Nurses use a checklist to perform a physical assessment.
A physical assessment is an important tool for a doctor prior to examining a patient for any illnesses. The assessment is an overview of the patient's general condition, as well as a verbal history of major illnesses, medical procedures and allergies. The assessment is generally done by a nurse who has a checklist of items to document.
Preliminary Work
Begin by knocking on the door for entry and explaining the procedure to the patient. Wash your hands, remove the bed railing and raise the bed to a height that is comfortable for you and the patient. Take down vital statistics such as name, age, and the patient's reason for being there. Assess his consciousness level by asking if he knows where he is and who is the current president of the United States.
History
Ask the patient about any allergies or reactions to medicine. Find out if he has had any major surgeries, chronic illnesses or physical or mental impairments. Ask if he is currently on any type of medications, prescription or otherwise, and for what reasons. Document any findings in the medical chart or input them into a computer used specifically for documenting physical assessments.
Physical Exam - Upper Body
Using a penlight, examine the pupils for size and reaction. Examine the mucus membranes and note any excess mucus, color other than clear and fluidity. Take note of the patient's skin color, any abnormalities, temperature and moisture. Take the patient's temperature, heart rate and blood pressure. Press your finger on the end of the patient's finger and time how long it takes for the color to return. Tell the patient to grasp your fingers to test for strength, and then have him take deep breaths as you check lung function.
Physical Exam - Lower Body
Inspect the patient's stomach and check for intestinal and bowel sounds. Press your finger against the foot's dorsum for several seconds to assess any swelling or restriction of blood flow. Have the patient press his feet against your hands to gauge foot strength.
Closing
Thank the patient for his cooperation and inform him that the doctor will be in shortly. Return the bed to the initial position and wash your hands before leaving. Finish placing the information into the computer and move on to the next patient.
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