nursing assessment template pdf

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Nursing Assessment Forms

39 printable nursing assessment forms (+examples).

People who go to the hospital seeking medical information or help will be first attended by any member of the nursing staff before going to a doctor. As a nurse, you would perform a nursing assessment, which includes height and weight measurements, temperature, blood pressure , heart, and respiratory rate. You record your results in a nursing assessment form.

Table of Contents

• 1 Nursing Assessment Forms
• 2 What is a nursing assessment?
• 3 Nursing Assessment Templates
• 4 Why is a nursing assessment important?
• 5 Nursing Assessment Examples
• 6 How do you write a nursing assessment?
• 7 Nursing Assessment Sheets

What is a nursing assessment?

A nursing assessment form contains a collection of information about the physiological, psychological, spiritual, and sociological status of a patient. The assessment is the first step in the nursing process.

Although you can use nursing skin assessment forms and other forms to identify the current and future needs of a patient, it still has a very broad scope. You should go through certain set procedures before you can properly evaluate an individual.

Typically, you will use a nursing assessment sheet that you will fill up when conducting these evaluations. The nursing assessment is an organized set of processes you use to provide optimal care for your patients.

You cannot delegate this assessment to unlicensed nurses, although nursing students unless with the guidance of their clinical instructors. This assessment has a broad scope because it focuses on the whole body system. There are different types that focus only on specific parts of the assessment. These include:

• Learning Needs Here, you identify deficiencies in knowledge that serve as the basis of the learning needs of a person that you can analyze. This functions as a guide in teaching by a healthcare provider.
• Competency This is the continuous evaluation of the knowledge, skills, and development of a person that enables them to perform activities.
• Physical This is a thorough head-to-toe assessment of a patient.
• Admission Before a patient gets confined in a hospital, they must go through physical assessments and statistics. This serves as a baseline for the required actions you must take and for the patient records.
• Holistic This approach toward a patient involves sociological, cultural, spiritual, and psychological needs. You derive your nursing implementations from the information you gather from your patient.

Nursing Assessment Templates

Why is a nursing assessment important?

In general, nurses know that a comprehensive nursing assessment is an important first step in the development of a plan to deliver the best possible patient care. As a nurse, you also know that a nursing assessment form is a key part of your responsibilities and roles.

A nursing assessment example is a tool used to learn about a patient’s symptoms, overall health, and concerns. A nursing assessment template is an essential factor because this is where you gather comprehensive data to help in the determination of your diagnoses, which you then use to develop nursing care plans to help improve health outcomes.

The comprehensive data on these forms include psychological, socioeconomic, social, and physiological determinants of health, lifestyle, and spiritual information. The comprehensive health assessment has many components.

Before the assessment begins, you must develop a rapport with your patients by first introducing yourself, then explaining what you will do during the assessment and why.

Patients become anxious when you conduct these assessments and establishing a rapport with them helps put them at ease although this could also depend upon the setting of the assessment or the reason for their visit.

Most comprehensive nursing assessments usually begin with the health history of the patient and this includes information about their past injuries or illnesses including childhood immunizations and illnesses, surgeries, hospitalizations, allergies, chronic illnesses, and the illnesses that run in their family.

One of the components of a nursing assessment is the health history of the patient. Here, you will ask a patient to describe the symptoms they feel, when their symptoms began, and how they developed before you forward the process to the physical examination.

Physical examinations are very familiar to most people and they usually start with a complete set of vital signs including blood pressure, respiratory rate, temperature, and heart rate.

Because of the increasing rate of chronic conditions and the growing elderly population, it is necessary to learn how to keep up with distinct patient characteristics. This is another important aspect of the BSN and RN program.

Nursing Assessment Examples

How do you write a nursing assessment?

One of the most important roles of filling out nursing assessment examples is to provide accurate, safe, and effective nursing care. This is the first step in the nursing process and it involves exploring the psychological, physical, social, and spiritual aspects of a patient.

In other words, nursing skin assessment forms and other forms are a systematic and holistic guide for you to gain a better understanding of the needs and wants of a patient. A nursing assessment sheet is the underlying foundation of the process on which you base the other parts of the process.

You use the nursing assessment form as the starting point to building a therapeutic patient-nurse relationship and you can establish this during your first encounter. Actually, the assessment is the first encounter between you and a patient. You will both make first impressions and these judgments can have a great effect on how a patient perceives you.

Through this assessment, you can get information essential for providing your patient with effective holistic care. You can use nursing assessment framework tools to get from a patient, accurate information about them.

The initial assessment, which you based on both objective and subjective data, can be your basis in determining the actual issues of a patient, as well as, any potential issues. When making this assessment, include the following:

• Admission Assessment You should complete this with the patient, a caregiver, or a parent upon the patient’s arrival and you must be complete it within 24 hours of their admission. Then you enter any additional information into the progress notes of the patient. It is important to consider the privacy of your patient at all times.
• Patient History As a nurse, you should discuss the following with your patient: The history of the patient’s current injury or illness Other relevant details about their past history Any allergies and similar reactions Any medications the patient is currently taking Immunization status Implants, social, and family history You should also discuss any recent overseas travel and documented this information Assessment of your patients’ overall emotional, behavioral, and physical state. You should conduct this upon their admission then continue to observe them throughout their stay in the hospital.
• Vital Signs This involves recording baseline observations on your patient’s observation flowsheet. This is an important aspect of admission documentation and assessment. You should complete an ongoing assessment of vital signs as indicated for your patient. It is very important to review the VICTOR graph every two hours or as your patient’s condition requires. This allows you to observe any trending of vital signs that might support your clinical assessment process.
• Physical Assessment Conducting a structured physical examination can help you get a complete assessment of your patient. Some techniques used to obtain this information include inspection or observation, percussion, auscultation, and palpation. You should use your clinical judgment to decide on the extent of the assessment needed. Assessment information includes, but isn’t limited to: Primary assessment Shift Assessment Focused Assessment Neurological System A complete neurological nursing assessment includes sensory function, neurological observations, growth and development including gross and fine motor skills. seizures and other concerns. Respiratory System Generally, children are more susceptible to respiratory illnesses and other similar conditions that cause respiratory distress. Therefore, you should conduct an assessment of the severity of their respiratory conditions. Gastrointestinal Ensure that your patient’s stomach isn’t full when conducting this assessment as this might induce vomiting. This assessment can include inspection, light palpation and auscultation of the abdomen to find visible abnormalities, softness or tenderness and bowel sounds. Musculoskeletal You can conduct this assessment while observing a child or in bed or as they move about a room. Keep in mind that during periods of rapid growth, children usually complain of normal muscle aches. You should compare their joints and limbs bilaterally throughout your assessment. Skin You conduct this to identify any cutaneous issues or systematic diseases. Eye You should perform eye inspection on children very carefully and only when the child is completely compliant. Ear, Nose, and Throat (ENT) Conducting this assessment is important as respiratory illnesses are very common in children. It should also involve a comprehensive examination of the throat, the mouth, and the oral cavity. Common diseases here might include allergies, upper respiratory infections, facial or oral trauma, pharyngitis and dental caries.
• Assessment Evaluation Make sure that the information you collect is properly documented, complete, and accurate before going to the evaluation phase of your assessment. You must use problem-solving and critical thinking skills in making clinical decisions and the plan of care for the patient you’re assessing. Should you discover any abnormal findings, it will be your responsibility to take appropriate action. These actions may include communicating your findings to the medical team, the ANUM in charge of your shift, or related allied health team. Patients should undergo continuous assessment for any changes in their condition while under your care. Moreover, these assessments should be regularly documented.

Nursing Assessment Sheets

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Free Printable Nursing Assessment Form Templates [PDF, Word]

Nursing assessments can be described as the process of identifying an individual’s health status, focusing on the identification, assessment, and evaluation (IE) of current and future patient situations, problems, and needs; it also includes communication with physicians, other clinicians and members of the extended healthcare team.

People in the world who go to hospitals seeking any help/treatment will first be attended to by a nurse. Nurses also have the main responsibility of patients’ health and treatment; therefore, they should be well-trained and skilled in this field. A nursing assessment is the most important factor in a nurse’s duties.

Table of Contents

Nursing Assessment Templates

Enhance your nursing practice and improve patient care with our comprehensive collection of Nursing Assessment Templates. These free, printable templates provide a systematic and organized approach to conducting patient assessments, ensuring accurate documentation of vital signs , medical history, symptoms, and more.

Designed specifically for nurses, these templates cover a wide range of assessment areas, including general health assessment, mental health assessment, pediatric assessment , geriatric assessment, and more. Streamline your nursing workflow, improve efficiency , and ensure standardized documentation with our ready-to-use templates . Download, print, and start using these templates to enhance your nursing assessments and provide quality care to your patients.

What is a nursing assessment?

A nursing assessment is a process where a nurse gathers, sorts, and analyzes a patient’s health information to gain more insight into the patient’s overall health, symptoms, and concerns. It is one of the most important parts of any nurse’s job responsibilities.

One of the most important skills a nurse can get taught is how to accurately and appropriately assess for any situation. Without assessments, no diagnoses can be made, which means patient safety and care could be at risk.

What is included in a nursing assessment?

Nursing assessment is an integral part of nursing care . It is the process of gathering information about the health status, functional abilities, and psychosocial needs of a person to identify actual or potential health problems and formulate a plan of care. The purpose of nursing assessment is to ensure that health information is collected promptly, that the patient’s history is documented accurately, and that the data obtained from the assessment are used to guide evidence-based practice.

Nursing assessment can be defined as “the systematic collection and interpretation of data concerning the patient’s physical, psychological, social and spiritual condition”. A nursing assessment includes collecting subjective and objective data using evidence-informed tools to assess the patient. These include:

Environmental Assessment:

The environment is the first thing that a nurse will assess. The nurse should be aware of what can affect the patient’s health and safety, such as lighting and noise levels. They should also know if their patient is inclined to fall and if there are any hazards in the room.

Cultural Assessment:

A cultural assessment includes knowing about different cultures and how they interact with each other. It also includes knowing what language a patient speaks, if they have an interpreter, and if they prefer to speak that language over another one. A cultural assessment also includes knowing if people from other countries any special needs have when it comes to medical care or medications. For example, some medications may cause negative reactions in certain cultures because of religious beliefs or other reasons.

Physical Assessment:

The physical assessment begins with checking the general appearance of your patient including things like skin color, hair condition, body odor, etc. Once you have examined their general appearance you can go on to look at specific parts of the body such as eyesight and hearing ability as well as reflexes such as coughing or sneezing reflexes when someone touches their chest or back respectively.

Psychological Assessment:

The mental status examination is an assessment of a patient’s cognitive (ability to think), affective (ability to feel), and behavioral (ability to act) functioning. It includes assessing orientation, awareness, judgment, thought processes, memory, insight/judgment, and social interaction. This is done through observation and communication with the patient.

Psychosocial Assessment:

This type of assessment focuses on identifying psychosocial risk factors that may influence health outcomes such as relationships with family members and friends and participating in activities outside of work or home life. The nurse may ask questions about these areas to gather this information from the patient.

Safety Assessment:

Safety assessments are conducted for all patients at admission into a facility as well as throughout their stay at the facility. These assessments focus on identifying any safety risks so that appropriate actions can be taken to ensure that patients are protected from harm while being cared for by healthcare providers. For example, if a patient has diabetes.

What should a nurse consider when determining an assessment?

Evaluation: It is the first step of the nursing process. It is key in determining the nature of the patient’s illness or injury, how severe the problem is the need for an intervention or the response to an intervention.

It is necessary to approach the assessment of each patient’s condition in a systematic way. It is necessary to immediately identify life-threatening situations and set priorities for care.

A systematic approach helps us determine the priorities of the evaluation and the treatment priorities that the patient needs.

During the evaluation process, two types of information are collected, subjective and objective; What is subjective is the data provided by the patient himself and his relatives. However, these data may not point to the real problem. For example, the patient’s chest ached, but perhaps substance use does not tell him.

Objective data is the data we collect; These observable and measurable data are safer. Data such as inspection, auscultation, palpation, percussion, sniffing, laboratory data, and measurements are objective data.

Collected objective data clinically confirm or exclude subjective data from the patient.

During this evaluation, the nurse; Nursing features such as personal communication skills, anatomy and physiology knowledge, physical assessment skills, critical thinking ability, and common sense are very effective.

Importance of Nurse Assessment

Nurse assessments are a vitally important step in the nursing process. This article explains why health assessments help nurses accurately collect vital information about each patient and develop personalized care plans based on those needs.

Assessments are a critical component of nursing and nursing practice. Accountability for assessments is required in many healthcare settings and the information obtained from such assessments is used to develop patient care plans, determine interventions, and implement best-practice standards for patient care.

How do you write a nursing assessment?

1. Collect Information

The first step is to collect all relevant information about the patient, including a history of current problems, past medical problems, family history, medications, and allergies. This will help you determine what type of care the patient needs.

2. Focused Assessment

In this step, you will focus on the current problem or complaint that brought the patient into the hospital or clinic. You need to include details about their current condition such as vital signs (temperature, pulse rate, respiration rate), pain level on a scale from 1-10 (1 being low pain), and other symptoms like nausea/vomiting or coughing up blood, etc. This assessment helps you determine what type of care they need at this moment in time (e.g., IV fluids). Also assess if there are any immediate dangers such as choking hazards (e.g., food lodged in the throat), the risk of falling downstairs, etc.

3. Analyze the patient’s information

The nurse should look at all available data about the patient, including medical history, physical examination results, laboratory findings, and diagnostic studies (e.g., x-rays).

4. Comment on your sources of information

A nurse needs to state where he/she obtained his/her information from so that other healthcare professionals will know where they can find it if needed. For example, if there is a chart or record that has been used to complete an assessment report, there should be some indication of its source such as “per medical record” or “per chart review.”

5. Decide on the patient’s issues

Once all relevant information has been collected and reviewed, it is time for you to decide what issues need addressing first among those given by your hospital or institution guidelines or policies; this may include prioritizing your concerns.

What is a Nursing Assessment?

A Nursing Assessment is the first step in the nursing process where a nurse collects comprehensive information about a patient’s physical, psychological, sociological, and spiritual health to identify their healthcare needs.

Why is a Nursing Assessment important?

It is crucial for planning effective nursing care, setting goals for treatment, evaluating the progress of the condition, and ensuring the safety and comfort of the patient.

How often should Nursing Assessments be conducted?

The frequency of assessments can vary based on the patient’s condition, healthcare setting, and specific requirements of the situation. It can range from every few hours to once per shift or daily.

What is the difference between a Nursing Assessment and a Medical Assessment?

While both are vital, a Medical Assessment focuses on diagnosing and treating medical conditions, whereas a Nursing Assessment focuses on a patient’s overall wellness, comfort, and ability to care for themselves.

What skills are required for conducting a Nursing Assessment?

Essential skills include excellent communication, observation, critical thinking, problem-solving, and a thorough understanding of anatomy, physiology, and the standards of nursing practice.

Can patients refuse a Nursing Assessment?

Yes, patients have the right to refuse treatment; however, they should be informed about the potential risks and benefits of refusing the assessment.

How should findings from a Nursing Assessment be documented?

Findings should be documented accurately, clearly, and promptly in the patient’s medical record following the healthcare facility’s documentation guidelines.

Can family members provide information for a Nursing Assessment?

Yes, family members can provide valuable information, especially if the patient is unable to communicate effectively. However, it’s essential to verify the information when possible.

Are there specialized Nursing Assessments?

Yes, there are specialized assessments for different areas of care such as mental health, pediatric, geriatric, and cardiovascular assessments among others.

What are the main components of a Nursing Assessment?

• The main components include:
• Patient history
• Physical examination
• Psychological and social examination
• Review of systems
• Vital signs
• Medication review.

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• Nursing Assessment

Nursing Assessment Templates

When it comes to providing the best possible care for patients, nursing assessment plays a crucial role. A nursing assessment is a vital document that captures all the necessary information about a patient's health condition, allowing healthcare professionals to develop a personalized plan of care. Also known as nurse assessment, nursing assessment template, nursing assessment form, or nursing assessment document, this collection of documents ensures that all relevant data is captured accurately and efficiently.

These documents are designed to address the specific needs of different healthcare settings and jurisdictions. For instance, the Form 8584-CDS Comprehensive Nursing Assessment and Plan of Care - Hcs Program - Texas caters to the unique requirements of the Home and Community-based Services program in Texas. Similarly, the Form ODM02376 Private Duty Nursing (Pdn) Assessment - Ohio and Private Duty Nursing Acuity Grid - Utah offer comprehensive assessment tools for private duty nursing services in Ohio and Utah, respectively.

Other examples include the Form 8584 Comprehensive Nursing Assessment - Texas, which provides a comprehensive evaluation of a patient's health status , and the Form CVH-171 Connecticut Valley Hospital Admission Nursing Assessment - Connecticut, focusing on the admission process for patients in Connecticut Valley Hospital.

These nursing assessment documents are invaluable resources for healthcare professionals. They streamline the data collection process and ensure that no critical information is overlooked. By utilizing these documents, healthcare providers can enhance patient safety , improve treatment outcomes, and deliver optimal care.

• Form number

Nurse Report Sheet Template

This document is a template that enables nurses to organize and record important information during their shift. It helps to ensure that all necessary patient details, medications, treatments, and vital signs are accurately documented.

2 Patient Nursing Report Form - Nursing Brains

This Form is used for reporting patient information in a nursing setting. It helps nurses organize and document important details about the patients they are caring for.

2 Patient Medical Analysis Assessment Form - Nursing Brains

This document is a form used for assessing and analyzing the medical condition of patients. It is commonly used in nursing practice to gather important information and assess the patient's needs.

Braden-Scale Chart - Igap

This document is a Braden Scale Chart used for assessing a patient's risk for developing pressure ulcers. It helps healthcare professionals determine the appropriate preventative measures and interventions needed to prevent skin breakdown.

Nursing Report Sheet Template

A Nursing Report Sheet is a document that should be completed by medical professionals to provide details for nursing their patients.

DA Form 3888 Medical Record - Nursing History and Assessment

This Form is used for documenting the nursing history and assessment in a patient's medical record.

DA Form 5441-57 Evaluation of Clinical Privileges - Psychiatric Advanced Practice Nurse

Form dcf-2270 congregate care quarterly nursing assessment - connecticut.

This form is used for conducting quarterly nursing assessments in congregate care facilities in Connecticut.

Form NDP20O Risk for Impaired Skin Integrity - Alabama

This document is used to assess the risk for impaired skin integrity in the state of Alabama. It helps healthcare professionals identify individuals who may be at risk for developing skin problems and implement appropriate preventive measures.

School Licensed Practical Nurse Performance Evaluation - New Mexico

This form is used for evaluating the performance of Licensed Practical Nurses (LPNs) in schools in the state of New Mexico. It provides a standardized assessment of their performance and helps in determining their effectiveness in providing healthcare services to students.

DSHS Form 13-784 Nursing Services Assessment - Washington

This form is used for assessing nursing services in Washington state. It helps gather information about the level of care needed and the services provided to individuals.

Form FA-19 Level of Care Assessment for Nursing Facilities - Nevada

This form is used for assessing the level of care needed for nursing home facilities in Nevada.

Form 6515 Community Living Assistance and Support Services (Class)/Deaf Blind With Blind With Multiple Disabilities (Dbmd) Nursing Assessment - Texas

This Form is used for nursing assessments related to the Community Living Assistance and Support Services (CLASS) and Deaf Blind with Blind with Multiple Disabilities (DBMD) programs in Texas.

Form 8584-CDS Comprehensive Nursing Assessment and Plan of Care - Hcs Program - Texas

This form is used for comprehensive nursing assessment and plan of care for the HCS Program in Texas. It helps in evaluating and developing care plans for individuals requiring nursing services.

DSHS Form 10-339 Nursing Care Consultant Assessment - Washington

Form 3091 comprehensive nursing assessment - texas.

This form is used for a comprehensive nursing assessment in Texas. It gathers detailed information about a patient's health, medical history, and care needs to create an effective care plan.

Form 8584 Comprehensive Nursing Assessment - Texas

Private duty nursing acuity grid - utah, form odm02376 private duty nursing (pdn) assessment - ohio.

This form is used for assessing the private duty nursing (PDN) services in the state of Ohio. It helps in determining the needs and eligibility of individuals for PDN care.

Form ODM02373 Private Duty Nursing (Pdn) Assessment Outcome - Ohio

This form is used for assessing the outcome of private duty nursing (PDN) services in Ohio.

Aspiration Risk Management: Nursing Collaborative Assessment Tool - New Mexico

This document is a tool used for collaborative assessment of nursing risks in New Mexico. It helps healthcare professionals identify and manage potential risks to patient safety in the nursing field.

Form DOC13-557 Close Observation Nursing Assessment - Washington

This form is used for close observation nursing assessment in the state of Washington. It helps healthcare providers assess and monitor patients who require close observation for their medical condition.

Assessment for Topical Medication Administration - Wisconsin

This Form is used for assessing the administration of topical medications in Wisconsin.

Form SFN692 Money Follows the Person (Mfp) Nursing Assessment Billing Worksheet - North Dakota

This form is used for billing and assessment purposes in the Money Follows the Person (MFP) program for nursing services in North Dakota.

Form SFN704 Authorization to Provide Money Follows the Person Nursing Assessment - North Dakota

This form is used for authorizing the provision of a nursing assessment in the context of the Money Follows the Person program in North Dakota.

Form NDP-8 Mas Rn Assessment - Alabama

This Form is used for conducting a Mas Rn Assessment in the state of Alabama.

Form CVH-171 Connecticut Valley Hospital Admission Nursing Assessment - Connecticut

This document is utilized for the intake process at Connecticut Valley Hospital, allowing medical professionals to assess a new patient's nursing needs upon admission. It encompasses a wide range of health factors crucial to designing an effective care plan.

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Head-to-Toe Assessment: Complete Physical Assessment Guide

Assessment is the first and most critical phase of the nursing process . Incorrect nursing judgment arises from inadequate data collection and may adversely affect the remaining phases of the nursing process : diagnosis, planning, implementation , and evaluation . Get the complete picture of your patient’s health with this comprehensive head-to-toe physical assessment guide.

Table of Contents

What is head-to-toe assessment, 1. general appearance/survey, 2. chief complaint, 3. health history, 4. assessment of the integument, 5. assessment of the head and neck, 6. assessment of the eye and vision, 7. assessment of the ear, 8. assessment of the mouth, throat, nose, sinus, 9. assessment of the thoracic and lung, 10. assessment of the breast and lymphatic system, 11. assessment of the heart and neck vessels, 12. assessment of the peripheral vascular system, 13. assessment of the abdomen, 14. assessment of the female genitalia, 15. assessment of the male genitalia, 16. assessment of the anus, rectum, prostate, 17. assessment of the musculoskeletal system, 18. assessment of the neurologic system.

A head-to-toe assessment is a comprehensive physical assessment data collection method to gather patient data and determine the patient’s health status. It involves examining the entire body from head to toe in a systematic and thorough manner to identify health issues the patient may be experiencing.

At the end of the head-to-toe assessment, the nurse or healthcare provider should have gathered information that can help the patient’s treatment plan and have a clear understanding of the patient’s overall physical health and any potential issues that may need to be addressed.

For more information about assessment, please visit: The Nursing Process: A Comprehensive Guide .

Assessment Techniques

To make your head-to-toe assessment systematic, you need to know about the four basic assessment techniques. These techniques are inspection, palpation, percussion, and auscultation.

• Inspection involves using the senses of vision, smell , and hearing to observe and detect any normal or abnormal findings.
• Palpation consists of using parts of the hand to touch and feel for the following characteristics: texture, temperature, moisture, mobility , consistency, the strength of pulses, size, shape, and degree of tenderness.
• Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.
• Auscultation involves the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system , movement of the bowel , and movement of air through the respiratory tract.

Using COLDSPA mnemonic

The COLDSPA mnemonic is a useful memory aid for exploring each symptom of health concern.

History of Present Health Concerns

This section takes into account several aspects of the health problem and asks questions whose answers can provide a detailed description of the concern.

Past Health History

These are questions to elicit data related to the client’s past, strengths, and weaknesses in their health history.

Family Health History

• The family history should include as many generic relatives as the client can recall; in addition to genetic predisposition, it is also helpful to see other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems.

Lifestyle and Health Practices

These questions are used to assess how the clients are managing their lives, their awareness of health, and unhealthy living patterns. These are usually open-ended questions to promote dialogue with the client.

Physical Assessment Guide

This section is where we’ll start the head-to-toe assessment. We’ll start with the general survey and identify the patient’s chief complaint, then the assessment of each body system.

NOTE: Remember to use the COLDSPA mnemonic (Character, Onset, Location, Duration, Severity, Patterns, and Associated Factors) to investigate and collect information for each symptom the client shares.

The general appearance or general survey is the first step in a head-to-toe assessment. The information gathered during the general survey provides clues about the overall health of the client. The general survey includes the overall impression of the client, mental status exam, and vital signs.

The chief complaint is the main reason why a client is seeking medical attention. It is the symptom or problem that is most concerning to the patient and is the focus of their visit. It is typically the first thing the healthcare provider asks about when seeing a patient, as it helps to provide context and background for the rest of the assessment and treatment.

The health history is an excellent way to begin the assessment process because it lays the groundwork for identifying nursing problems and provides a focus for the physical examination. The importance of health history lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual’s lifestyle and current health status.

The skin, hair , and nails are external structures that serve a variety of specialized functions. Diseases and disorders of the skin, hair, and nails can be local or they may be caused by an underlying systemic problem. To perform a complete and accurate assessment, the nurse needs to collect data about current symptoms, the client’s past and family history, and lifestyle and health practices.

History of present health concern

• Are you experiencing any current skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising, swelling , or increased pigmentation? What aggravates the problem? What relieves it?
• Describe any birthmarks, tattoos, or moles, changes in their color, size, or shape.
• Have you noticed any change in your ability to feel pain , pressure, light touch, or temperature changes? Are you experiencing any pain , itching, tingling, or numbness?

Hair and Nails

• Have you had any hair loss or change in the condition of your hair? Describe.
• Have you had any change in the condition or appearance of your nails ? Describe.

Past health history

• Describe any previous problems with skin, hair, or nails, including any treatment or surgery and its effectiveness.
• Have you ever had any allergic skin reactions to food, medications, plants, or other environmental substances?
• Have you had a fever , nausea, vomiting , GI, or respiratory problems?
• For female clients: Are you pregnant? Are your menstrual periods regular?

Family history

• Has anyone in your family had a recent illness, rash, other skin problems, or allergy ? Describe.
• Has anyone in your family had skin cancer ?

Lifestyle and health practices

• Do you sunbathe? How much sun or tanning booth exposure do you get? What type of sun protection do you use?
• In your daily activities, are you regularly exposed to chemicals that may harm the skin?
• Do you spend long periods of time sitting or lying in one position?
• Have you had any exposure to extreme temperatures?
• What are your daily routine for skin, hair, and nail care?
• What kinds of foods do you consume in a typical day? How much fluid do you drink each day?
• Do skin problems limit any of your normal activities?
• Describe any skin disorder that prevents you from enjoying your relationships.
• How much stress do you have in your life? Describe.
• Do you perform a skin self-examination once a month?

Skin Physical Assessment

Physical assessment of the skin, hair, and nails provides the nurse with data that may reveal local or systemic problems.

Inspection of the skin

• Inspect general skin coloration. Keep in mind that the amount of pigment in the skin accounts for the intensity of color as well as hue.
• Inspect for color variations. Inspect localized parts of the body, noting any color variation.
• Check skin integrity . Especially carefully in pressure point areas (e.g. sacrum, hips, elbows); if any skin breakdown is noted use a scale to document the degree of skin breakdown.
• Inspect for lesions. Observe the skin surface to detect abnormalities; note color, shape, and size of lesion; if you suspect a fungus, shine a Wood’s light (an ultraviolet light filtered through a special glass) on the lesion.

Palpation of the skin

• Palpate skin to assess texture. Use the palmar surface of the three middle fingers to palpate skin texture.
• Palpate to assess thickness. If lesions are noted when assessing skin thickness, put gloves on and palpate the lesions between the thumb and finger; observe the drainage or other characteristics.
• Palpate to assess moisture. Check under skin folds and in unexposed areas.
• Palpate to assess temperature. Use the dorsal surfaces of the hands to palpate the skin.
• Palpate to assess mobility and turgor. Ask the client to lie down; using two fingers, gently pinch the skin on the sternum or under the clavicle.
• Palpate to detect edema . Use your thumbs to press down on the skin or the feet or ankles to check for edema .

Inspection and Palpation of the hair

• Inspect the scalp and hair. Have the client remove any hair clips, hair pins, or wigs, then inspect the scalp and hair for general color and condition.
• Inspect and palpate for cleanliness, dryness or oiliness, parasites, and lesions. At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness, or oiliness, parasites, and lesions; wear gloves if lesions are suspected or if hygiene is poor.
• Inspect the amount and distribution of scalp, body, axillae, and pubic hair. Look for unusual growth elsewhere in the body.

Inspection of the nails

• Inspect nail grooming and cleanliness. Normal findings would be the nails should be clean and manicured.
• Inspect nail color markings. Normal findings should be pink tones should be seen; some longitudinal ridging is normal.
• Inspect shape of nails. There is normally a 160-degree angle between the nail base and the skin.

Palpation of the nails

• Palpate nail to assess texture. Nails are hard and basically immobile.
• Palpate to assess texture and consistency. Note whether the nail plate is attached to the nailbed.
• Test capillary refill. Test capillary refill in nailbeds by pressing the nail tip briefly and watching for color change.

Head and neck assessment focuses on the cranium , face, thyroid gland, and lymph node structures contained within the head and neck.

• Do you experience neck pain ?
• Do you experience headaches? Describe.
• Do you have any facial pain? Describe.
• Do you have any difficulty moving your head or neck?
• Have you noticed any lumps or lesions on your head or neck that do not heal or disappear? Describe their appearance and location.
• Have you experienced any dizziness, lightheadedness, spinning sensation, or loss of consciousness? Describe.
• Have you noticed a change in the texture of your skin, hair, or nails?
• Have you noticed changes in your energy level, sleep habits, or emotional stability?
• Have you experienced any palpitations, blurred vision, or changes in bowel habits?
• This portion of the health history focuses on questions related to the client’s past, from the earliest beginnings to the present.
• Describe any previous head or neck problems you have had. How were they treated? What were the results?
• Have you ever undergone radiation therapy for a problem in your neck region?
• Is there a history of head and neck cancer in your family?
• Is there a history of migraine headaches in your family?

This is a very important section of the health history because it deals with the client’s human responses.

• Do you smoke or chew tobacco? If yes, how much?
• Do you wear a helmet when riding a horse, bicycle, motorcycle, or other open sports vehicle? Do you wear a hard hat for hazardous occupations?
• What is your typical posture when relaxing, during sleep , and when working?
• In what kinds of recreational activities do you participate? Describe the activity.
• Have any problems with your head or neck interfered with your relationships with others or the role you occupy at home or at work?

Head and Face

• Inspect the head. Inspect for size, shape, and configuration.
• Inspect for involuntary movement. Head should be held still and upright.
• Inspect the face. Inspect for symmetry, features, movement, expression, and skin condition.
• Palpate the head. Palpate for consistency; the head is normally hard and smooth without lesions.
• Palpate the temporal artery. This should be located between the top of the ear and the eye.
• Palpate the temporomandibular joint. To assess the temporomandibular joint, place your index finger over the front of each ear as you ask the client to open your mouth .
• Inspect the neck. Observe the client’s slightly extended neck for position, symmetry, and lumps or masses. Shine a light from the side of the neck across to highlight any swelling.
• Inspect the movement of the neck structures. Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage and thyroid gland.
• Inspect the cervical vertebrae. Ask the client to flex the neck (chin to chest, ear to shoulder, twist left to right and right to left, and backward and forward.
• Inspect range of motion. Ask the client to turn the head to the right and to the left (chin to shoulder), touch each ear to the shoulder, touch chin to chest, and lift the chin to the ceiling.
• Palpate the trachea . Place your finger in the sternal notch. Feel each side of the notch and palpate the tracheal rings. The first upper ring above the smooth tracheal rings is the cricoid cartilage.
• Palpate the thyroid gland. Locate key landmarks with your index finger and thumb; ask the client to swallow as you palpate

Auscultation

• Auscultate the thyroid gland only if you find an enlarged thyroid gland during inspection or palpation. Place the bell of the stethoscope over the lateral lobes of the thyroid gland; ask the client to hold his breath (to obscure any tracheal breath sounds while you auscultate).

Lymph nodes of the head and neck

• Palpate the preauricular nodes, postauricular nodes, occipital nodes. There should be no swelling or enlargement and no tenderness.
• Palpate the tonsillar nodes. Palpate the tonsillar nodes at the angle of the mandible on the anterior edge of the sternomastoid muscle .
• Palpate the submental nodes , which are a few centimeters behind the tip of the mandible.
• Palpate the superficial cervical nodes in the area superficial to the sternomastoid muscle.
• Palpate the posterior cervical nodes in the area posterior to the sternomastoid and anterior to the trapezius in the posterior triangle.
• Palpate the deep cervical chain nodes deeply within and around the sternomastoid muscle.
• Palpate the supraclavicular nodes by hooking your fingers over the clavicles and feeling deeply between the clavicles and sternomastoid muscles.

To perform a thorough assessment of the eye, one needs a good understanding of the external structures of the eye, the internal structures of the eye, the visual fields and pathways, and the visual reflexes.

When interviewing a client about eye health and vision, remember to investigate and analyze any reported symptoms or signs further.

Visual Problems

• Describe any recent changes in your vision. Were they sudden or gradual?
• Do you see spots or floaters in front of your eyes?
• Do you experience blind spots? Are they constant or intermittent?
• Do you see halos or rings around lights?
• Do you have trouble seeing at night?
• Do you experience double vision?
• Do you have any eye pain or itching? Describe.
• Do you have any redness or swelling in your eyes?
• Do you experience excessive watering or tearing of the eye? One eye or both eyes?
• Have you had any eye discharge? Describe.
• Have you ever had problems with your eyes or vision?
• Have you ever had eye surgery?
• Describe any past treatments you have received for eye problems. Were these successful? Were you satisfied?
• Is there a history of eye problems or vision loss in your family?
• Are you exposed to conditions or substances in the workplace or home that may harm your eyes or vision? Do you wear safety glasses during exposure to harmful substances?
• Do you wear sunglasses during exposure to the sun?
• What types of medication do you take?
• Has your vision loss affected your ability to care for yourself? To work?
• When was your last eye examination?
• Do you have a prescription for corrective lenses? Do you wear them regularly? If you wear contacts, how long do you wear them? How do you clean them?

Evaluation of Vision

• Test distant visual acuity. Position the client 20 feet from the Snellen or E chart and ask her to read each line until she cannot decipher the letters or their direction.
• Test near visual acuity. Use this test for middle-aged clients and others who complain of difficulty reading. Give the client a hand-held vision chart to hold 14 inches from the eyes. Have the client cover one eye with an opaque card before reading from top to bottom.
• Test visual fields for gross peripheral vision. To perform the confrontation test, position yourself approximately 2 feet away from the client at eye level. Have the client cover his left eye while you cover your right eye. Look directly at each other with your uncovered eyes. Next fully extend your left arm at midline and slowly move one finger upward from below until the client sees your finger.

External eye structures

Inspection and Palpation

• Inspect the eyelids and eyelashes. Note the width and position of palpebral fissures. Assess the ability of eyelids to close. Note the position of the eyelids in comparison with the eyeballs. Observe for redness, swelling, discharge, or lesions.
• Observe the position and alignment of the eyeball in the eye socket. Eyeballs are symmetrically aligned in sockets without protruding or sinking.
• Inspect the bulbar conjunctiva and sclera . Have the client keep her head straight while looking from side to side and then up toward the ceiling. Observe clarity, color, and texture.
• Inspect the palpebral conjunctiva. Put on gloves for this assessment procedure. First, inspect the palpebral conjunctiva of the lower eyelid by placing your thumbs bilaterally at the level of the lower bony orbital rim and gently pulling down to expose the palpebral conjunctiva.
• Inspect the lacrimal apparatus . Assess the areas over the lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid).
• Inspect the cornea and lens. Shine a light from the side of the eye for an oblique view. Look through the pupil to inspect the lens.
• Test pupillary reaction to light. Test for direct response by darkening the room and asking the client to focus on a distant object.
• Test accommodation of pupils. Hold your finger or a pencil about 12 to 15 inches from the client. Ask the client to focus on your finger or pencil and to remain focused on it as you move it closer toward the eyes.
• Palpate the lacrimal apparatus. Put on disposable gloves to palpate the nasolacrimal duct to assess for blockage. Use one finger and palpate just inside the lower orbital rim.

Internal eye structures

• Inspect the optic disc. Keep the light beam focused on the pupil and move closer to the client from a 15-degree angle. You should be very close to the client’s eye (about 3 to 5 cm), almost touching the eyelashes. Note the shape, color, size, and physiologic cup.
• Inspect the retinal vessels. Remain in the same position as described previously. Inspect the sets of retinal vessels by following them out to the periphery of each section of the eye. Note the number of sets of arterioles and venules.
• Inspect retinal background. Remain in the same position described previously and search the retinal background from the disc to the macula, noting the color and the presence of any lesions.
• Inspect the fovea (sharpest area of vision) and macula. Remain in the same position described previously. Shine the light beam toward the side of the eye or ask the client to look directly into the light. Observe the fovea and the macula that surrounds it.
• Inspect the anterior chamber. Remain in the same position and rotate the lens wheel slowly to +10, +12, or higher to inspect the anterior chamber of the eye.

Beginning when the nurse first meets the client, the assessment of hearing provides important information about the client’s ability to interact with the environment.

• If the client complains of or reports a history of ear infections or suspects hearing loss, collect as much related data as possible.

Changes in Hearing

• Describe any recent changes in your hearing.
• Are all sounds affected by this change, or just some sounds?

Other Symptoms

• Do you have any ear drainage? Describe the amount and any odor.
• Do you have any ear pain? If so, do you have an accompanying sore throat , sinus infection , or problem with your teeth or gums?
• Do you experience any ringing or crackling in your ears?
• Do you ever feel like you are spinning or that the room is spinning? Do you ever feel dizzy or unbalanced?
• Have you ever had any problems with your ears such as infections, trauma, or earaches?
• Describe any past treatments you have received for ear problems. Were these successful? Were you satisfied?
• Is there a history of hearing loss in your family?
• Do you work or live in an area with frequent or continuous loud noise? How do you protect your ears from the noise?
• Do you spend a lot of time swimming or in the water? How do you protect your ears?
• Has your hearing loss affected your ability to care for yourself? To work?
• Has your hearing loss affected your socializing with others?
• When was your last hearing examination?
• How do you care for your ears?

External ear structures

• Inspect the auricle , tragus, and lobule. Note size, shape, and position. Observe for lesions. discolorations, and discharge.
• Palpate the auricle and mastoid process. Normally the auricle, tragus, and mastoid process are not tender.

Internal ear structures

• Inspect the external auditory canal. Use the otoscope. A small amount of odorless cerumen is the only discharge normally present.
• Inspect the tympanic membrane (eardrum). Note color, shape, consistency, and landmarks.
• Perform Weber’s test if the client reports diminished or lost hearing in one ear. Strike a tuning fork softly with the back of your hand and place it in the center of the client’s head or forehead. Ask whether the client hears the sound better in one ear or the same in both ears.
• Perform the Rinne test. The Rinne test compares air and bone conduction. Strike a tuning fork and place the base of the fork on the client’s mastoid process. Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the sound is audible after the fork is moved.
• Perform the Romberg test. Ask the client to stand with feet together and arms at the sides and eyes open and then with eyes closed.

Subjective data related to the mouth, throat, nose, and sinus can aid in detecting diseases and abnormalities that may affect the client’s activities of daily living .

Tongue and Mouth

• Do you experience tongue or mouth sores or lesions? Are they painful? How long have you had them? Do they recur? Is it single, or do you have many?
• Do you experience redness, swelling, bleeding , or pain in the gums or mouth? How long has this been happening? Do you have any toothache? Have you lost any permanent teeth?

Nose and Sinuses

• Do you have pain in your sinuses?
• Do you experience any nosebleeds? How much bleeding ? What color is the blood?
• Do you experience frequent clear or mucous drainage from your nose?
• Can you breathe through both of your nostrils? Do you have a stuffy nose at times during the day or night?
• Do you have seasonal allergies? Describe the timing of the allergies and symptoms.
• Have you experienced a change in your ability to smell or taste?
• Do you have difficulty chewing or swallowing food? How long have you had this? Do you have any pain?
• Do you have a sore throat? How long have you had it? Describe. How often do you get sore throats?
• Do you experience hoarseness ? How long?
• Have you ever had any oral, nasal, or sinus surgery? Do you have a history of sinus infections? Describe your symptoms. Do you use nasal sprays?
• Is there a history of mouth, throat, nose, or sinus cancer in your family?
• Do you smoke or use smokeless tobacco? If so, how much? Are you interested in quitting this habit?
• Do you drink alcohol? How much and how often?
• Do you grind your teeth?
• Describe how you care for your teeth or dentures. How often do you brush and use dental floss? When was your last dental examination?
• If the client wears braces: How do you care for your braces? Do you avoid any specific types of foods? Describe your usual dietary intake for a day.
• If the client wears dentures: How do your dentures fit?
• Do you brush your tongue?
• How often are you in the sun? Do you use lip sunscreen products?
• Inspect the lips. Observe lip consistency and color.
• Inspect the teeth and gums. Ask the client to open their mouth. Note the number, color, condition, and alignment of the teeth.
• Inspect the buccal mucosa. Use a penlight and tongue depressor to retract the lips and cheeks to check color and consistency. Also, note Stenson’s ducts (parotid ducts) located on the buccal mucosa across from the second upper molars.
• Inspect and palpate the tongue. Ask the client to stick out the tongue. Inspect for color, moisture, size, and texture. Observe for fasciculations (fine tremors), and check for midline protrusions. Palpate any lesions present for induration.
• Assess the ventral surface of the tongue. Ask the client to touch the tongue to the roof of the mouth, and use a penlight to inspect the ventral surface of the tongue.
• Inspect for Wharton’s ducts. These are openings from the submandibular salivary glands located on either side of the frenulum on the floor of the mouth.
• Observe the sides of the tongue. Use a square gauze pad to hold the client’s tongue to each side. Palpate for any lesions, ulcers, or nodules for induration.
• Check the strength of the tongue. Place your fingers on the external surface of the client’s cheek. Ask the client to press the tongue’s tip against the inside of the cheek to resist pressure from your fingers.
• Check the anterior tongue’s ability to taste by placing drops of sugar and salty water on the tip and sides of the tongue with a tongue depressor.
• Inspect the hard (anterior) and soft (posterior) palates and uvula. Ask the client to open the mouth wide while you use a penlight to look at the roof. Observe color and integrity.
• Note odor . While the mouth is wide open, note any unusual or foul odor.
• Assess the uvula. Apply a tongue depressor to the tongue and shine a penlight into the client’s wide-open mouth. Note the characteristics and positioning of the uvula. Ask the client to say “Aaah” and watch for the uvula and soft palate to move.
• Inspect the tonsils . Using the tongue depressor to keep the mouth open wide, Inspect the tonsils for color, size, and presence of exudate or lesions. Tonsils should be graded.
• Inspect the posterior pharyngeal wall. Keeping the tongue depressor in place, shine the penlight on the back of the throat. Observe the color of the throat, and note any exudate or lesions.
• Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness.
• Check the patency of airflow through the nostrils by occluding one nostril at a time and asking the client to sniff.
• Inspect the internal nose. To inspect the internal nose, use an otoscope with a short wide-tip attachment. Use your non-dominant hand to stabilize and gently tilt the client’s head back. Insert the short wide tip of the otoscope into the client’s nostril without touching the sensitive nasal septum.
• Palpate the sinuses. Palpate the frontal sinuses by using your thumbs to press up on the brow on each side of the nose. Palpate the maxillary sinuses by pressing with thumbs up on the maxillary sinuses.
• Percuss the sinuses. Lightly tap over the frontal sinuses and over the maxillary sinuses for tenderness.

Transillumination

• Transilluminate the sinuses . Transilluminate the frontal sinuses by holding a strong, narrow light source snugly under the eyebrows. Use your other hand to shield the light. Transilluminate the maxillary sinuses by holding a strong, narrow light source over the maxillary sinus and asking the client to open his or her mouth.

Subjective data related to the thoracic and lung assessment provide many clues about underlying respiratory problems and associated nursing diagnoses , as well as clues about the risk for the development of lung disorders.

Difficulty of breathing

• Do you ever experience difficulty breathing? Describe the difficulty.
• Do you experience any other symptoms when you have difficulty breathing?
• Do you have difficulty breathing when resting, or do any specific activities cause the difficulty?
• Do you have difficulty breathing when you sleep ? Do you use more than one pillow or elevate the head of the bed when you sleep ?
• Do you snore when you sleep ? Have you been told that you stop breathing at night when you snore?
• Do you have chest pain ? Is the pain associated with a cold, fever, or deep breathing ?
• Do you have a cough? When and how often does it occur?
• Do you produce any sputum when you cough? If so, what color is the sputum? How much sputum do you cough up? Has this amount increased or decreased recently? Does the sputum have an odor?
• Do you wheeze when you cough or when you are active?

GI symptoms

• Do you have gastrointestinal symptoms such as heartburn, frequent hiccups, or chronic cough?
• Have you had prior respiratory problems?
• Have you ever had any thoracic surgery, biopsy , or trauma?
• Have you been tested for or diagnosed with allergies?
• Have you ever had a chest x-ray, tuberculosis (TB) skin test, or influenza immunization? Have you had any other pulmonary studies in the past?
• Have you recently traveled outside of the country? Have you been in close contact with anyone known or suspected to have SARS ?
• Is there a history of lung disease in your family?
• Did any family members in your home smoke when you were growing up?
• Is there a history of other pulmonary illnesses/disorders in the family?
• Have you ever smoked cigarettes or other tobacco products? Do you currently smoke? At what age did you start? How much do you smoke, and how much have you smoked in the past? What activities do you usually associate with smoking? Have you ever tried to quit?
• Are you exposed to any environmental conditions that affect your breathing? Where do you work? Are you around smokers?
• Do you have difficulty performing your usual daily activities? Describe any difficulties.
• What kind of stress are you experiencing at this time? How does it affect your breathing?
• Are you currently taking medications for breathing problems or other medications that affect your breathing? Do you use any other treatments at home for your respiratory problems?
• Have you used any herbal medicines or alternative therapies to manage colds or other respiratory problems?

Posterior thorax

• Inspect for nasal flaring and pursed lip breathing. Nasal flaring is not observed in normal findings.
• Observe the color of the face, lips, and chest. The client has an evenly colored skin tone without unusual or prominent discoloration.
• Inspect the color and shape of the nails. Pink tones should be seen in the nailbeds. There is normally a 160-degree angle between the nail base and the skin.
• Inspect configuration. While the client sits with her arms at her sides, stand behind her and observe the position of the scapulae and the shape and configuration of the chest wall.
• Observe the use of accessory muscles. Watch as the client breathes and does not use it.
• Inspect the client’s positioning. Note the client’s posture and ability to support weight while breathing comfortably.
• Palpate for tenderness and sensation. Palpation may be performed with one or both hands; however, the sequence of palpation is established. Start toward the midline at the level of the left scapula and move your hand from left to right, comparing findings bilaterally. Move systematically downward and out to cover the lateral portions of the lungs at the bases.
• Palpate for crepitus. Crepitus, also called subcutaneous emphysema , is a crackling sensation that occurs when air passes through fluid or exudate. Use your fingers and follow the above sequence when palpating.
• Palpate surface characteristics. Use gloves and your fingers to palpate any lesions you noticed during the inspection.
• Palpate for fremitus. Following the above sequence, use the ball or ulnar edge of one hand to assess for fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall.
• Assess chest expansion. Place your hands on the posterior chest wall with your thumbs at the level of T9 or T10 and press together a small skin fold.
• Percuss for tone. Start at the apices of the scapulae and percuss across the tops of both shoulders. Then percuss the intercostal spaces across and down, comparing sides. Percuss the lateral aspects at the bases of the lungs, comparing sides.
• Percuss for diaphragmatic excursion. Ask the client to exhale forcefully and hold their breath. Beginning at the scapular line, percuss the intercostal spaces of the right posterior chest wall. Percuss downward until the tone changes from resonance to dullness. Next, ask the client to inhale deeply and hold it. Percuss the intercostal spaces from the mark downward until resonance changes to dullness.
• Auscultate for breath sounds. To begin, place the diaphragm of the stethoscope firmly and directly on the posterior chest wall at the apex of the lung at C7. Ask the client to breathe deeply through his or her mouth for each area of auscultation in the auscultation sequence so you can best hear inspiratory and expiratory sounds.
• Auscultate for adventitious sounds. Adventitious sounds are sounds added or superimposed over normal breath sounds and heard during auscultation.
• Auscultate voice sounds. Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall.

Other Assessment Techniques

• Egophony: Ask the client to repeat the letter E while you listen over the chest wall.
• Whispered Pectoriloquy: Ask the client to whisper the phrase “one-two-three” while you auscultate the chest wall.

Anterior thorax

• Inspect for shape and configuration. Have the client sit with her arms at her sides. Stand in front of the client and assess shape and configuration.
• Inspect the position of the sternum. Observe the sternum from an anterior and lateral viewpoint. Watch for sternal retraction.
• Inspect the slope of the ribs. Assess the ribs from an anterior and lateral viewpoint.
• Observe the quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth.
• Inspect intercostal spaces. Ask the client to breathe normally and observe the intercostal spaces.
• Observe for use of accessory muscles. Ask the client to breathe normally and observe for use of accessory muscles.
• Palpate for tenderness, sensation, and surface masses. Use your fingers to palpate for tenderness and sensation. Start with your hand positioned over the left clavicle and move your hand left to right, comparing findings bilaterally. Move your hand systematically downward toward the midline at the level of the breasts and outward at the base to include the lateral aspect of the lung.
• Palpate for fremitus. Using the sequence for the anterior chest above, palpate for fremitus using the same technique as for the posterior thorax.
• Palpate anterior chest expansion. Place your hands on the client’s anterolateral wall with your thumbs along the costal margins and pointing toward the xiphoid process.
• Percuss for tone. Percuss the apices above the clavicles. Then percuss the intercostal spaces across and down, comparing sides.
• Auscultate for anterior breath sounds, adventitious breath sounds, and voice sounds. Place the diaphragm of the stethoscope firmly and directly on the anterior chest wall. Auscultate from the apices of the lungs slightly above the clavicles to the bases of the lungs at the sixth rib. Listen at each site for at least one respiratory cycle. Follow the sequence for anterior auscultation.

This chapter covers the examination of non-pregnant women’s breasts. Remember, if the client reports any symptoms, you need to explore further by performing a symptom analysis using the following guide.

• Have you noticed any lumps or swelling in your breasts? If so, where? when did you first notice? has the lump grown or has the swelling increased? Is the lump or swelling associated with other problems? Does the lump or swelling change during your menstrual cycle ?
• Have you noticed any lumps or swelling in the underarm area?
• Have you noticed any redness, warmth, or dimpling of your breasts? Any rash on the breast, nipple, or axillary area?
• Have you noticed any change in the size or firmness of your breasts?
• Do you experience any pain in your breasts? If so, where? Does it occur at any specific time during your menstrual cycle?
• is there a certain activity that seems to initiate the pain?
• Do you have any discharge from the nipples? If so, describe its color, consistency, and odor, if any. When did it start? Which nipple has the discharge?
• Have you had any prior breast disease? Have you ever had breast surgery, a breast biopsy, breast implants, or breast trauma? If so, when did this occur? What was the result?
• How old were you when you began to menstruate? Have you experienced menopause ?
• Have you given birth to any children? At what age did you have your first child?
• When was the first and last day of your menstrual cycle?
• Is there a history of breast cancer in your family? Who?
• Are you taking any hormones, contraceptives, or antipsychotic agents?
• Do you live or work in an area where you have excessive exposure to radiation, benzene, or asbestos?
• What is your typical daily diet?
• How much alcohol do you drink each day?
• How much coffee, tea, and cola do you consume each day?
• Do you engage in any regular exercise? If so, what type of bra do you wear when you exercise?
• How important are your breasts to you in relation to a positive feeling about yourself and your physical appearance? Do you have any fears regarding breast disease?
• Do you examine your own breasts? Describe when you do this. Have you noted any changes in your breasts such as a lump, swelling, skin irritation, or dimpling, nipple pain or retraction, redness or scaliness or nipple of breast skin, or discharge? If yes, have you reported this to your healthcare provider?
• Have you ever had your breasts examined by a physician? When was your last examination?
• Have you ever had a mammogram ? If so, when was your last one?

Female breasts

• Inspect size and symmetry. Have the client disrobe and sit with arms hanging freely. Explain what you are observing to help ease client anxiety .
• Inspect color and texture. Be sure to note the client’s overall skin tone when inspecting the breast skin. Note any lesions.
• Inspect superficial venous pattern. Observe the visibility and pattern of breast veins.
• Inspect the areolas. Note the color, size, shape, and texture of the areolas of both breasts.
• Inspect the nipples. Note the size and direction of the nipples of both breasts. Also note any dryness, lesions, bleeding, or discharge.
• Inspect for retraction and dimpling. To inspect the breasts accurately for retraction and dimpling, ask the client to remain seated while performing several different maneuvers. Ask the client to raise her arms overhead, then press her hands against her hips. Next, ask her to press her hands together.
• Palpate texture and elasticity. Smooth, firm, elastic tissue is a normal finding.
• Palpate tenderness and temperature. A generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications.
• Palpate for masses . Note location, size in centimeters, shape, mobility, consistency, and tenderness. Also, note the condition of the skin over the mass.
• Palpate the nipples. Wear gloves to compress the nipple gently with your thumb and index finger. Note any discharge.
• Palpate mastectomy or lumpectomy site. If the client has had a mastectomy or lumpectomy, it is still important to perform a thorough examination. Palpate the scar and any remaining breast and axillary tissue for redness, lesions, lumps, swelling, or tenderness.
• Inspect and palpate the axillae. Ask the client to sit up. Inspect the axillary skin for rashes or infections. Hold the client’s elbow with one hand, and use the three fingerpads of your other hand to palpate firmly the axillary lymph nodes . First, palpate high into the axillae, moving downward against the ribs to feel for the central nodes. Continue to move down the posterior axillae to feel for the posterior nodes.

Male breasts

• Inspect and palpate the breasts, areolas, nipples, and axillae. Note any swelling, nodules, or ulceration. Palpate the flat disc of underdeveloped breast tissue under the nipple.

Subjective data collected about the heart and neck vessels helps the nurse to identify abnormal conditions that may affect the client’s ability to perform activities of daily living and to fulfill his role and responsibilities.

Chest pain and Palpitations

• Do you experience chest pain ? When did it start? Describe the type of pain, location, radiation, duration, and how often you experience the pain. Rate the pain on a scale of 0 to 10, with 10 being the worst possible. Does the activity make the pain worse? Did you have perspiration with the chest pain?
• Do you experience palpitations?
• Do you tire easily? Do you experience fatigue ? Describe when the fatigue started. Was it sudden or gradual? Do you notice it at any particular time of the day?
• Do you have difficulty breathing or shortness of breath ?
• Do you wake up at night with an urgent need to urinate? How many times at night?
• Do you experience dizziness?
• Do you experience swelling ( edema ) in your feet, ankles, or legs?
• Do you have frequent heartburn? When does it occur? What relieves it? How often do you experience it?
• Have you been diagnosed with a heart defect or a murmur?
• Have you ever had rheumatic fever ?
• Have you ever had heart surgery or cardiac balloon interventions?
• Have you ever had an electrocardiogram? When was the last one performed? Do you know the results?
• Have you ever had a blood test called a lipid profile? Based on your last test, do you know what your cholesterol levels were?
• Do you take medications or use other treatments for heart disease? How often do you take them? Why do you take them?
• Do you monitor your own heart rate or blood pressure ?
• Is there a history of hypertension , myocardial infarction , coronary heart disease, elevated cholesterol levels, or diabetes mellitus in your family?
• Do you smoke? How many packs of cigarettes per day and for how many years?
• What type of stress do you have in your life? How do you cope with it?
• Describe what you usually eat in a 24-hour period.
• How much alcohol do you consume each day/week?
• Do you exercise? What type of exercise and how often?
• Describe your daily activities. How are they different from your routine 5 or 20 years ago? Does fatigue , chest pain, or shortness of breath limit your ability to perform daily activities? Describe. Are you able to care for yourself?
• Has your heart disease had any effect on your sexual activity?
• How many pillows do you use to sleep at night? Do you get up to urinate during the night? Do you feel rested in the morning?
• How important is having a healthy heart to your ability to feel good about yourself and your appearance? What fears about heart disease do you have?

Neck Vessels

• Observe the jugular venous pulse. Inspect the jugular venous pulse by standing on the right side of the client. The client should be in a supine position with the torso elevated 30 to 45 degrees. Ask the client to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualizations of pulsations as well as shadows.
• Evaluate jugular venous pressure. Evaluate jugular venous pressure by watching for the distention of the jugular vein .

Auscultation and Palpation

• Auscultate the carotid arteries. Auscultate the carotid arteries if the client is middle-aged or older or if you suspect cardiovascular disease. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so breath sounds do not conceal any vascular sounds.
• Palpate the carotid arteries. Palpate each carotid artery alternately by placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck.
• Inspect pulsations. with the client in a supine position with the head of the bed elevated between 30 and 45 degrees, stand on the client’s right side and look for the apical impulse and abnormal pulsations.
• Palpate the apical pulse. Remain on the client’s right side and ask the client to remain supine. Use the palmar surfaces of your hand to palpate the apical impulse in the mitral area.
• Palpate for abnormal pulsations. Use your palmar surfaces to palpate the apex, left sternal border, and base.
• Auscultate heart rate and rhythm. Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse.
• If you detect an irregular rhythm, auscultate for a pulse rate deficit. This is done by palpating the radial pulse while you auscultate the apical pulse. Count for a full minute.
• Auscultate to identify S1 and S2. Auscultate the first heart sound (S1 or “lub”) and the second heart sound (S2 or “dub”). Use the diaphragm of the stethoscope to best hear S1. Use the diaphragm of the stethoscope to hear S2 and ask the client to breathe regularly.
• Auscultate for extra heart sounds. Use the diaphragm first, then the bell, to auscultate over the entire heart area. Note the characteristics of any extra sound heard. auscultate during the systolic pause.
• Auscultate for murmurs. Use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches. Also, auscultate with the client in different positions because some murmurs occur or subside according to the client’s position.
• Auscultate with the client assuming other positions. Ask the client to assume a left lateral position . Use the bell of the stethoscope and listen at the apex of the heart. Ask the client to sit up, lean forward, and exhale. Use the diaphragm of the stethoscope and listen over the apex and along the left sternal border.

It is important for the nurse to ask questions about the symptoms that the client may consider inconsequential. It is also important for the nurse to ask about personal and family history of vascular disease. It is especially important to evaluate aspects of the client’s lifestyle and health factors that may impair peripheral vascular health.

• Have you noticed any color, temperature, or texture changes in your skin?
• Do you experience pain or cramping in your legs? Describe the pain (aching, stabbing). how often does it occur? Does it occur with activity? Does it wake you from sleep?
• Do you have any leg veins that are ropelike, bulging, or contorted? Do you have any sores or open wounds on your legs? Where are they located? Are they painful?
• Do you have any swelling (edema) in your legs or feet? At what time of day is swelling worst? Any pain with swelling?
• Do you have any swollen glands or lymph nodes? If so, do they feel tender, soft, or hard?
• For male clients: Have you experienced a change in your usual sexual activity? Describe.
• Describe any problems you had in the past with the circulation in your arms and legs.
• Have you had any heart or blood vessel surgeries or treatments such as coronary artery bypass grafting, repair of an aneurysm, or vein stripping?
• Do you have a family history of diabetes, hypertension , coronary heart disease, or elevated cholesterol or triglyceride levels?
• Do you (or did you in the past) smoke cigarettes or use any form of tobacco? How much and for how long?
• Do you exercise regularly?
• For female clients: Do you take oral or transdermal contraceptives?
• Describe the degree of stress you normally have.
• How have problems with your circulation affected your ability to function?
• Do leg ulcers or varicose veins affect how you feel about yourself?
• Do you regularly take medications prescribed by your physician to improve your circulation?
• Do you wear support hose to treat varicose veins?
• Observe arm size and venous pattern; also look for edema. Arms are bilaterally symmetric with minimal variation in size and shape. No edema or prominent venous patterning.
• Observe the coloration of the hands and arms. Color varies depending on the client’s skin tone, although color should be the same bilaterally.
• Palpate the client’s fingers, hands, and arms, and note the temperature. Skin is warm to the touch bilaterally from fingertips to upper arms.
• Palpate to assess capillary refill time. Compress the nailbed until it blanches. release the pressure and calculate the time it takes for the color to return.
• Palpate the radial pulse. Gently press the radial artery against the radius. Note elasticity and strength.
• Palpate the ulnar pulses. Apply pressure with your first three fingertips to the medial aspects of the inner wrists.
• Palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client’s right and left medial antecubital creases.
• Palpate the epitrochlear lymph nodes. Take the client’s left hand in your right hand as if you were shaking hands. Flex the client’s elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles.
• Perform the Allen test. The Allen test evaluates the patency of the radial or ulnar arteries. The test begins by assessing ulnar patency. Have the client rest the hand palm side-up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries. Note that the palm remains pale. Release the pressure on the ulnar artery and watch for color to return to the hand.

Inspection , Palpation , and Auscultation

• Observe skin color while inspecting both legs from the toes to the groin. Ask the client to lie supine. Then drape the groin area and place a pillow under the client’s head for comfort .
• Inspect the distribution of hair. Hair covers the skin on the legs and appears on the dorsal surface of the toes.
• Inspect for lesions or ulcers. Legs are free of lesions or ulcerations.
• Inspect for edema. Inspect the legs for unilateral and bilateral edema. Note veins, tendons, and bony prominences.
• Palpate edema. If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting. Press the edematous area with the tips of your fingers, hold for a few seconds, then release.
• Palpate bilaterally for the temperature of the feet and legs. Use the backs of your fingers. Compare your findings in the same areas bilaterally.
• Palpate the superficial inguinal lymph nodes. First, expose the client’s inguinal area, keeping the genitals draped. Feel over the upper medial thigh for the vertical and horizontal groups of superficial inguinal lymph nodes.
• Palpate the femoral pulses. Ask the client to bend the knee and move it out to the side. Press deeply and slowly below and medial to the inguinal ligament. Release pressure until you feel the pulse.
• Auscultate the femoral pulses. If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and listen for bruits.
• Palpate the popliteal pulses. Ask the client to raise the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse.
• Palpate the dorsalis pedis pulses. Dorsiflex the client’s foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe.
• Palpate the posterior tibial pulses. Palpate behind and just below the medial malleolus. Palpating both posterior tibial pulses at the same time aids in making comparisons.
• Inspect for varicosities and thrombophlebitis . Ask the client to stand because varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. As the client is standing, inspect for superficial vein thrombophlebitis.
• Check for Homan’s sign. First, flex the client’s knee about 5 degrees, place your hand under the client’s calf muscle, and quickly squeeze the muscle against the tibia . Ask the client to report any pain or tenderness.

The nurse may collect subjective data concerning the abdomen as part of a client’s overall health history interview or as a focused history for a current abdominal complaint. The data focus on symptoms of particular abdominal organs and the function of the digestive system along with aspects of nutrition, usual bowel habits, and lifestyle.

Abdominal Pain

• Are you experiencing abdominal pain?
• How would you describe the pain? How bad is the pain (severity) on a scale of 1 to 10, with 10 being the worst?
• How did (does) the pain begin?
• Where is the pain located? Does it move or has it changed from the original location?
• When does the pain (timing and relation to particular events)?
• What seems to bring on the pain (precipitating factors) make it worse (exacerbating factors), or make it better (alleviating factors)?
• Is the pain associated with any other symptoms such as nausea, vomiting , diarrhea , constipation , gas, fever, weight loss , fatigue , or yellowing of the eyes or skin?

Indigestion

• Do you experience indigestion? Describe.
• Does anything, in particular, seem to cause or aggravate this condition?

Nausea and Vomiting

• Do you experience nausea? Describe. Is it triggered by any particular activities, events, or other factors?
• Have you been vomiting ? Describe the vomitus. Is it associated with any particular trigger factors?
• Have you noticed a change in your appetite? Has this change affected how much you eat or your normal weight?

Bowel Elimination

• Have you experienced a change in bowel elimination patterns? Describe.
• Do you have constipation? Describe. Do you have any accompanying symptoms?
• Have you experienced diarrhea? Describe. Do you have any accompanying symptoms?
• Have you experienced any yellowing of your skin or whites of your eyes, itchy skin, dark urine , or clay-colored stools?
• Have you ever had any of the following gastrointestinal disorders: ulcers, gastroesophageal reflux, inflammatory or obstructive bowel disease, pancreatitis , gallbladder or liver disease, diverticulosis, or appendicitis ?
• Have you had any urinary tract diseases such as infections, kidney disease or nephritis, or kidney stones?
• Have you ever had viral hepatitis ? Have you ever been exposed to viral hepatitis?
• Is there a history of any of the following diseases or disorders in your family: colon , stomach , pancreatic, liver, kidney, or bladder cancer, liver disease, gallbladder disease, or kidney disease?
• Do you drink alcohol? How much? How often?
• What types of foods and how much food do you typically consume each day? How much caffeine do you think you consume each day?
• How much and how often do you exercise? Describe your activities during the day.
• What kind of stress do you have in your life? How does it affect your eating or elimination habits?
• If you have a gastrointestinal disorder, how does it affect your lifestyle, and how do you feel about yourself?

Always follow this sequence when assessing the abdomen: inspection, auscultation, percussion, and palpation. Changing the order can alter the frequency of bowel sounds and make your findings less accurate.

• Observe the coloration of the skin. Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the elements.
• Note the vascularity of the abdominal skin. Scattered fine veins may be visible.
• Note any striae. Old, silvery, white striae or stretch marks from past pregnancies or weight gain are normal.
• Inspect for scars . Ask about the source of a scar, and use a centimeter ruler to measure the scar’s length. Document the location by quadrant and reference lines, shape, length, and specific characteristics.
• Assess for lesions and rashes. The abdomen is free of lesions or rashes. Flat or raised brown moles, however, are normal and may be apparent.
• Inspect the umbilicus. Note the color of the umbilical area. Observe the umbilical location. Assess the contour of the umbilicus.
• Inspect abdominal contour. Look across the abdomen at eye level from the client’s side from behind the client’s head, and from the foot of the bed. Measure abdominal girth as indicated.
• Assess abdominal symmetry. Look at the client’s abdomen as she lies in a relaxed supine position.
• Inspect abdominal movement when the client breathes. Abdominal respiratory movement may be seen, especially in male clients.
• Observe aortic pulsations. A slight pulsation of the abdominal aorta , which is visible in the epigastrium, extends full length in thin people.
• Observe for peristaltic waves. Normally peristaltic waves are not seen, although they may be visible in very thin people as slight ripples on the abdominal wall.
• Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client’s abdomen.
• Auscultate for vascular sounds. Use the bell of the stethoscope to listen for bruits over the abdominal aorta and renal, iliac, and femoral arteries.
• Auscultate for a friction rub over the liver and spleen. Listen over the right and left lower rib cage with the diaphragm of the stethoscope.
• Percuss for tone. Lightly and systematically percuss all quadrants.
• Percuss the span or height of the liver by determining its lower and upper borders. To assess the lower border, begin in the RLQ at the mid-clavicular line and press upward. Note the change from tympany to dullness. To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness.
• Percuss the spleen. Begin posterior to the left mid-axillary line (MAL), and percuss downward, noting the change from lung resonance to splenic dullness.
• Perform blunt percussion on the liver. Percuss the liver by placing your left hand flat against the lower right ribcage. Use the ulnar side of your right fist to strike your left hand.
• Perform light palpation. Using the fingertips, begin palpation in a non-tender quadrant, and compress to a depth of 1cm in a dipping motion. Then gently lift your fingers and move to the next area.
• Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses. Using the palmar surface of the fingers, compress to a maximum depth (5 to 6 cm). Perform bimanual palpation if you encounter resistance or assess deeper structures.
• Palpate for masses. Note their location, size, shape, consistency, demarcation, pulsatility, tenderness, and mobility. Do not confuse a mass with a normally palpated organ or structure.
• Palpate the umbilicus and surrounding area for swellings, bulges, or masses. Umbilicus and the surrounding area are free of swellings, bulges, or masses.
• Palpate the aorta. Use your thumb and first finger or two hands and palpate deeply in the epigastrium, slightly to the left of the midline. Assess the pulsation of the abdominal aorta.
• Palpate the liver. Note consistency and tenderness. To palpate bimanually, stand at the client’s right side and place your left hand under the client’s back at the level of the eleventh to twelfth ribs. Lay your right hand parallel to the right costal margin. Ask the client to inhale, then compress upward and inward with your fingers.
• Palpate the spleen. Stand at the client’s right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client’s head. Ask the client to inhale and press inward and upward as you provide support with your other hand.
• Palpate the kidneys. To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL.
• Palpate the urinary bladder . Palpate for a distended bladder when the client’s history or other findings warrant. Begin at the symphysis pubis and move upward and outward to estimate bladder borders.

When interview topics turn to the reproductive system and female genitalia, keep in mind the sensitivities of the client as well as your own feelings regarding body image , fear of cancer, sexuality, and the like.

Before proceeding with the interview, keep both the topic of the health history and the client’s culture clearly in mind. In some cases, your gender may interfere with accurate results.

Menstrual Cycle

• What was the date of your last menstrual period? Do your menstrual cycles occur on a regular schedule? How long do they last? Describe the typical amount of blood flow you have with your periods. Any clotting ?
• What other symptoms do your experience before or during your period?
• How old were you when you started your period?
• Have you stopped menstruating, or have your periods become irregular? Do you have any spotting between periods? What symptoms have you experienced?
• Are you still having periods? Have your periods changed?
• Are you experiencing any symptoms of menopause?
• Are you on a hormone replacement therapy regimen? If so, what type and dosage?  Are you satisfied with HRT?
• What are your concerns about going through menopause?

Vaginal discharge, pain, masses

• Are you experiencing vaginal discharge that is unusual in terms of color, amount, or odor?
• Do you experience pain or itching in your genital or groin area?
• Do you have any lumps, swelling, or masses in your genital area?
• Do you have any difficulty urinating? Do you have any burning or pain with urination? Has your urine changed color or developed an odor? Have you noticed any blood in your urine?
• Do you have difficulty controlling your urine?

Sexual Dysfunction

• Do you have any problems with your sexual performance?
• Have you recently had a change in your sexual activity pattern or libido?
• Do you experience problems with fertility?
• Describe any prior gynecologic problems you have had and the results of any treatment.
• When was your last pelvic examination by a healthcare provider? Was a Pap test performed? What was the result?
• Have you ever been diagnosed with a sexually transmitted disease? If so, what? How was it treated?
• Have you ever been pregnant? How many times? How many children do you have? Is there any chance that you might be pregnant now? Any miscarriages or abortions?
• Have you ever been diagnosed with diabetes?
• Is there a history of reproductive or genital cancer in your family? What type? How is the family member related to you?
• Do you smoke?
• How many sexual partners do you have?
• Do you use contraceptives? What kind? How often?
• Do you have any genital problems that affected your life?
• What is your sexual preference?
• Do you feel comfortable communicating with your partner about your sexual likes and dislikes?
• Do you have any fears related to sex? Can you identify any stress in your current relationship that relates to sex?
• Do you have concerns about fertility? If you have trouble with fertility, how has this affected your relationship with your partner or family?
• Do you perform monthly genital self-examinations?
• How do you feel about going through menopause?
• Do you take estrogen replacement therapy?
• Have you ever been tested for HIV ? What was the result? Why were you tested?
• What do you know about toxic shock syndrome?
• What do you know about STDs and their prevention?
• Do you wear cotton underwear and avoid tight jeans?
• After a bowel movement or urination, do you wipe from front to back?
• Do you douche frequently?

External female genitalia

• Inspect the Mons Pubis. Wash your hands and put on gloves. As you begin the examination, note the distribution of pubic hair. Also, be alert for signs of infestation.
• Observe and palpate inguinal lymph nodes. There should be no enlargement or swelling of the lymph nodes.
• Inspect the labia majora. Observe the labia majora and perineum for lesions, swelling, and excoriation.
• Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. Use your gloved hand to separate the labia majora and inspect for lesions, excoriation, swelling, and/or discharge.
• Palpate Bartholin’s glands. If the client has labial swelling or a history of it, palpate Bartholin’s glands for swelling, tenderness, and discharge. Place your index finger in the vaginal opening and your thumb on the labia majora. With a gentle pinching motion, palpate from the inferior portion of the posterior labia majora to the anterior portion.
• Palpate the urethra . If the client reports urethral symptoms or urethritis, or if you suspect inflammation of Skene’s glands, insert your gloved index finger into the superior portion of the vagina and milk the urethra from the inside, pushing up and out.

Internal female genitalia

• Inspect the size of the vaginal opening and the angle of the vagina. Insert your gloved index finger into the vagina, noting the size of the opening. Then attempt to touch the cervix. Next, while maintaining tension, gently pull the labia majora outward. Note hymenal configuration and transections.
• Inspect the vaginal musculature. Keep your index finger inserted in the client’s vaginal opening. Ask the client to squeeze around your finger. Use your middle and index fingers to separate the labia minora. Ask the client to bear down.
• Inspect the cervix. With the speculum inserted in position to visualize the cervix, observe the cervical color, size, and position. Also, observe the surface and the appearance of the os. Look for discharge and lesions as well.
• Inspect the vagina. Unlock the speculum and slowly rotate and remove it. Inspect the vagina as you remove the speculum. Note the vaginal color, surface, consistency, and any discharge.

When interviewing the male client for information regarding his genitalia, keep in mind that this may be a very sensitive topic for the client and for the examiner as well. Moreover, the examiner should be aware of his own feelings regarding body image , fear of cancer, and sexuality.

• Do you have pain in your penis, scrotum, testes, or groin?
• Have you noticed any lesions on your penis or genital area? If so, do the lesions itch, burn, or sting? Please describe the lesions.
• Have you noticed any discharge from your penis? If so, how much? What color is it? What type of odor does it have?
• Lumps, swelling, masses
• Do you have any lumps, swelling, or masses in your scrotum, genital, or groin area? Have you noticed a change in the size of the scrotum?
• Do you have a heavy, dragging feeling in your scrotum?
• Do you experience difficulty urinating? How many times do you urinate during the night?
• Have you noticed any change in the color, odor, or amount of your urine?
• Do you experience any pain or burning when you urinate?
• Do you ever experience urinary incontinence or dribbling?
• Have you recently had a change in your pattern of sexual activity or sexual desire?
• Do you have difficulty attaining or maintaining an erection? Do you have any problem with ejaculation? Do you have pain with ejaculation?
• Do you have or have you had any trouble with fertility?
• Describe any prior medical problems you have had, how they were treated, and the results.
• When was the last time you had a testicular examination by a physician? What was the result?
• Have you ever been tested for HIV , human papillomavirus, herpes simplex, chlamydia, gonorrhea, and/or trichomoniasis ? What were the results? Why were you tested?
• Is there a history of cancer in your family? What type and which family member(s)?
• What kind of birth control method do you use, if any?
• Are you satisfied with your current level of activity and sexual functioning?
• Do you have concerns regarding your fertility? If you experience fertility troubles, how has this affected your relationship?
• Are you currently exposed to chemicals or radiation? Have you been exposed in the past?
• Describe the activity you perform on a typical day. Do you do any heavy lifting?
• Do you perform testicular self-examinations?
• When was the last time you performed this examination?
• Inspect the base of the penis and pubic hair. Sit on a stool with the client facing you and standing. Ask the client to raise his gown or drape. Note pubic hair growth pattern and any excoriation, erythema, or infestation at the base of the penis and within the pubic hair.
• Inspect the skin of the shaft. Observe for rashes, lesions, or lumps.
• Palpate the shaft. Palpate any abnormalities noted during the inspection. Also, note any hardened or tender areas.
• Inspect the foreskin. Observe the color, location, and integrity of the foreskin in uncircumcised men.
• Inspect the glans. Observe for size, shape, lesions, or redness.
• Palpate the urethral discharge. Gently squeeze the glans between your index finger and thumb.
• Inspect the size, shape, and position. Ask the client to hold his penis out of the way. Observe for swelling, lumps, or bulges.
• Inspect the scrotal skin. Observe color, integrity, and lesions or rashes. To perform an accurate inspection, you must spread out the scrotal folds of the skin. Lift the scrotal sac to inspect the posterior skin.
• Palpate the scrotal contents. Palpate each testis and epididymis between your thumb and first two fingers. Note size, shape, consistency, nodules, and tenderness.
• Continue examination of a scrotal mass by auscultating with a stethoscope. Normal findings are not expected. Bowel sounds may be auscultated over a hernia but will not be heard over a hydrocele .
• Transilluminate the scrotal contents. If an abnormal mass or swelling was noted in the scrotum, transillumination should be performed. Darken the room and shine a light from the back of the scrotum through the mass. Look for a red glow.

Inguinal area

• Inspect for inguinal or femoral hernia. Inspect the inguinal and femoral areas for bulges. Ask the client to turn their head and cough or to bear down as if having a bowel movement, and continue to inspect the areas.
• Palpate for inguinal hernia and inguinal nodes. Ask the client to shift his weight to the left for palpation of the right inguinal canal and vice versa. Place your right index finger into the client’s right scrotum and press upward, invaginating the loose folds of skin. Palpate up the spermatic cord until you reach the triangular-shaped, slitlike opening of the external inguinal ring. Try to push your finger through the opening and, if possible, continue palpating up the inguinal canal.
• Palpate inguinal lymph nodes. If nodes are palpable, note size, consistency, mobility, or tenderness.
• Palpate for femoral hernia. Palpate on the front of the thigh in the femoral canal area. Ask the client to bear down or cough. Feel for bulges. Repeat on the opposite thigh.
• Inspect and palpate for scrotal hernia. Ask the client to lie down; note whether the bulge disappears. If the bulge remains, auscultate it for bowel sounds. Finally, gently palpate the mass and try to push it upward into the abdomen.

The data gathered during subjective assessment provide clues to the client’s overall health and whether he is at risk for diseases and disorders of the anus, rectum, or prostate.

Bowel Patterns

• What is your usual bowel pattern? Have you noticed any recent changes in the pattern? Any pain while passing a bowel movement?
• Do you experience constipation?
• Do you experience diarrhea? Is your diarrhea associated with any nausea or vomiting ?
• Do you have trouble controlling your bowels?

Itching and Pain

• Do you experience any itching or pain in the rectal area ?
• What is the color of your stool ? Hard or soft? Have you noticed any blood on or in your stool ? If so, how much?
• Have you noticed any mucus in your stool ?
• Have you ever had anal or rectal trauma or surgery? Were you born with any congenital deformities of the anus or rectum? Have you had prostate surgery? Have you had hemorrhoids or surgery for hemorrhoids?
• When was the last time you had a stool test to detect blood?
• Have you ever had a proctosigmoidoscopy?
• When was the last time you had a digital rectal examination (DRE) by a physician?
• Have you ever had blood taken for a prostate screening, which measures the level of prostate-specific antigen in your blood? When was the test, and what was the result?
• Is there a history of polyps, colon , rectal cancer, or prostate cancer in your family?
• Do you use any laxatives, stool softeners, enemas, or other bowel movement-enhancing medications?
• Do you engage in anal sex?
• Do you take any medications for your prostate?
• How much high-fiber food and roughage do you consume every day? Do you eat foods high in saturated fats?
• Do you engage in regular exercise?
• Do you use calcium supplements?
• For postmenopausal women: Do you use hormone replacement therapy?
• Has any anal or rectal problem affected your normal activities of daily living ?

Anus and rectum

• Inspect the perianal area. Spread the client’s buttocks and inspect the anal opening and surrounding area.
• Inspect the sacrococcygeal area. Inspect this area for any signs of swelling, redness, dimpling, or hair.
• Palpate the anus. Inform the client that you are going to perform the internal examination at this point. Lubricate your gloved index finger; ask the client to bear down. As the client bears down, place the pad of your index finger on the anal opening. When you feel the sphincter relax, insert your finger gently with the pad facing down.
• Palpate the rectum. Insert your finger further into the rectum as far as possible. Next, turn your hand clockwise. This allows palpation of as much rectal surface as possible. Note tenderness, irregularities, nodules, and hardness.
• Palpate the peritoneal cavity. This area may be palpated in men above the prostate gland in the area of the seminal vesicles on the anterior surface of the rectum. In women, this area may be palpated on the anterior rectal surface in the area of the rectouterine pouch Note tenderness or nodules.

Prostate gland

• In male clients, palpate the prostate. The prostate can be palpated on the anterior surface of the rectum by turning the hand fully counterclockwise so the pad of your index finger faces toward the client’s umbilicus. Note the size, shape, and consistency of the prostate, and identify any nodules or tenderness.
• Inspect the stool. Withdraw your gloved finger. Inspect any fecal matter on your glove. Assess the color, and test the feces for occult blood. Provide the client with a towel to wipe the anorectal area.

Assessment of the musculoskeletal system helps to evaluate the client’s level of functioning with activities of daily living.

• Have you had any recent weight gain?
• Describe any difficulty that you have chewing. Is it associated with tenderness or pain?
• Describe any joint, muscle, or bone pain you have. Where is the pain? what does the pain feel like? When did the pain start? When does it occur? How long does it last? Any stiffness, swelling, or limitation of movement?
• Describe any past problems or injuries you have had to your joints, muscles, or bones. What treatment was given? Do you have any after-effects from the injury or problem?
• When were your last tetanus and polio immunizations?
• Have you ever been diagnosed with diabetes mellitus , sickle cell anemia , systemic lupus erythematosus, or osteoporosis ?
• For middle-aged women: Have you started menopause? Are you receiving estrogen replacement therapy?
• Do you have a family history of rheumatoid arthritis , gout, or osteoporosis?
• What activities do you engage in to promote the health of your muscles and bones?
• What medication are you taking?
• Do you smoke tobacco? How much and how often?
• Do you drink alcohol or caffeinated beverages? How much and how often?
• Describe your typical 24-hour diet. Are you able to consume milk or milk-containing products? Do you take any calcium supplements?
• Describe your activities during a typical day. How much time do you spend in the sunlight?
• Describe any routine exercise that you do.
• Describe your occupation.
• Describe your posture at work and at leisure. What type of shoes do you usually wear?
• Do you have difficulty performing normal activities of daily living? Do you use assistive devices to promote your mobility?
• How have your musculoskeletal problems interfering with your ability to interact or socialize with others? Have they interfered with your usual sexual activity?
• How did you view yourself before this musculoskeletal problem, and how do you view yourself now?
• Has your musculoskeletal problem added stress to your life? Describe.
• Observe gait. Observe the client’s gait as the client enters and walks around the room.
• Assess for the risk of falling backward in the older or handicapped client by performing the “nudge test”. Stand behind the client and put your arms around the client while you gently nudge the sternum.

Temporomandibular joint

• Inspect and palpate the TMJ. Have the client sit, and put your index and middle fingers just anterior to the external ear opening. Ask the client to open the mouth as widely as possible; move the jaw from side to side; and protrude and retract the jaw.
• Test range of motion. Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V.

Sternoclavicular joint

• With the client sitting, inspect the sternoclavicular joint for location in midline, color, swelling, and masses. Then palpate for tenderness or pain.

Cervical, thoracic, lumbar spine

• Observe the cervical, thoracic, and lumbar curves from the side and then from behind. Have the client standing erect with the gown positioned to allow an adequate view of the spine. Observe for symmetry, noting differences in height of the shoulders, the iliac crests, and the buttock areas.
• Palpate the spinous processes and the paravertebral muscles on both sides of the spine for tenderness or pain.
• Test ROM of the cervical spine. Test ROM of the cervical spine by asking the client to touch the chin to the chest and to look up at the ceiling.
• Test ROM of the thoracic and lumbar spine. Ask the client to bend forward and touch the toes. Observe for symmetry of shoulders, scapula, and hips.
• Test for back and leg pain. If the client has low back pain that radiates down the back, perform Lasegue’s test (straight leg raising) to check a herniated nucleus pulpous. Ask the client to lie flat and raise each relaxed leg independently to the point of pain. At the point of pain, dorsiflex the client’s foot.
• Measure leg length. If you suspect the client has one leg longer than the other, measure them. Ask the client to lie down with their legs extended. With a tape, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side.

Shoulders, arms, elbows

• Inspect and palpate shoulders and arms. With the client standing or sitting, inspect anteriorly and posteriorly symmetry, color, swelling, and masses. Palpate for tenderness, swelling, or heat.
• Test ROM. Ask the client to stand with both arms straight down at the sides. Nest, ask him to move the arms forward and then backward with elbows straight. Then have the client bring both hands together overhead, elbows straight, followed by moving both hands in front of the body past the midline with elbows straight.
• Inspect for size, shape, deformity, redness, or swelling. Inspect elbows in both flexed and extended positions.
• Test ROM. Ask the client to flex the elbow and bring the hand to the forehead, straighten the elbow, hold the arm out, turn the palm down, then turn the palm up.

Hands, wrists, fingers

• Inspect wrist size, shape, symmetry, color, and swelling. Then palpate for tenderness and nodules. Palpate the anatomic snuffbox (the hollow area on the back of the wrist at the base of the fully extended thumb.
• Test ROM. Ask the client to bend their wrist down and back. Next, have the client hold the wrist straight and move the hand outward and inward.
• Test for carpal tunnel syndrome. Perform Phalen’s test. Ask the client to place the backs of both hands against each other while flexing the wrists 90 degrees downward. Have the client hold this position for 60 seconds
• Inspect size, shape, symmetry swelling, and color. Palpate the fingers from the distal end proximally, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint.
• Test ROM. Ask the client to spread the fingers apart, make a fist, bend the fingers down and then up, move the thumb away from other fingers, and touch the thumb to the base of the small finger.
• With the client standing, inspect the symmetry and shape of the hips. Palpate for stability, tenderness, and crepitus.
• Test ROM. With the client supine, ask the client to: Raise the extended leg; flex the knee up to the chest while keeping the other leg extended; move an extended leg away from the midline of the body as far as possible and then toward the midline of the body as far as possible. Bend the knee and turn the leg inward and then outward.
• With the client supine and then sitting with knees dangling, inspect for size, shape, symmetry, swelling, deformities, and alignment. Observe for quadricep muscle atrophy.
• Test for swelling. The bulge test helps detect a small amount of fluid in the knee. With the client in the supine position, use the ball of your hand firmly to stroke the medial side of the knee upward. three to four times, to displace any accumulated fluid. Then press on the lateral side of the knee and look for a bulge on the medial side of the knee.
• Perform the ballottement test. With the client in a supine position, firmly press your non-dominant thumb and index finger on each side of the patella. Then with your dominant fingers, push the patella down on the femur .
• Test ROM. Ask the client to bend each knee up toward the buttocks or back, straighten the knee, and walk normally.
• Test for pain and injury. With the client in the supine position, ask the client to flex one knee and hip. Then place your thumb and index finger of one hand on either side of the knee. Use your other hand to hold the heel of the foot up. Rotate the lower leg and foot laterally. Slowly extend the knee, noting pain or clicking.

Ankles and feet

• With the client sitting, standing, and walking , inspect position, alignment, shape, and skin.
• Palpate ankles and feet for tenderness, heat, swelling, and nodules. Palpate the toes from the distal end proximally, noting tenderness, swelling, boney prominences, nodules, or crepitus of each interphalangeal joint.
• Test ROM. Ask the client to point toes upward then downward, turn soles outward then inward, rotate foot outward then inward, turn toes under foot and then upward.

Problems with other body systems may affect the neurologic system, and neurologic system disorders can affect all other body systems. Regardless of the source of neurologic problems, the client’s total lifestyle and level of functioning are often affected.

Numbness and Tingling

• Do you experience any numbness or tingling? When and where does this occur?
• Do you experience seizures ?
• Describe what happens before you have the seizure and where on your body the seizure starts. Does anything seem to initiate a seizure? Do you lose control of your bladder during the seizure? How do you feel afterward? Do you take medications for seizures? Do you wear medical identification to alert others that you have seizures? Do you take safety precautions regarding driving or operating dangerous machinery?
• Do you experience headaches? When do they occur, and what do they feel like?
• Do you experience dizziness or lightheadedness or problems with balance or coordination ? If so, how often? Does it occur with activity? Or have you experienced any falling ? Do you have any clumsy movements?
• Have you noticed a decrease in your ability to smell or taste?
• Have you experienced any ringing in your ears or hearing loss?
• Have you noticed any change in your vision?

Difficulty Speaking

• Do you have difficulty understanding when people are talking to you? Do you have difficulty in making others understand you? Do you have difficulty forming words or verbally interpreting your thoughts?

Difficulty Swallowing

• Do you experience difficulty swallowing?

Muscle Control

• Have you lost bowel or bladder control, or do you retain urine?
• Do you have muscle weakness ? If so, where?
• Do you experience any tremors? If so, where?

Memory Loss

• Do you experience any memory loss?
• Have you ever had any type of head injury with or without loss of consciousness? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you receive?
• Have you ever had meningitis , encephalitis , injury to the spinal cord , or a stroke ? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you receive?
• Do you have a family history of high blood pressure , stroke, Alzheimer’s disease, epilepsy , brain cancer , or Huntington’s chorea?
• Do you take any prescription or nonprescription medications? How much alcohol do you drink? Do you use recreational drugs such as marijuana , tranquilizers, barbiturates , or cocaine ?
• Do you wear your seatbelt when riding in vehicles? Do you wear protective headgear when riding a bicycle or playing sports?
• Describe your usual daily diet.
• Have you ever had prolonged exposure to lead, insecticides, pollutants, and other chemicals?
• Do you frequently lift heavy objects or perform repetitive motions?
• Can you perform your normal activities of daily living?
• Has your neurologic problem changed the way you view yourself? Describe.
• Has your neurologic problem added much stress to your life? Describe.

Neurological status, Mental status, and LOC

• Observe the level of consciousness. Call the client’s name and not the response. If the client does not respond, call the name louder. If necessary, shake the client gently. If the client still does not respond, apply a painful stimulus.
• Observe posture and body movements. Be alert for tense, nervous, fidgety, and restless behavior, which may be seen in anxiety or may simply reflect the client’s apprehension during a physical examination.
• Observe dress, grooming , and hygiene . Keep the examination setting and the reason for the assessment in mind as you note the client’s degree of cleanliness and attire.
• Observe facial expressions. Note particularly eye contact and affect.
• Observe speech. Observe and listen to the tone, clarity, and pace of speech.
• Observe mood, feelings, and expressions. Ask the client, “How are you feeling today?” and “What are your plans for the future?”
• Observe thought processes and perceptions. Observe thought processes for clarity, content, and perception by inquiring about the client’s thoughts and perceptions expressed.
• Observe cognitive abilities. Ask for the client’s name and names of family members, the time, and where the client lives or is now. Note the client’s ability to focus and stay attentive to you during the interview and examination. Ask the client, “What did you have to eat today?” or “What is the weather like today?”. Ask the client, “When did you get your first job?” or “When is your birthday?” Ask the client to repeat four unrelated words. The words should not rhyme, and they cannot have the same meaning. Have the client repeat these words in 5 minutes, again in 10 minutes, and again in 30 minutes
• Perform the Mini-Mental State Examination if time is limited and a quick standard measure is needed to evaluate or reevaluate the cognitive function.

Cranial nerves

• Test CN I (olfactory). For all assessments of the cranial nerves , have the client sit in a comfortable position at your eye level. Ask the client to clear the nose to remove any mucus, then to close their eyes, occlude one nostril, and identify a scented object that you are holding.
• Test CN II (optic). Use the Snellen chart to assess vision in each eye. Ask the client to read a newspaper or magazine paragraph to assess near vision. Assess the visual fields of each eye by confrontation. Use an ophthalmoscope to view the retina and optic disc of each eye.
• Assess CN III ( oculomotor ), IV (trochlear), and VI (abducens). Inspect the margins of the eyelids of each eye. Assess extraocular movements. If nystagmus is noted, determine the direction of the fast and slow phases of movement. Assess pupillary response to light and accommodation in both eyes.
• Assess CN V (trigeminal). Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contraction. Test sensory function. Tell the client: “I am going to touch your forehead, cheeks, and chin with the sharp or dull side of this safety pin or paper clip. Please close your eyes and tell me if you feel a sharp or dull sensation. also, tell me where you feel it.”
• Test CN VII (facial). Test motor function. Ask the client to smile, frown and wrinkle the forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes tightly against resistance.
• Test CN VIII (acoustic/vestibulocochlear). Test the client’s hearing ability in each ear and perform the Weber and Rinne tests to assess the cochlear (auditory) component of cranial nerve VIII.
• Test CN IX (glossopharyngeal) and X (vagus). Test motor function. Ask the client to open their mouth wide and say “ah” while you use a tongue depressor on the client’s tongue. Test the gag reflex by touching the posterior pharynx with the tongue depressor.
• Test CN XI (spinal accessory). Ask the client to shrug the shoulders against resistance to assess the trapezius muscle. Ask the client to turn the head against resistance, first to the right and then to the left, to assess the sternocleidomastoid muscle.
• Test CN XII (hypoglossal). To assess the strength and mobility of the tongue, ask the client to protrude the tongue, move it to each side against the resistance of a tongue depressor, then put it back in the mouth.

Motor and cerebellar systems

• Assess the condition and movement of muscles. Assess the size and symmetry of all muscle groups. Assess the strength and tone of all muscle groups. Note any unusual involuntary movements such as fasciculations, tics, or tremors.
• Evaluate balance. To assess gait, ask the client to walk naturally across the room. Note posture, freedom of movement, symmetry, rhythm, and balance. Ask the client to walk in heel-to-toe fashion, next on the heels, then on the toes. Perform Romberg test. Ask the client to stand erect with arms at the side and feet together. Note any unsteadiness or swaying.
• Assess coordination . Demonstrate the finger-to-nose test to assess the accuracy of movements, then ask the client to extend and hold arms out to the side with eyes open. Next, say, “Touch the tip of your nose first with your right index finger, then with your left index finger.

Sensory systems

• Assess light touch, pain, and temperature sensations. For each test, ask clients to close both eyes and tell you what they feel and where they feel it. Scatter stimuli over the distal and proximal parts of all extremities and the trunk to cover most of the dermatomes. To test the light touch sensation, use a wisp of cotton to touch the client. To test pain sensation, use the blunt and sharp ends of a safety pin or paper clip. to test temperature sensation, use test tubes filled with hot and cold water.
• Test vibratory sensation. Strike a low-pitched tuning fork on the heel of your hand and hold the base on a bony surface of the fingers or big toe. Ask the client to indicate what he feels.
• Test sensitivity to position. Ask the client to close both eyes. Then move the client’s toes or a finger up or down. Ask the client to tell you the direction it is moved.
• Assess tactile discrimination (fine touch). Remember that the client should have her eyes closed. To test stereognosis, place a familiar object such as a quarter, paper clip, or key in the client’s hand and ask the client to identify it. To test point localization, briefly touch the client and ask the client to identify the points touched.  to test graphesthesia, use a blunt instrument to write a number on the palm of the client’s hand. Ask the client to identify the number.

33 thoughts on “Head-to-Toe Assessment: Complete Physical Assessment Guide”

I appreciate the topics you are posting. It helps a lot and very informative. It enhances my nursing practice. Keep up the good work!

all the topics are really helpful!!! thanks a lot! godspeed! keep up the good work :)

Thank you. I appreciate your hard work by putting everything together and sharing

hi, please help me if you have OSCE review notes. Thanks

this is a very reliable source of information for nursing students, I always recommend it to my mates, I really love it. Please make more notes on drug study so we don’t have to look elsewhere

It is a big helpful source of info which today im using it for our activity regarding to physical assestment. I really appreciate it. Thank you. From 1st yr nursing student.

Your post are very helpful. Thank you

you are awesome….thanks

Good site to refer for your care plans and physical assessments. Thank You

thank you so much all your post are very helpful ,it makes our studying much easier

great topics , it makes my studying much easier

Thank you for what you do. It helps when I am trying to understand something the instructors are lecturing about, but don’t have time to answer all the questions we have.

Great detailed cheat sheet. Thanks!

You are awesome! Thanks and God bless!

DEAR MATT VERA, Excellent work you are doing for the nurses world. Your contents are very good. I am Dr.M.Sumathi, PhD Nurse from India. I am a nurse educator. I am proud of you dear. keep doing this for the young budding nurses.

You are definitely doing God’s work. Thank you.

I really appreciate your help. It has really simplified the physical assessment techniques.

Yes you right

Exactly what have looking for! Much blessings

Thank you so much for this!

Excelente trabajo complementa y facilita la enseñanza gracias

Thanks you this gives an excellent insight on health assessment and will surely apply.

Good job, it’s very helpful

This is very informative and I do appreciate your hard work and effort. I will share this information with my classmates I feel it is very useful.

This is very useful and important to read all nurses. Thank you

Hi Estifanos, You’re very welcome! I’m glad you found the head-to-toe physical assessment guide so valuable. It’s definitely a fundamental skill for all nurses. Which part of the head-to-toe assessment do you find most challenging, or is there a particular aspect you’d like to learn more about? Happy to help anytime!

Good job,very helpful

Glad to be of help, Lincy.

I want to be part of this community

Thanks alot for the time and effort taken. Pls guide on communicating a patients condion on an accurate summarized way especially when handing over or when providing updates.

This is so detailed and helpful. Learning this for the first time I’m actually very happy that I finally have a stop for everything place to learn❤️

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39 Free Templates For Nursing Assessment

Discover meticulously crafted Nursing Assessment templates designed to streamline patient evaluations, ensuring comprehensive care through detailed documentation and analysis, tailored to healthcare professionals' needs.

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Tips For Using Nursing Assessment Templates

• 1. Clarify Patient Information: Ensure the template starts with a section for detailed patient identification. Include fields for the patient's name, DOB, and medical record number. Accurate data is critical.
• 2. Organize Assessment Criteria: Structure the template to systematically cover physical examination, patient history, and current condition. This helps in maintaining consistency and thoroughness across assessments.
• 3. Highlight Critical Observations: Provide a designated area for nurses to note urgent issues that require immediate attention. This ensures vital information is promptly communicated to the healthcare team.

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Nursing Assessment Form

Create nursing assessment forms in a few clicks with PandaDoc’s drag-and-drop form builder and templates library. Streamline your healthcare organization’s whole document workflow.

No credit card required

How does a nursing assessment form differ from a physical assessment?

It is common for nurses to perform a physical exam, which will usually involve monitoring “vital signs” like pulse rate and blood pressure, when filling out nursing assessment forms. 

Unlike physical assessments, however, nursing assessments are also used to record information about the following: 

• Medical history
• Habits and lifestyle choices
• Long-term health conditions of close family members
• Current treatment or medication plans
• Current symptoms
• Results of a health examination
• Results of any lab tests (for example, blood and saliva) conducted before the assessment

Sometimes, a psychological evaluation may also be involved. Finally, if a patient has any additional cultural requirements, such as the need for a translator or a doctor of a particular sex, this information may also be included. 

What are the four types of nursing assessments?

It’s common for nursing assessments to fall into one of the following four categories:

• Preliminary assessment – During an initial health assessment (or “triage”), which represents the first stage of the nursing process, a nurse or caregiver will gather general patient details and put together a health history. Registered nurses may conduct tests to measure turgor pressure, capillary refill time, musculoskeletal pain, cardiovascular, gastrointestinal, neurological,  psychosocial, and mental health, presence of edema, hypertension, or cyanosis, and so on. 
• Tailored assessment – During a tailored or focused assessment, any specific problems which became apparent during the preliminary evaluation are investigated in more depth for the purpose of putting together a personal treatment or care plan. 
• Follow-up assessment – A follow-up assessment is conducted after a patient has received treatment. It is designed to measure the rate of recovery and to identify any ongoing nursing care needs related to health status, which may be the case in individuals with impairments, catheters, and so on. 
• Emergency assessment – Emergency assessments are used to identify immediate problems in high-risk patients requiring hospitalization. 

What are the different types of nursing assessment forms?

Nursing forms are used in a wide variety of situations. They are usually tailored to the unique needs of the organization responsible for drafting them. That said, nursing assessment forms will usually fall into one of the following three loose categories: 

• New patient assessment – Whenever a new patient enrolls with a medical organization, they will often be required to undergo an evaluation conducted by a nurse. New patient assessments tend to be geared towards collecting a broad set of data-points, including medical history, measurements of vital signs, daily habits, lifestyle choices, chronic conditions, and so on. 
• Ongoing care assessment – Patients who require continuing care will often have regular reviews to track their treatment plan’s efficacy and so that their care package can be adjusted based on any progress or deterioration. Often, this kind of nursing assessment will focus on a small handful of relevant measurements. 
• Triage assessment – During triage, a nurse will identify and record symptoms so that a patient can be assigned an urgency level and directed to the best-qualified specialist. 

It’s also worth pointing out that a nursing assessment is not the same as a medical diagnosis, for which a doctor would usually be responsible. Instead, nursing assessment forms are used to evaluate the patient’s general health, identify any current or potential care needs, and flag any issues that need to be looked at by a doctor or qualified expert. 

What is included in a nursing assessment form? 

Nursing assessment forms are almost always tailored to meet the specific needs of the organizations that will be using them. However, there are usually several commonalities in terms of structure and general areas of information.

Here are the main areas that a nursing assessment form should include: 

• Patient information – Nurse assessment forms usually begin with a section for basic patient information like name, address, contact details, and occupation. 
• Patient evaluation – The patient evaluation area may include sections for measurements of vital signs, personal information such as height, weight, and any existing medical conditions or allergies, and information about current medical complaints and symptoms. 
• Patient medical history – The patient’s medical history will usually include fields for past conditions and any common family illnesses. 
• Nurse signature – Assessment forms will have a field for the nurse conducting the evaluation to provide their details and signature. 

Should you use a template to create nursing assessment forms?

Because most medical organizations use large amounts of nursing assessment forms, it is often possible for them to save significant amounts of time and money by working from a template. Rather than draft a document from scratch every time a new form is needed, organizations can work from a tested template, making adjustments as required. 

What’s more, once a template has been verified by every individual involved in the drafting process, it will be possible to make minor adjustments without the need for extensive checks, dramatically cutting down on completion time. 

Get started with the free, fully-customizable nursing evaluation form template provided by PandaDoc. 

Are all nursing assessment forms all the same? 

While nursing assessment forms are tailored to the particular healthcare organization responsible for issuing them, they tend to be uniform in structure. They will usually include similar sections for vital signs (body temperature, respiratory rate, blood pressure, pulse rate, etc.), lifestyle habits (exercise, smoking, alcohol consumption, etc.), and any specific medical issues.

What are nursing assessment forms used for?

Nursing assessment forms are used to gather information about new and existing patients and identify any current, ongoing, or potential care needs. They allow medical organizations to collect data in a standardized manner, thus enabling healthcare professionals to administer treatment and track patient health efficiently.

If your organization regularly uses nursing assessment forms, you will likely be able to save significant amounts of resources and employee time by streamlining your workflow, specifically by using a base template and automating parts of the information-gathering and storage process.

What is a nursing assessment form?

A nursing assessment form is a document used by nurses to assess patients. Nursing assessment forms will generally fall into one of two categories: forms for general patient assessments and forms for ongoing assessments related to specific health conditions.

Nurses often conduct comprehensive evaluations – covering general quality of health, pre-existing conditions, lifestyle choices and habits, and so on – on patients that join a healthcare practice for the first time. Alternatively, nurses may carry out regular assessments on patients undergoing long-term treatment for an illness such as cancer, chronic pain, heart disease, and so on.

Nursing assessment forms can be used to determine the appropriate level of urgency if a patient has a particular complaint and ensure that they are assigned to the doctor best suited to treat the issue. This process is also commonly referred to as “triaging”.

What are the 4 types of nursing assessments?

The four main types of nursing assessment are:

• initial assessment, to obtain a person’s medical history,
• focused assessment, to focus on a particular treatment or vital signs,
• time-lapsed assessment, to compare the current and previous medical records of patients, and 
• emergency assessment, to focus on a root cause of concern.

Nursing Skills Assessment

Know how to evaluate nursing skills and competencies with our comprehensive guide. Includes an example template for a Nursing Skills Assessment. Free PDF download available.

By Audrey Liz Perez on Aug 06, 2024.

Fact Checked by Ericka Pingol.

What is a Nursing Skills Assessment?

A Nursing Skills Assessment is a systematic process designed to evaluate a nurse's ability to perform various clinical tasks, ranging from physical assessments and physical examinations to interpreting the Glasgow Coma Scale. This evaluation is integral to nursing education, ensuring that nurses possess the theoretical knowledge required for their roles and the practical skills necessary for providing high-quality care.

By incorporating a wide range of competencies, the assessment helps identify areas where nurses excel and where further improvement is needed, fostering a continuous learning environment.

Undergoing a Nursing Skills Assessment is crucial for nurses as it ensures they meet the high standards expected in healthcare settings. It evaluates their nursing knowledge and proficiency in conducting physical assessments and examinations and collaborating with other health professionals to deliver patient-centered care.

The assessment serves as a cornerstone for professional development, highlighting the importance of a solid foundation in nursing education and practical skills application. It helps nurses stay updated with the latest clinical practices and technologies, ultimately enhancing patient safety and outcomes.

Nursing Skills Assessment Template

Nursing skills assessment example.

Skills evaluated during a nursing assessment

The Nursing Skills Assessment evaluates many competencies essential for providing top-notch patient care. Here are five critical nursing skills that are commonly assessed:

Physical assessment

A registered nurse's ability to conduct thorough physical assessments and examinations is crucial. This includes gathering a comprehensive medical history, checking vital signs and blood pressure, and using tools like the Glasgow Coma Scale to evaluate a patient's condition accurately. Mastery of this skill allows nurses to detect potential health issues early and take appropriate action.

Time management

Effective time management is essential for nurses to prioritize tasks and ensure patients receive timely and appropriate care. This skill involves scheduling treatments, managing multiple patients simultaneously, and coordinating with the healthcare team to provide efficient and effective care.

Communication

Nurses must communicate effectively with patients, families, and other health professionals to ensure that care is well-coordinated and that patients understand their conditions, treatments, living arrangements, etc. This includes listening actively, providing guidance and emotional support, and conveying information clearly and compassionately.

Critical thinking and clinical decisions

The ability to make informed clinical decisions based on a patient's condition, test results, and other relevant information is a key skill for nurses. This involves using critical thinking skills to assess situations and emotional states, identify problems, and determine the best action to respond to complex healthcare scenarios.

Medication management

A comprehensive understanding of medication management, including accurately recording medical history, understanding drug interactions, and administering medications safely, is vital. Nurses must be able to assess patients’ responses to medications and adjust their care plans accordingly, ensuring patient safety and the effectiveness of treatments.

Assessing these and other essential skills helps ensure that registered nurses are competent and confident in providing high-quality care.

How does our Nursing Skills Assessment template work?

Our Nursing Skills Assessment template is an essential tool designed to evaluate nurses' comprehensive skills and competencies in a clinical setting. It systematically guides evaluators through steps to ensure a thorough and consistent assessment of nursing capabilities, ranging from theoretical knowledge to practical skills. Here's how it works:

Step 1: Assess theoretical knowledge

The first step involves evaluating the nurse's foundational knowledge in nursing education, including understanding physical assessment techniques and the importance of the Glasgow coma scale in assessing a patient's condition. This essential part of the assessment ensures that the nurse possesses the theoretical background to make informed clinical decisions. You can also use the Glasgow Coma Scale Template to systematically assess and document a patient's level of consciousness.

Step 2: Evaluate clinical skills

Next, the template focuses on the practical application of nursing skills, such as performing a vital sign check and conducting a comprehensive physical exam. This step is crucial for assessing the nurse's ability to apply theoretical knowledge in a real-world clinical setting, ensuring they can effectively monitor and respond to the patient's condition.

Step 3: Critical thinking and decision-making

This step evaluates the nurse's capability to use critical skills in clinical decisions. It involves analyzing the nurse's response to simulated scenarios or real-life situations, assessing their ability to take appropriate action, and providing guidance based on the patient's condition and medication history.

Step 4: Communication and team collaboration

An integral part of nursing is effective communication and teamwork. This step assesses the nurse's ability to work cohesively with other health professionals in the healthcare team, ensuring timely management of the patient's care and facilitating a collaborative approach to treatment and decision-making.

Step 5: Professionalism and ethical practice

Finally, the assessment reviews the nurse's professionalism, ethical practice, and commitment to ongoing learning. This step is vital for ensuring that the registered nurse upholds the highest standards of nursing practice, demonstrating a dedication to patient care and continuous improvement.

Following these steps, our Nursing Skills Assessment template provides a comprehensive framework for evaluating nurses' critical skills and competencies, ensuring they are well-equipped to deliver high-quality care in clinical settings.

When is this assessment normally conducted?

Nursing Skills Assessments are critical tools to gauge a nurse's capabilities in providing patient care, conducting physical assessments, and executing the nursing process with sound clinical judgment. These assessments are conducted in various situations to ensure nurses are well-prepared to meet the demands of their roles. Here are three common scenarios where these assessments are typically conducted:

• During nursing education : Nursing students undergo skills assessments as part of their clinical education to evaluate their ability to apply theoretical knowledge in practice. This includes performing physical examinations, using clinical judgment to assess patients' conditions, and effectively implementing the nursing process. These assessments help identify areas where students may need further training or improvement.
• Pre employment assessment : Before hiring, healthcare facilities often conduct pre-employment assessments to test the clinical skills and judgment of prospective nurses. This ensures that candidates possess the necessary technical skills and can conduct physical assessments and examinations, making them a reliable addition to the healthcare team.
• Annual competency evaluations : Nurses are also assessed regularly throughout their careers to ensure ongoing competency in essential nursing duties. These evaluations often focus on a nurse's clinical judgment, ability to conduct comprehensive physical assessments, and adherence to the latest best practices in patient care. It helps maintain high standards of nursing care and ensure patient safety.

In each of these situations, the Nursing Skills Assessment plays a pivotal role in validating the nurse's proficiency and readiness to provide high-quality care to patients, making it an integral part of nursing education, employment, and professional development processes.

Benefits of conducting a Nursing Skills Assessment

Conducting a Nursing Skills Assessment offers numerous advantages that contribute significantly to nursing practice, patient care, and overall health outcomes. By systematically evaluating a nurse's ability to perform vital signs monitoring, physical assessments, and examinations, these assessments ensure that nurses are competent and confident in their roles. Here are four key benefits of conducting this assessment:

Improves patient health outcomes

Regular assessment of nurses’ skills in conducting health assessments and physical examinations directly impacts the quality of patient care. Competent nurses are better equipped to identify health issues early, leading to timely interventions and improved patient health outcomes.

Ensures standardization of care

By assessing essential nursing skills, including the accurate measurement of vital signs and thorough physical assessments, healthcare facilities can ensure a standardized level of care across their nursing staff. This standardization helps in maintaining high-quality care and safety for all patients.

Enhances clinical decision-making

Nurses are encouraged to refine their clinical judgment and decision-making skills by evaluating their proficiency in health assessments and physical examinations. This improves their ability to respond to patient needs effectively and supports better clinical outcomes.

Identifies areas for professional development

The Nursing Skills Assessment provides valuable feedback on a nurse’s strengths and areas needing improvement, highlighting specific aspects of nursing practice that may require additional education or training. This focus on continuous professional development ensures that nurses remain competent in the ever-evolving healthcare field, ultimately contributing to advancing nursing practice and patient care quality.

By systematically evaluating nursing skills in vital signs monitoring, physical examination, and health assessment, these assessments play a crucial role in enhancing nursing practice, ensuring high-quality patient care, and fostering continuous professional growth and development among nurses.

Commonly asked questions

A Nursing Skills Assessment includes evaluation of theoretical knowledge, clinical skills (like vital signs and physical examinations), critical thinking, communication abilities, and professionalism.

Assessments are typically conducted during nursing education, pre-employment evaluations, and annual competency reviews to ensure ongoing nursing proficiency.

Yes, Carepatron's practice management software can streamline the process by organizing assessment schedules, managing patient data for evaluations, and facilitating the documentation of assessment outcomes.

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The Ultimate Nursing Report Sheet Guide - Free Downloads!

As a nurse, you know the importance of clear and concise communication, especially when it comes to patient care. Nursing report sheets play a vital role in ensuring seamless handovers between shifts, ultimately contributing to improved patient outcomes. However, navigating these sheets can sometimes feel overwhelming, especially for new nurses.

What are Nursing Report Sheets?

Nursing report sheets are standardized forms used to document a patient's condition, including vital signs, medications, treatments, and any relevant observations. They serve as a communication tool between nurses, ensuring continuity of care throughout the patient's journey.

Benefits of Using Nursing Report Sheets:

• Improved patient care: Clear and accurate documentation facilitates better communication and collaboration among healthcare professionals, leading to improved patient care.
• Enhanced safety: Reporting potential risks and concerns helps identify and address issues promptly, ensuring patient safety.
• Reduced errors: Standardized formats minimize the risk of errors and omissions associated with free-form documentation.
• Increased efficiency: Pre-structured templates save time and improve efficiency during shift changes.

Essential Components of a Nursing Report Sheet:

• Patient demographics: Basic information like name, age, diagnosis, and admitting date.
• Vital signs: Temperature, pulse, blood pressure, respiratory rate, and oxygen saturation.
• Medications: Current medication list, including dosages, frequencies, and routes of administration.
• Treatments: Treatments received and planned, including interventions like dressing changes, oxygen therapy, and suctioning.
• Laboratory and diagnostic reports: Summary of recent tests and results.
• Neurological status: Level of consciousness, orientation, and any neurological deficits.
• Pain assessment and management: Description of pain, pain score, and current pain management strategies.
• Fluid intake and output: Total intake and output for the shift.
• Activity and mobility: Level of independence and assistance required for daily activities.
• Skin integrity: Assessment of skin condition and any pressure injuries.
• Nutritional status: Dietary intake and any nutritional concerns.
• Discharge planning: Current discharge plan and any anticipated needs.

Tips for Using Nursing Report Sheets Effectively:

• Complete the sheet comprehensively and accurately.
• Use clear and concise language.
• Document all relevant observations and concerns.
• Proofread the sheet carefully before handing off to the next nurse.
• Ask questions and clarify any uncertainties.
• Utilize standardized abbreviations and terminology.

By mastering nursing report sheets, you can enhance communication, improve patient care, and ensure a smooth and safe transition between shifts. Remember, accurate and efficient reporting is not just a good practice, it's a vital aspect of providing quality patient care.

10 Free Nursing Report Sheet Downloads

Our report sheets are used extensively throughout health systems across the country.

• Download and print PDFs, or edit in Google Docs/Microsoft Word.
• 1-4 patients per sheet, with portrait and landscape options.
• SBAR and Brain format:  Perfect for Med-Surg, ICU, Tele, Step-Down, and ER units.

1. Full-Size SBAR Nurse Report Sheet

• Perfect for new grads and nursing students
• Fly through report by circling options instead of writing everything
• 1 patient per sheet
• SBAR format
• Great for all units

2. Brain Nursing Report Sheet Template

• Brain format

3. ICU Nurse Report Sheet

• Great for ICU

4. Mini SBAR Nursing Report Sheet

• 3 patients per sheet
• Quick report taking with circling options
• Great for med surg and tele units

5. 4 Patient Nurse Report Sheet

• 4 patients per sheet

6. Brain Nursing Report Sheet

7. 2 Patient Landscape Nurse Report Sheet

• 2 patients per sheet

8. 3 Patient SBAR Nurse Report Sheet

9. Full-size Nurse Report Sheet Template

10. History and Physical Template

• H&P format
• Great for nurse practitioners and NP students

Free Downloads!

How to give an effective nursing report: a comprehensive guide.

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Leveraging Data and Analytics in Nursing Education

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The Importance of AI in Nurse Clinical Tracking Systems

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Nursing Assessment Form

A Nursing Assessment Form is a form template designed to streamline the evaluation of patients and their symptoms by registered nurses.

Healthcare Forms

• Nurse Forms

A nursing assessment form is used by registered nurses to evaluate patients and their symptoms. If you’re a nurse manager or administrator, this free Nursing Assessment Form will make it easier for your nursing staff to assess patients and store medical data online. Simply customize the form to meet your needs and share it with nurses via email to let them fill it out using any device. You’ll instantly receive submissions in your secure Jotform account, assisted with HIPAA compliance features if you’ve upgraded your plan.

Customizing your Nurse Assessment Form takes only a few clicks with our drag-and-drop Form Builder. Without any coding, you can add form fields to collect other patient data, e-signatures, or file uploads, and even sync form submissions to apps you already use — Jotform offers more than 100 integrations , including with optionally HIPAA-friendly software like Google Drive and Dropbox. Reduce paper usage at your hospital and make it easier for nurses to treat patients faster with a custom Nursing Assessment Form they can fill out on any device!

Nursing Assessment Form FAQs

1) why is a nursing assessment form template used.

A nursing assessment form template is used to systematically evaluate and document the physical, psychological, and social aspects of a patient's health. It helps healthcare professionals gather relevant information for diagnosis and treatment planning.

2) What should be included in a nursing assessment form?

A nursing assessment form should include sections for demographic information, medical history, current symptoms, physical examination findings, vital signs, and any other relevant data based on the specific healthcare setting.

3) When to use a nursing assessment form template?

A nursing assessment form template should be used whenever a patient is admitted to a healthcare facility, undergoes a significant change in their condition, or requires ongoing care and monitoring.

4) Who can use a nursing assessment form template?

Nursing assessment form templates are primarily used by registered nurses and other healthcare professionals involved in patient care, including nurse managers and administrators.

5) How to create a nursing assessment form with Jotform?

Creating a nursing assessment form with Jotform is simple. Start by selecting the Nursing Assessment Form template from the Jotform Template Library. Customize the form by adding or removing fields to meet your specific needs. You can also personalize the form's design and branding. Once the form is ready, you can easily share it with your nursing staff and start collecting data online.

6) What are the benefits of using a nursing assessment form template?

Using a nursing assessment form template like the one from Jotform offers several benefits. It improves efficiency by standardizing the assessment process, ensures accurate and comprehensive data collection, allows for secure storage and easy access to patient information, and enhances collaboration among healthcare professionals.

Medical History Form

A medical history form is a questionnaire used by healthcare providers to collect information about the patient’s medical history during a medical or physical examination. Whether you’re a doctor, nurse, physical therapist, or other medical professional, easily collect your patient’s medical history using this free medical history form. All you need to do is customize the form to match how you want to ask your questions, and then add it to your website. Or share it with a link or embed it! That way, patients can fill out the form at home, or you can print it out and gather responses in person using a tablet or computer.When you download our free mobile app, Jotform mobile forms, you’ll be able to view submissions on any device, even when you’re not in the office. And, you can automatically collect all the information you need by integrating the form with your other accounts. Just sync it with your crm or your storage service like Google Drive or Dropbox. Connect with your patients and capture their medical history with a free online medical history form.

Online Doctor Appointment Form

An online doctor appointment form is used by medical practices to schedule medical appointments through the practice website. With this free Online Doctor Appointment Form template, you can collect patient information to help you serve your patients better at your medical practice.Just customize the form to receive the necessary information and integrate it with your practice management system, or just embed the form on your website to get the information you need. With HIPAA friendly features, you can rest assured that the information you collect is secure — keeping your practice protected from damages.

COVID 19 Liability Waiver

A COVID-19 liability waiver is used to release a business of any legal responsibility if its customers contract the coronavirus while buying the business’ products or receiving the business’ services. With this free online COVID-19 liability waiver, businesses of any industry can seamlessly accept signed liability waivers online. Just customize the terms and conditions to match your needs, share the form with your clients or customers to fill out on any device, and watch as responses are securely deposited into your Jotform account — easy to view, manage, and automatically convert into PDF documents.Using our drag-and-drop Form Builder, you can add your company logo, update terms and conditions, or even change fonts and colors — with no coding required! Feel free to sync submissions to other accounts you’re already using, such as Google Drive, Dropbox, Box, Airtable, and more, with our 100+ free-form integrations. No matter which industry you belong to, keep your customers and your business safe during the coronavirus pandemic with a free online COVID-19 Liability Waiver that helps you collect e-signatures fast .

Medical Report Form

A medical report form is a document used by medical professionals for documenting a patient’s medical treatment. With Jotform’s free Medical Report Form template, you can collect information from patients instantly by embedding the form in your website — and the form can be filled out using a computer or tablet at your office, or using a mobile device at home.Just customize the Medical Report Form to match your practice — add your logo and colors, and easily add more form fields. As well as customizing fields and questions to match your needs, you can also update the design of this template. Jotform is a fully customized, easy-to-use Form Builder that includes changing, adding, or removing fields through the drag and drop function, and changing the colors, fonts, and background without any coding required. Easily embed this form either on your website or share it via URL. With Jotform’s 100+ integrations, you can also store and analyze your Medical Report Form submissions with Google Drive. All can be achieved without coding!

COVID 19 Vaccine Registration Form

A COVID-19 vaccine registration form is used by medical practices to sign up patients for the COVID-19 vaccine. Collect contact details and insurance information for your medical practice through a secure online COVID-19 Vaccine Registration Form! Just customize the form to receive the info you need — then embed the form in your website, share it with a link, or have patients fill it out in person on your office’s tablet or computer. You can even convert submissions into PDFs automatically, easy to download or print in one click.Want to make this registration form match your practice? Add your logo, change the background image, or add more form fields to collect clients’ medical history at the same time. You can even sync submissions or PDFs to 100+ popular platforms, including Google Drive, Dropbox, Box, and more! Just remember to upgrade to keep sensitive patient health info protected with HIPAA friendly features. Replace paper forms, be more efficient, and reduce contact time with a free online COVID-19 Vaccine Registration Form.

Coronavirus Self Declaration Form

A coronavirus self-declaration form is used by individuals infected with COVID-19 to report their medical status. Whether you’re an employer or manage HR for a company, this free Coronavirus Self-Declaration Form allows members of your staff to confirm if they have coronavirus, so they can proceed to seek medical treatment and prevent further contamination in your workplace. Employees can provide their contact details, describe their recent travel history, list people they have come into contact with, and check off any symptoms they may be experiencing.To keep your employees’ sensitive medical information as safe as possible, Jotform offers a HIPAA compliance option. If you’d like to make any adjustments to this readymade Coronavirus Self-Declaration Form, our drag-and-drop Form Builder lets you easily add form fields, conditional logic, images, and more to create a form that perfectly suits your needs. You can even integrate with 100+ popular apps to organize submissions in the other accounts you rely on. With our free Coronavirus Self-Declaration Form, you’ll be able to take the proper precautions and keep you and your employees safe during this pandemic.

These templates are suggested forms only. Before using this or any form as a contract or other legal document, please consult with an attorney to make sure it meets the legal needs or your situation. Do not use this form to send a legal request to Jotform.

A medical history form is a questionnaire used by health care providers to collect information about the patient’s medical history during a medical or physical examination.

An online doctor appointment form is used by medical practices to schedule medical appointments through the practice website.

Receive signed liability waivers and e-signatures online with our free COVID-19 Liability Waiver form. Easy to customize and share. No coding is required.

A medical report form is a document used by medical professionals for documenting a patient’s medical treatment.

Collect COVID-19 vaccine registrations online. Fill out on any device. Easy to customize, share, and embed. Convert submissions to PDFs instantly. HIPAA friendly features option.

Employees can complete this form online and report any COVID-19 symptoms they may have. No coding is required. HIPAA compliance option.

New Patient Enrollment Form

New Patient Enrollment Form which personal information, contact information, emergency contact people area and medical history information are provided; allowing you to have an easier and faster registration process.

Personal Training Consultation Questionnaire

A Personal Training Consultation Questionnaire is a form template designed to streamline the process of signing up for personal training sessions, setting exercise goals, and mitigating exercise-related injuries

Screening Checklist For Visitors And Employees

Prevent the spread of COVID-19 with a free Screening Checklist for Visitors and Employees. Ideal for hospitals or other organizations staying open during the crisis.

Patient Feedback Form

A patient feedback form is a survey with questions that allows medical doctors to gather feedback from patients regarding their overall experience with the clinic.

Physician Release To Return To Work Form

A Physician Release to Return to Work Form is a form template designed to showcase an employee's fitness to return to work after a period of illness or injury

Patient Medical History Form

The template is used by patients to register medical history through providing their personal information, weight, allergies, illnesses, operations, healthy habits, unhealthy habits. You can integrate the data to your own systems.

Negative COVID 19 Test Reporting Form

Receive submissions for COVID-19 test reports from your staff for your company or organization online. Use this Negative COVID-19 Test Reporting Form template and make your receiving process simple and manageable.

COVID 19 Vaccine Consent Form

Collect signed COVID-19 vaccine consent forms online. Easy to customize, share, and fill out on any device. Upgrade for HIPAA friendly features. Convert to PDFs instantly.

Coronavirus Case Report Template

People can report suspected cases of COVID-19 in their workplace or community. Easy to customize, integrate, and share online. No coding required.

Patient Supplies Order Form

Keeping a clear and organized medical order in the healthcare business is important because it saves time and enhances the efficiency of their medical order. This patient supplies order form is mostly used by medical staff and hospitals. The objective of this form is to assist and help medical staff for keeping the records of used supplies by patients. The form will need information such as patient information and medical supply information. The costs incurred for each service and the materials are also needed to complete the form.

Hospital Discharge Form

This hospital discharge form is suitable for hospitals and clinics worldwide. The staff of hospitals can use this form to ensure all requirements are meant before a patient is discharged.

Health Declaration Form

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Professional Counseling Informed Consent Form

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Coronavirus Screening Form

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A gym health questionnaire is a health form that is used by gym instructors to track the health and fitness of their clients.

COVID 19 Vaccine Survey

Get to know how people feel about the new COVID-19 vaccine with a custom online survey. Easy to personalize, embed, and share. Option for HIPAA friendly features.

Online Medical Consent Form

This excellent Online Medical Consent Form has form fields that ask about the patient information, parent/guardian or emergency contact details, medical data, and the consent waiver. In order to fully acknowledge the consent, this template is using the E-signature widget where the patient can sign digitally.

Pharmacy Forms

COVID 19 Vaccine Declination Form

Document the person's refusal from receiving the COVID-19 vaccination. Copy this COVID-19 Vaccination Declination Form to your Jotform account.

Coronavirus Response Forms

Passenger Disclosure And Attestation To The United States Of America

Follow CDC requirements with this free passenger attestment form for airlines and aircraft operators. Turns form submissions into PDFs automatically. No coding.

COVID 19 Liability Release Waiver

Start collecting your participants' liability release waiver for this pandemic using this COVID-19 Liability Release Waiver Template. Just connect your device to the internet and load your form and start collecting your liability release waiver. Get this here in Jotform!

Telehealth Forms

Sample Request Form

A sample request form is a quick and easy way to ask for examples of a product or service from a business.

Mental Health Intake Form

Perform patient intake online. Collect medical history, supporting documents, and fee payments. Protect patient data with optional HIPAA compliance.

CAHPS Surveys

CAHPS Clinician & Group Survey Version 3.0 (Adult)

Gather feedback from adult patients online. CAHPS Clinician and Group Survey for healthcare providers. Add supplemental items from AHRQ. No coding required.

CAHPS Cancer Care Radiation Therapy Survey

Readymade online CAHPS survey. Collect feedback from cancer patients receiving radiation therapy. Fill out on any device. Upgrade for HIPAA compliance.

CAHPS Health Plan Survey Version Adult Medicaid Survey 5.0

Get patient feedback about their current health plan. Free CAHPS Health Plan Survey for medical organizations. Easy to share and fill out on any device. No coding.

CAHPS Child Hospital Survey

Ready-to-use CAHPS survey for hospitals. Share with your patients’ parents to fill out on any device. Upgrade to protect data with HIPAA compliance.

Hospice Forms

COVID 19 Daily Health Screening Form

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Palliative Care Assessment Form

Classify the type of care that the patient with severe illness is needed by using this Palliative Care Assessment Form. This form is simple yet contains all necessary health questions to diagnose the patient correctly.

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Hospice patient satisfaction surveys are inquiries used by medical providers to seek feedback from patients about their hospice care. Collect patient feedback with a free online Hospice Patient Satisfaction Survey.

About Healthcare Forms Agents

Our collection of online healthcare form templates makes it easier to register new patients and learn about their medical history. Jotform’s online form builder provides healthcare practitioners with an array of widgets, applications, and themes to enhance patient engagement — enabling better communication between patient and provider to better understand patients and their needs.

Get started by choosing one of our healthcare templates or start customizing your own. Additionally, Jotform offers a simple way to update medical history, acquire consent e-signatures , collect bill payments, find new business, and more. Jotform also offers HIPAA compliance features so your healthcare forms stay secure.

Frequently Asked Questions

What are health forms used for.

Health forms have several important uses across the healthcare system. First, they are used to collect essential information about a patient’s medical history, current health status, and insurance details, making them a crucial aspect of the patient onboarding process. They also facilitate effective patient care by providing healthcare providers with an overview of a patient's medical history, which can drive proper diagnosis and treatment plans.

Health forms are generally handled in the administrative department of healthcare organizations, and they can aid in billing and insurance processing as well as legal and regulatory compliance. Carefully filing healthcare forms helps healthcare institutions adhere to laws and regulations related to patient privacy and data security. All in all, health forms are essential for ensuring quality healthcare and records.

How can healthcare services benefit from digital forms?

Taking healthcare services online can help streamline time-consuming manual tasks that bog down healthcare data collection. Digital forms allow patients to easily fill out forms online before their appointments, reducing time spent on manual data entry for administrative staff. Digital forms can also be customized to suit specific patient and healthcare needs, which allows healthcare providers to gather the relevant information they need.

With digital forms, healthcare providers can also retrieve patient data quickly rather than needing to sift through files. Digital healthcare forms also enhance overall patient experience by allowing them to complete forms online before an appointment, and review and update their medical history as needed. As such, they help to facilitate a more efficient, streamlined, and patient-centric healthcare experience.

What are the subtypes of health forms?

There are many different types of health forms across the healthcare industry, and they can cover everything from insurance to medical history to discharge. The main types of health forms are telehealth forms, patient registration forms, pharmacy forms, hospice forms, hospital release forms, and medical surveys. However, these forms can also cover topics like informed consent, prescriptions, insurance claims, and referrals.

View our full collection of online healthcare form templates below.

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.

Nursing Skills [Internet].

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Appendix C – Head-to-Toe Assessment Checklist

Head-to-toe assessment checklist.

This checklist is intended as a guide for a routine, general, daily assessment performed by an entry-level nurse during inpatient care. Students should use a systematic approach and include these components in their assessment and documentation. Assessment techniques should be modified according to life span considerations. Focused assessments should be performed for abnormal findings and according to specialty unit guidelines. Unanticipated findings should be reported per agency protocol with emergency assistance obtained as indicated.

Gather supplies: stethoscope, penlight, watch with second hand, gloves, hand sanitizer, and wound measurement tool.

Perform hand hygiene before providing care and clean stethoscope. Check the room for transmission-based precautions.

Greet the patient, introduce oneself, explain the task, and provide privacy.

Knock before entering the room.

Greet the patient and others in the room. Ask the patient’s preferred way of being addressed. Ask if the patient is comfortable if others are present in the room during the assessment.

Introduce your name and role.

Explain the planned task and estimate the duration of time to complete it.

Provide for privacy.

During the assessment, listen and attend to patient cues. Use appropriate listening and questioning skills.

Identify the patient with two appropriate identifiers.

Perform a primary survey to ensure medical stability. Obtain emergency assistance if needed.

Airway:  Is the airway open? Is suctioning needed?

Breathing:  Is the patient breathing normally?

Circulation:  Are there any abnormal findings in the overall color and moisture of the patient’s skin (cyanosis, diaphoresis)

Mental Status:  Is the patient responsive and alert?

Perform a general survey while completing the head-to-toe assessment. Include general appearance, behavior, mood, mobility (i.e., balance and coordination), communication, overall nutritional status, and overall fluid status.

Address patient needs before starting assessment (toileting, glasses, hearing aids, etc.).

Evaluate chief concern using PQRSTU (i.e., ask the patient their reason for seeking/receiving care). Ask, “Do you have any concerns or questions you’d like to talk about before we begin?”

Obtain and/or analyze vital signs. (Initiate emergency assistance as needed.)

Evaluate for the presence of pain or other type of discomfort. If pain or discomfort is present, perform comprehensive pain assessment using PQRSTU.

Perform a neuromuscular assessment:

Perform a subjective assessment. Ask if headache, dizziness, weakness, numbness, tingling, or tremors are present. Inquire if the patient has experienced loss of balance, decreased coordination, previous falls, or difficulty swallowing. Be aware of previously diagnosed neuromuscular conditions and currently prescribed medications and how these impact your assessment findings.

Assess level of consciousness and orientation to person, place, and time.

Assess PERRLA using penlight.

Assess motor strength and sensation:

Bilateral hand grasps

Upper strength and resistance

Lower strength and resistance

Sensation in extremities

Note unanticipated neurological findings in symmetrical facial expressions, extremity movement, and speech and obtain emergency assistance as needed.

Assess fall assessment risk per agency policy.

Perform a focused assessment if neurological or musculoskeletal condition is present.

Perform a basic head, neck, eye, and ear assessment:

Perform a subjective assessment. Be aware of previously diagnosed head, neck, eye, or ear conditions and associated medications and how these impact your assessment findings.

Ask if they are having any problems with their teeth or gums, and if so, has this impacted their ability to eat.

Ask if they use glasses, hearing aids or dentures.

Ask if they have any difficulty seeing or blurred vision.

Ask if they have trouble hearing or experience ringing in their ears.

Inspect the external eye and the external ear. Inspect the oral cavity for lesions, tongue position, moisture, and oral health. Ask the patient to swallow their saliva and note any difficulty swallowing.

Palpate the lymph nodes (per agency policy).

Perform a cardiovascular system assessment:

Perform a subjective assessment. Ask if they are having chest pain, shortness of breath, edema, palpitations, calf pain, or pain in their feet or lower legs when exercising. Be aware of previously diagnosed cardiovascular conditions and currently prescribed medications and how these impact your assessment findings.

The face, lips, and extremities for pallor or cyanosis.

The neck for JVD in upright position or with head of bed at 30-45 degree angle.

The bilateral upper and lower extremities for color, warmth, and sensation.

The lower extremities for hair distribution, edema, and signs of deep vein thrombosis (DVT)

Palpate and compare the radial, brachial, dorsalis pedis, and posterior tibial pulses bilaterally. Note the presence and amplitude of pulses.

Palate the nail beds for capillary refill.

Auscultate:

Auscultate with both the bell and the diaphragm of the stethoscope over the five auscultation areas of the heart. Note the rate and rhythm. Identify S1 and S2 and any unexpected findings (i.e., extra sounds or irregular rhythm).

Measure the apical pulse for one minute.

Perform a respiratory assessment:

Perform a subjective assessment. Ask if they have shortness of breath or a cough. Ask if the cough is dry or productive. Ask if they smoke, and if so, what products, how many a day, and if they are interested in quitting. Be aware of previously diagnosed respiratory conditions and currently prescribed medications or treatments and how these impact your assessment findings.

Level of consciousness and for signs of irritability, restlessness, anxiety, or confusion

Breathing pattern, including rate, rhythm, effort, and depth of breathing. Note signs of difficulty breathing such as nasal flaring, use of accessory muscles, or pursed-lip breathing.

Skin color of lips, face, hands and feet for cyanosis and pallor

Trachea (midline)

Symmetrical chest movement

Auscultate lung sounds using stethoscope directly on the skin over anterior and posterior auscultation areas. Compare sounds from side to side and note any adventitious sounds such as rhonchi, crackles, wheezing, stridor, or pleural rub.

If oxygen equipment is prescribed:

Note if the patient is using oxygenation devices during the exam or on room air.

If the patient is using an oxygenation device, document the name of device and current flow rate and/or fraction of inspired oxygen (FiO2).

Inspect for signs of skin breakdown due to the use of oxygenation devices.

If a tracheostomy is present, document the condition of the tracheostomy site and characteristics of sputum present.

Perform an abdominal assessment:

Perform a subjective assessment:

Ask if the patient is having any abdominal pain, cramping, nausea, vomiting, constipation, loss of appetite, or difficulty swallowing. Inquire about the date of the last bowel movement, if there have been any changes in the pattern or consistency of the stool, and if any blood is present or dark stool. Be aware of previously diagnosed gastrointestinal or genitourinary conditions and currently prescribed medications and how these impact your assessment findings.

Ask if the patient has pain or problems with urination or leakage of urine.

Inspect the general contour and symmetry of the abdomen and for distension.

Auscultate for bowel sounds over four quadrants for one minute, note any hypoactive, high pitched sounds.

Palpate lightly for tenderness and masses.

Analyze weight trend and 24-hour input and output, as appropriate for patient status.

If enteral tube is present, assess tube insertion site, tube placement, and amount of enteral feeding/fluids administered during your shift per agency policy.

If an indwelling urinary catheter is present, assess urine output and urine characteristics. Document continued need for indwelling catheter per agency policy.

If an ostomy is present, document the condition of stoma and peristomal skin. Document amount and characteristics of output during your shift.

Perform an integumentary assessment:

Perform a subjective assessment. Ask if the patient has any skin concerns such as itching, rashes, or an unusual mole or lump. Be aware of previously diagnosed integumentary conditions and currently prescribed medications or treatments and how these impact your assessment findings.

Assess overall skin color and note pallor, cyanosis, jaundice, erythema, bruising, mositure, and turgor.

If an intravenous site is present, assess the insertion site for redness, warmth, tenderness, or induration. If intravenous fluids and/or medications are infusing, document the type and amount of fluids during your shift per agency policy.

Assess for skin breakdown in pressure points (behind ears, occipital area, elbows, sacrum, and heels).

If a pressure injury is present, stage from 1 to 4.

If a wound is present, perform a wound assessment.

Palpate for temperature, moisture, and texture. If erythema or rashes are present, assess for blanching. If edema is present, document the depth of indentation and the time it takes to rebound to original position and grade on a scale from 1 to 4.

When the assessment is completed, assist the patient back to a comfortable position. Thank them and ask if anything is needed before you leave the room.

Ensure safety measures before leaving room:

Call light is within reach.

Bed is low and locked.

Side rails are secured.

Table and personal items are within reach.

Room is risk-free for falls.

Remove any PPE before leaving the room. Perform hand hygiene and clean stethoscope.

Document assessment findings and report unanticipated findings according to agency policy.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Appendix C – Head-to-Toe Assessment Checklist.
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Such problems are expressed as either potential or actual. A nurse has to check out the medical history of a patient before creating the pattern of a nursing assessment form. After checking out all the conditions of the patient a nurse has to fill out  all the fields of the assessment form. There are certain types of nursing assessment form. You may also see  Self Assessment Forms

Nursing Head To Toe Assessment Form

usnnursing.pbworks.com

The name of the form says it all. Nursing head to toe assessment form includes the conditions of the each body part of a patient. A nurse has to gather information about the condition of the patient’s entire health before making the head to toe assessment form. A head to toe assessment form includes all the personal details of the patients. Additionally, the form also contains all the information of  various muscles, their condition, sensations strength and so on.   The form includes respiratory assessment, cardiovascular assessment, genitourinary assessment, gastrointestinal assessment, skin integrity assessment, pain assessment, IV assessment, cardiac rhythm assessment and so on.

Nursing Physical Assessment Form

nursing.wright.edu

Nursing physical assessment form is a complete documentation of the health condition of an individual patient. A nurse has to check out the entire health condition of a patient in order to fill out the nursing physical assessment form. Such forms include the name, age , gender and occupation of the patient, the name of the examiner and details about the general survey of the patient. These forms include a patient’s  basic information such as the level of consciousness, skin color, height , weight, nutritional status, positions and postures, physical deformities, facial expressions, mood swings, body temperature and much more.  The form helps the doctors a lot to treat the patient properly.

Nursing Assessment Form For Home Care

health.ny.gov

In the U.S, while organizing several health care programs, nursing assessment forms for home care come into action. The form includes all the important information of each patient. The basic information of the patients are a must, other than that, the form includes the health conditions and  medical history of the patient. The form also includes the financial condition of te patient. It conveys whether the patient is capable of directing a home care worker. This application form is based on the personal observation of the patient. Home care agencies use these kinds of forms.

Comprehensive Nursing Assessment Form

dhmh.maryland.gov

A comprehensive nursing assessment form conveys whether the patient has any kind of allergies.  The form also contains the diagnosis and the important signs and symptoms of the allergies experienced by the patient. Other than that the form also contains the nutritional stage, the condition of the skin, musculoskeletal conditions, dental, respiration and circulation conditions of the patient.  These forms also include the possible methods of medication and the treatments of the patient.  When an individual moves to a new residence, he/she needs to check out whether the ambiance of the new place is suitable for his/her health. Comprehensive nursing assessment form helps to diagnose that if the environment of the new location is comfortable for the health condition of the patients.

Nursing Care Health Assessment Form

greatwestlife.com

A member of a health care program and his/her physician is required to fill out  the nursing care health assessment form. The patient and his physician have to fill out the form at the time of claiming something from the health care center. The patient and the doctor need to read out the form very well before filling it out. they have to fill out te entire form and submit it as soon as possible. The form includes all the details of the health care plan and the membership of the individual. It also contains the medical history of the patient, the surgical procedures and so on.

Nursing Health and Safety Assessment Form

ucedd.georgetown.edu

Nursing health and safety assessment form is used by a registered nurse at the time of diagnosing patients with DD/ID challenges.  This assessment is created for patients who require  twentyfour-hours staff supports or an ICF level of care. Additionally, the director of the nursing department might need to use this form to access all the data related to an individual’s health and the status of the helath care services provided. The health care management plan  is an essential part of the nursing health and safety assessment form. It is very important to attach the details of the health care management plan. Or else, the form will be invalid.

Nursing College Assessment Form

Nursing college assessment form is an essential part of the entire nursing procedure. This assessment can be regarded as the base of the entire nursing process.  Nurses can create an improper nursing  plans and programs with an improper nursing assessment of any patient. That is w3hy it is very important to examine the physical condition of the patients before making the nursing college assessment form.

Why is it Important to Examine a Patient Before Diagnosing Him/Her?

It is very important to examine the entire health condition of a patient before trating him/her. The  family members of  a patient always consider a doctor responsible for  all the outcomes of the treatment or the surgery. Therefore, a doctor should never compromise to check the medocalo condition of the patient before tretainmg him/her. Examining the health of the patient helps a doctor to understand what kind of treatment will suit the patient.

Mediacal diagonosis starts with determining the disease and the conditions of the patient. The health care provider needs to check out every signs and sympotoms experienced by the patient before treating him/ her.

The doctor needs to gather certain Information related to the specific health conditions of each individuals. It is really essential to consider each little details of the medical history of a particular individual. Often the patients need to undergo several medical tests. The results of such tests make  huge differences in the procedure of treatments. Hence, such outcomes of these tests are also required to be included in the assessment forms.

Diagnosing a patient often becomes quite challenging for a health care provider. Different patients come with different illnesses and side effects. Sometimes same symptoms can be the indication of distinctive diseases. Having all the details of the physical, psycological, sociological and spiritual conditions of the patient ready at hand helps a physician to take immediate initiatives. Useful  Student Assessment Forms

Both the patient and the physician need to keep a copy of the nursing assessment form. Losing this form can be really problematic at the time of the treatment.

Online Availability of Nursing Assessment Forms

In the past days, all people had to search for these forms or any kind of documents in the market. It was really difficult for them to get these documents in a well drafted and printed manner. But the days of difficulties are gone. Nowadays, everyone turns to the internet regarding any kind of information. These forms are easily available on several websites.

If you are still finding it hard to get the nursing assessment form, you can easily download it from our website. You can download these forms, both in the PDF or doc format. These forms do not require any special kind of software or operating system to download. These do not consume much memory space also. Download and print these forms as per your preferences. You can also see  Interview Assessment Forms

If you are not okay with the pattern of the form, we can edit the form for you. Contact us anytime to get help with your requirements.

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Nursing Assessment Form Template

A nursing assessment is a systematic process of collecting and analyzing patient data to determine their healthcare needs. Using a nursing assessment template ensures comprehensive and consistent documentation of patient information.

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Assessment of patients is one of the essential responsibilities of nurses, with their help, nurses can identify the specialized needs of patients and then plan an effective healthcare intervention. These are fundamental for providing patient-cantered care plans to ensure their overall safety. 

In this blog post, you will discover more about nursing assessments, how with the help of a template such assessments can be made simple, and the best practices for using that template. 

• What Is Nursing Assessment?

Nursing assessment is a process of gathering, examining, and diagnosing details about a patient’s health. This process is critical for analyzing patient’s needs and planning appropriate healthcare interventions. Based on the collected information about a patient’s condition, healthcare providers can make informed decisions about their treatment.

Nurses perform such assessments at the start of a shift, possibly as indicated by the physician, or in case, there is an abrupt change in the patient’s condition. With such assessments, nurses ensure that patients receive the necessary care on time and accurately.

• Free Nursing Assessment Template

• A Template Can Simplify The Nursing Assessment

Nursing assessments are crucial for the safety and risk assessment of patients. Such assessments help in the process of making important decisions about the health of any patient. It also assists in the process of documentation and collaboration with different departments of a hospital. Nursing assessment can be a complex and time-consuming process, but with the help of a template, you can make a comprehensive form that provides constant structure for patient data collection and data entry. A form also provides proper fields to ask, assess, and input required information in an organized manner and eliminate the chances of missing any assessment point. Furthermore, a constant structure also helps any on-duty doctor or nurse to go through the assessment knowing where to look for required information. Here is how we have arranged the information and structured this template:

Nursing assessment

At the start of this nursing assessment template, you can write the date when this assessment was completed. Besides, there is space for writing the date of the 45-day nursing review, including the name of the person who performed this assessment. 

Patient information

Within this section of the template, you can write the particulars of a patient, such as their name, age, gender, date of birth, and patient ID. The admission date (when the patient was admitted to the hospital), name of referring physician, attending nurse, room/bed number, and the results of primary diagnosis can also be entered here. This information helps in the identification of a patient while planning a specialized treatment strategy for them. Moreover, it also assists in fulfilling the legal and ethical adjustments. 

In the following section, you can note down the specifications of the allergies that the patient may have, such as food allergies, pollen, dust mites, and more. You can also write the diagnosis of specific conditions, which may include hypertension, diabetes mellitus, pneumonia, appendicitis, or any other.  

In the vital signs section, you can write the results of the tests, such as BP, which shows blood pressure, P stands for pulse, R represents respiration rate, and T denotes temperature. Similarly, the HT is for height, and the WT denotes the weight. Writing down all these details is crucial as it helps in ensuring patient safety, effective care planning, and delivering quality healthcare. 

Patient history

Knowing the overall history of a patient facilitates the analysis of any emergencies, and ensures the patient’s safety by better understanding any conditions they may have. Additionally, it is necessary for legal and ethical considerations. It increases the awareness about a patient and their family history.

Medical history

Analyzing a patient’s medical history helps define a comprehensive care plan, and identify risk factors, and continuity of care. Within this section of the template, you can write about the medical history of a patient, such as chronic conditions (long-term diseases) if any, previous suggestions by any physicians, current medications, allergies (when the immune system reacts to a foreign substance), and specifying if there is a family history of the disease. 

Social history

Knowing about the social history of the patient is crucial for their proper assessment and treatment. Within the provided section, you can specify whether the patient is a smoker or drinker, or use any other substances. You can also write their occupation and living arrangements (type of residence, and location). 

Physical assessments

Physical assessments of a patient ease the early detection of health issues and provide holistic patient care, accurate diagnosis, and data collection. Within this section of the template, you can write about the general and system-specific examination of the patient.

General appearance

As a nurse, you must describe the general appearance of a patient. By using this template, you can specify whether your patient is conscious and able to move or not. You can also choose their nutritional status from the options, such as well-nourished, malnourished, or obese. Hygiene is important during the treatment of patients, so this template has provided space for describing the cleanliness of a patient.

System-specific examination

System-specific examinations refer to the assessments of the body systems to identify any issues or abnormalities. Such a system-specific examination includes:

• Cardiovascular: A section is added to help you assess the proper functioning of the patient’s heart and its blood vessels. It involves assessing the heart rate, rhythm, and murmurs (any abnormal heart sounds) of the patient.
• Respiratory: Knowing how the respiratory system of your patient is functioning is essential for their thorough assessment. In this section of the template, you can write the breath sounds, respiratory effort, use of accessory muscles, and more to check the proper functioning of the respiratory system.
• Gastrointestinal: Gastrointestinal refers to the abdomen and intestine. This section is added to enable you to examine the proper functioning of these organs. Within this section, you can write the results of the bowel sounds, abdominal tenderness, and distention.
• Neurological: Whether the nervous system of the patient is functioning properly or not, you can assess in this section. Here, you can write about the orientation, reflexes, strength, and sensations of the patient.  
• Musculoskeletal: Examination of the musculoskeletal system includes the assessment of the range of motion, joint function, and muscle strength. It eases the identification of the disorders, and chronic conditions if any. 
• Integumentary: Within this template, you can write about the integumentary examination of your patient’s body. It helps in the early detection of skin conditions, indicators of systematic diseases, infection control, and monitoring of chronic conditions. You can write the details of the skin integrity, wounds, and pressure ulcers. 
• Psychological: Writing the psychological details of a patient helps in the early detection of mental health issues, understanding the impact of illness, and enhancing communication. You can write about the mood, behavior, and cognition of the patient in this section.     

• Special Considerations

There might be some specific factors or unique aspects of a patient’s condition. You can write the details of such conditions in this section of the template. These may include

Risk assessments

Analyzing the risk factors comes within the scope of the nursing assessment. Within this section, you assess the risks associated with the treatment of a patient, these may include, fall risk (increased chances that a person may fall owing to various reasons), pressure ulcer risk (in old-aged patients, injuries due to prolonged sitting in the same position), and others. 

Advance directives

In some situations, patients are not able to communicate their decisions, owing to such conditions legal documents are used. Such documents contain instructions about a person’s preferences for medical treatment. There are three options available for such patients, these may include a living will, healthcare proxy, and DNR.

A living will is a legal document that outlines the particular types of medical supervision that the individual may or may not want at the time when they are no longer able to express their wishes. In the case of an unconscious person or a person suffering from a terminal illness, the doctors can consult the living will to know about their choice for life-sustaining treatments which may include tube feeding, assisted breathing, and more. It helps prevent ethical dilemmas during serious medical conditions.

Sometimes patients cannot make their own health-related decisions. In such cases, another person would make medical decisions for them. This person would be called a health proxy.

Depending on various scenarios and situations, some patients might not want to receive CPR (cardiopulmonary resuscitation), in case their heart stops functioning. Such a situation is called DNR , it is a type of advance directive. Its sole purpose is to respect the decision made by the patient. 

Cultural and religious needs

While providing healthcare services to a patient, it is essential to keep in consideration their cultural and religious needs. It involves respecting the preferences of the patient, improving compliance, and personalizing patient care. In this section, you can highlight the cultural and religious needs to avoid misunderstandings.

Language and communication needs

Effective communication is compulsory while treating a patient. In this section of the template, you can write the specific requirements of a patient to communicate. Without effective communication, there are greater chances of medical errors, incorrect administration, and safety issues. 

Nursing care plan

Writing a thorough care plan helps ensure that there is a systematic, and structured plan for healthcare. It increases the satisfaction of the patients and the quality of the overall care plan. Within this section of the template, you can write short-term and long-term goals. 

The short-term goals can be relieving the patient’s coughing and clearing breath in 48 hours, the patient should consume enough healthy meals, and the patient’s stress and anxiety would reduce in 48 hours and more. 

The long-term goals can be maintaining the blood pressure of the patient within 6 months, a patient will lose 15% of weight in 14 months, the patient will quit smoking in a year, and more.

Interventions

Interventions refer to the actions or strategies, as a nurse you perform to meet the expected outcomes of a patient. These may include management of pain, wound care, mobility assistance, or nutritional support. You can write the actions and rationales of these interventions.

Once the overall nursing plan is developed, it is time for its assessment or evaluation. With this, it can be analyzed how effective the plan is, further increasing its accountability and efficiency. Within this section, you can write the criteria that would be used for evaluating the effectiveness of the nursing care plan. 

By the end of this template, you can write your signature, date, and print name.

• Best Practices to Use Nursing Assessment Template:
• Before using the template, you should familiarize yourself with the purpose of each section provided in the template. 
• While filling out this template, avoid using vague terms instead use proper medical terminology. 
• You should involve your patient in the assessment process. Ask them questions that are open-ended and in-depth. It will help them understand their care plan, and you can gather more information about them.
• There should be no compromise on privacy, so make sure that all the information recorded on the template is kept confidential and complies with HIPPA or other privacy regulations of your state. 
• Make sure to store the completed templates securely, whether on electronic health records systems (EHR) or as physical files. 
• Record the system-specific examinations and physical assessments in the template after careful examination to avoid mistakes. Double-check the recorded information to ensure that everything is correct. 
• Write the detailed goals of the patient’s treatment plan and the intervention plan to take care of the patient in the respective sections of the template. It brings clarity for you to achieve these goals. 
• Closing Thoughts

The nursing assessment template is professionally designed to assist you in assessing your patients with accurate and consistent documentation. It is easily customizable and you can personalize it per your needs. It is available in multiple file formats, such as ODT, DocX, DotX, and Google Docs. It is also print-ready so for offline usage, you can print it. Assessment of patients is made simple and easy with the help of this template leading to better health outcomes and enhanced patient satisfaction. 

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Step 1: Patient Details

Step 2: structure of the form, step 3: medical information, step 4: care plan, step 5: monitoring and evaluation.

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