Physical assessment checklist -wanted

[Pat_Pat RN]

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

[catlover13]

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

[catlover13]

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.

[Daytonite, BSN, RN]

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:

https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-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.

• [attach]5519[/attach] student clinical worksheet