Client Assessment Tool

Client Assessment Tool

The Client Assessment Tool provides a comprehensive guide for use when completing a client assessment in the clinical setting. The Client Assessment Tool can be downloaded or printed from the Online Companion and taken to the clinical sitefor assessing a client's physical and psychosocial needs.You are encouraged to write pertinent client assessment data on the assessment tool. You can add write-in space or delete items as required by your clinical setting and individual needs. (NOTE: Each nursing program can determine the extent of assessment each student will perform.)

Health History

Demographic information

Reason for seeking health care

Perception of health status

Does client have fears or concerns about health status at this time?

Previous illnesses, hospitalizations, and surgeries

Client/Family medical history – hypertension, diabetes, cancer, alcoholism

Immunizations/exposure to communicable diseases

Allergies

Current medications– anticoagulants

Developmental level - (Refer to Erickson’s Stages of Psychosocial Developmental table in chapter 10)

Psychosocial history

Self-concept/self-esteem

Sources of stress

Ability to cope

Sociocultural history

Home environment

Family situation

Client’s role in family

Recreational drug use

Complementary/alternative therapy use

Use of herbal supplements

Activities of daily living

Describe client’s lifestyle

Capacity for self-care

Use/History of alcohol, drug abuse, smoking, chewing tobacco, snuff

Physical examination

Head-to-Toe assessment

Vital signs

Temperature

Pulse

Respirations

Blood pressure

Pulse oximetry

Pain

Height

Weight/body mass index

Head and neck assessment

Hair and scalp

Eyes

PERRLA

Snellen test

Use of contacts and/or glasses

Presence of drooping eyebrows and eyelids

Color of sclera and conjunctiva

Presence of drainage

Pupil size in millimeters

Nose

Note presence of deformity, inflammation, or prior trauma

Check patency of nostrils

Ask if has experienced nosebleeds, dryness, or decrease in sense of smell

Lips and mouth

Color, symmetry, moisture, or lesions

Breath odors

Inspect oral mucosa -- check color, moisture, and free of lesions

Inspect tongue to determine client’s hydration

Enuciation of words

Voice changes – hoarseness

Dental hygiene practices

History of tobacco usage

Neck

Full range of motion

Enlargement of lymph nodes or thyroid gland

Pulsations in the neck

Jugular vein distention

Mental and neurological status and affect

Assess short term and long term memory

Level of orientation to person, place and time

Responsive to environment

Check coordination skills - ability to touch the tip of the nose with a finger and the tip of the nurse’s finger as it is moved to different locations

Skin assessment

Skin Turgor < 3 sec

Assess boney prominences for redness, swelling, pain, skin breakdown,

Assess incision for signs and symptoms of infection, intactness, drainage, approximation, assess sutures and/or staples,

Presence of an IV – location, assessment for signs and symptoms of infection, infiltration, and discomfort at the IV site, how much fluid remaining in IV bag, what type of fluid and the rate

Color

Moisture/dryness

Edema

+0 no edema

+1 indentation of 2 mm (0–¼ inches), disappears rapidly

(trace)

+2 pitting of 4 mm (¼–½ inch), disappears in 10 to

15 seconds (mild)

+3 pitting of 6 mm (½–1 inch), lasts 1 to 2 minutes

(moderate)

+4 pitting of 8 mm or more (greater than 1 inch), lasts 2 to

5 minutes (severe)

Thoracic Assessment

Cardiovascular status

Apical pulse

Blood perfusion of peripheral vessels and skin

Note changes in skin temperature, color, and sensations

Note changes in pulses -- radial, dorsalis pedis, and posterior tibialis pulses

Capillary refill

Assess toes for warmth and color

Compare peripheral pulses bilaterally and note changes in strength and quality

Personal exercise habits

Past chest pain

Shortness of breath

Describe pain – location, intensity, rate on scale of 0-10

Past experience of fainting or feeling dizzy

Presence of lower leg swelling

Respiratory status

Nasal flaring

Respirations -- labored, non-labored, rate, rhythm, depth, chest expansion

Assess if on oxygen therapy (how many liters per minute)

History of asthma, use of inhaler

Breath sounds

Normal sounds – bronchial, bronchovesicular, vesicular

Adventitious sounds –sibilant and sonorous wheezes, fine and course crackles,pleural friction rub, stridor, rhonchi

Presence of a cough – productive, nonproductive, frequency

Expectoration of secretions (sputum) – COCA (Color, Odor, Consistency and Amount)

ABG lab values

Wounds, Scars, drains, tubes, dressings, ostomies

Type of drain (Hemovac, Jackson-Pratt, Penrose)

Skin sutures, skin staples, WoundVac

Document location, size, and amount of drainage or discharge, signs of inflammation

Breasts

Size and symmetry

Note any obvious masses, dimpling, or inflammation

Nipples and areola

Symmetrical in size, shape and color

Note discharge from the nipples

Assess axillary lymph nodes – enlargement, tenderness

Does client perform breast self-exams

Date of last mammogram

Abdominal assessment

Gastrointestinal status

Assess if client is passing flatus, experiencing constipation, diarrhea, cramping, nausea, vomiting, GERD, heartburn, belching

Nasogastric tube

Assess placement of NG placement

Assess NG tube for intactness, continuous or intermittent suction, COCA NG drainage

Presence of rashes and scars

Abdominal appearance

Abdominal girth

Flat, rounded, distended, soft, firm, hard, board-like

Symmetry

Visible signs of peristalsis or pulsations

Abdominal auscultation in all 4 quadrants

Bowel sounds -- active, hypoactive, hyperactive

Abdominal light palpation – for lesions, masses, and pain

Genitourinary assessment

Urinary output (COCA)

Presence of catheter (foley, use of straight cath)

Presence of pubic area enlargement or fullness

Presence of urinary meatus inflammation or discharge

Affect of present illness on sexual activity

Lesions or ulcerations indicating sexually transmitted infections

Voiding pattern and any recent changes

Female:

Number of pregnancies

Use of birth control

Menstrual cycle history

Present sexual activity

Protection during intercourse

Date of last Pap test

Male:

Inspect penis, urethral meatus, foreskin and scotum

Performance of testicular self-examination

History of urinary tract infections, kidney stones, change in the urinary stream, or painful urination or nocturia

Musculoskeletal and extremity assessment

Symmetry and strength of major muscle groups

Range of movement when changing position – active and passive ROM

Observe client’s movement and posture when walking across the room – gait assessment

Observe the client’s gross motor movements and posture when sitting up in bed to assess gross motor movement and posture

Assess muscle strength – using grade system, hand grasp, arm strength assessment and lower extremity assessment, pedal push and pull

Palpate muscles to identify swelling, tone, or specific changes in the shape of the muscles

Hand grasps and foot pushes

Assess client’s coordination skills

Assess strength and symmetry of major muscle groups

Use of aids for ambulation

Lower extremity assessment

Determine color, loss of feeling

Loss of hair

Change in temperature within the extremity and from one extremity to the other

Presence of varicose veins, ulcers, and edema

Presence of leg pain, cramps, or muscle weakness

Difficulty or pain when walking or performing routine daily activities

Observe for stiffness, crepitus, or fatigue during ambulation