope this helped hun!

thnx a lot guys, its a big help,, i also found a book "nursing fundamentals" it also was a big help.. in the book its states there health history and physical assessment. i was lost by what our instructor wants us to do,, he said nursing process whick was i thinkl ADPIE, he only wants A(assessment) part, which includes the health history and physical assesment. Happy New Year to all :)

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