What do you include in your Physical Assessment?

Daytonite, BSN, RN · Aug 1, 2008

are you looking for some specific information? learning to do assessments is a skill that takes some people time to master. it also depends on the kind of patient you are working with. sometimes you want to focus your assessment on a particular part of the body or a specific body system. there is a sticky thread on the nursing student assistance forum that has many weblinks and forms for different types of assessments including the all-purpose head-to-toe assessment:

https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms

i would tell you that assessment is a continuous process that you are constantly engaged in while you are with a patient. whenever you are at the bedside your eyes are always observing, your nose noting, your fingers paying attention to what they are feeling and your ears listening. every little piece of information gets added to the puzzle. the traditional assessment where you listen to the lungs and abdominal sounds, however, can be accomplished in 5 minutes. be aware though that as nurses we also assess how the patient is able to accomplish such things as eat, toilet, ambulate, dress, brush their teeth, and perform daily activities such as that. those thing are not part of the traditional head-to-toe assessment, per se, but we are just as responsible for appraising for them.

there is an assessment form in the center of taber's cyclopedic medical dictionary around the listing for nursing. if you open up the link attached at the bottom of my post for the student clinical report sheet for one patient you will find that the bottom section is a review of systems (history) form part of a patient assessment along with an area to fill in physical assessment findings. you can copy that form and use it if you like.