Student Name:__________________________ Date:__________________________________

HENRY FORD COMMUNITY COLLEGE NURSING DIVISION

CLIENT ASSESSMENT GUIDE

Nsg 126, 155, 221, 222 CUES: Client Initials: Age: Sex: Date of this Admission: Client General Survey and Nurses' Initial Impression: (Description of client and environment) HEALTH CARE SITUATIONS: Why is nursing and/or health care being sought: Present Medical Diagnosis: Surgery this admission: (include date) BIOLOGICAL FACTORS: Chronic Diseases: Past Surgeries: (dates) Medications taken at home: (include dosages, if known) Allergies: (write in red) Patterns and Habits related to Physical Health: Values: Rank your health: Good, Fair, Bad SCR SCR SCR SCR

Please Note:
+ Include medications prescribed for client under the systems they affect. ++ Include dates and times for lab data and vital signs (abnormals should be written in red or highlighted) Vital signs: Include date and time Date: Time: ++B/P: ____ ____ ____ ____ SCR: T: P: R: SpO2 Pain: Ht: Wt:

+ Skin/Nails/Hair S: O: Chart Data: Braden Scale Score + Neurological System: S: O: *Hand grips *PERRL_________________

SCR:

*Orientation to person ____________________, place______________, time________________ Chart Data: Heinrich Fall Assessment + Sensory System :( sight, smell, hearing, taste and touch): S: O: Chart Data: + Musculo - Skeletal System: S: O: Chart Data: *ordered activity level_________________________ + Respiratory System: S: O: Chart Data: CHEST X-RAY ++ABGs SCR: SCR: SCR:

+ Cardiovascular System: S: O: Chart Data: EKG (summary statement) + Hematologic System: S: O: Chart Data: ++HGB: + Gastrointestinal System: S: O: Chart Data: I: Diet Orders ++Na ++K ++CO2 ++Protein/Albumin: O: SCR ++HCT: ++WBC: ++Transfusions SCR SCR

+ Genitourinary System: S: O: Chart Data: + Endocrine System: S: O: Chart Data: ++Blood Sugar: ++Thyroid Studies ++PSA PSYCHOLOGICAL FACTORS: Appearance: O: Affect: S: O: Behavior: S: O: SCR SCR SCR

PSYCHOLOGICAL FACTORS: (Cont.) Chart Data: Communication: O: (nonverbal) O: (verbal) Chart Data: Perceptions: S: (about illness) S: (current stressors) S: (priorities) Chart Data: Cognition: DEVELOPMENTAL DATA: Sexuality: S: Erickson=s Stage: (Where is your client and why) Life Cycle Events: S: O: Conditions affecting human development: S: O: SOCIO-CULTURAL DATA: Race: Religious/Spiritual Beliefs: Occupation: Insurance: Marital Status: Roles client has in family: Relationship and Support System: Home Environment: Education: Does the client have any financial concerns? Number of children: Ages: National Origin: Type of Residence: (Home, Apartment, Nursing Home) SCR O: Attention O: Memory SCR SCR SCR

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