<p> Client Assessment Tool</p><p>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 site for 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.)</p><p>Health History</p><p>Demographic information</p><p>Reason for seeking health care</p><p>Perception of health status </p><p>Does client have fears or concerns about health status at this time?</p><p>Previous illnesses, hospitalizations, and surgeries</p><p>Client/Family medical history – hypertension, diabetes, cancer, alcoholism</p><p>Immunizations/exposure to communicable diseases</p><p>Allergies </p><p>Current medications – anticoagulants</p><p>Developmental level - (Refer to Erickson’s Stages of Psychosocial Developmental table in chapter 10)</p><p>Psychosocial history</p><p>Self-concept/self-esteem </p><p>Sources of stress</p><p>Ability to cope</p><p>Sociocultural history</p><p>Home environment</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Family situation</p><p>Client’s role in family</p><p>Recreational drug use</p><p>Complementary/alternative therapy use </p><p>Use of herbal supplements </p><p>Activities of daily living</p><p>Describe client’s lifestyle</p><p>Capacity for self-care</p><p>Use/History of alcohol, drug abuse, smoking, chewing tobacco, snuff</p><p>Physical examination</p><p>Head-to-Toe assessment</p><p>Vital signs</p><p>Temperature</p><p>Pulse</p><p>Respirations</p><p>Blood pressure</p><p>Pulse oximetry</p><p>Pain</p><p>Height</p><p>Weight/body mass index</p><p>Head and neck assessment</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Hair and scalp</p><p>Eyes</p><p>PERRLA</p><p>Snellen test</p><p>Use of contacts and/or glasses</p><p>Presence of drooping eyebrows and eyelids</p><p>Color of sclera and conjunctiva</p><p>Presence of drainage</p><p>Pupil size in millimeters</p><p>Nose</p><p>Note presence of deformity, inflammation, or prior trauma</p><p>Check patency of nostrils</p><p>Ask if has experienced nosebleeds, dryness, or decrease in sense of smell</p><p>Lips and mouth</p><p>Color, symmetry, moisture, or lesions</p><p>Breath odors</p><p>Inspect oral mucosa -- check color, moisture, and free of lesions</p><p>Inspect tongue to determine client’s hydration</p><p>Enuciation of words</p><p>Voice changes – hoarseness</p><p>Dental hygiene practices</p><p>History of tobacco usage</p><p>Neck</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Full range of motion</p><p>Enlargement of lymph nodes or thyroid gland</p><p>Pulsations in the neck</p><p>Jugular vein distention</p><p>Mental and neurological status and affect </p><p>Assess short term and long term memory </p><p>Level of orientation to person, place and time</p><p>Responsive to environment</p><p>Check coordination skills - ability to touch the tip of the nose with a finger and </p><p> the tip of the nurse’s finger as it is moved to different locations</p><p>Skin assessment </p><p>Skin Turgor < 3 sec</p><p>Assess boney prominences for redness, swelling, pain, skin breakdown, </p><p>Assess incision for signs and symptoms of infection, intactness, drainage, </p><p> approximation, assess sutures and/or staples, </p><p>Presence of an IV – location, assessment for signs and symptoms of infection, </p><p> infiltration, and discomfort at the IV site, how much fluid remaining in IV </p><p> bag, what type of fluid and the rate</p><p>Color</p><p>Moisture/dryness</p><p>Edema</p><p>+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</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 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)</p><p>Thoracic Assessment</p><p>Cardiovascular status</p><p>Apical pulse </p><p>Blood perfusion of peripheral vessels and skin </p><p>Note changes in skin temperature, color, and sensations</p><p>Note changes in pulses -- radial, dorsalis pedis, and posterior </p><p> tibialis pulses</p><p>Capillary refill</p><p>Assess toes for warmth and color</p><p>Compare peripheral pulses bilaterally and note changes in strength </p><p> and quality</p><p>Personal exercise habits</p><p>Past chest pain</p><p>Shortness of breath</p><p>Describe pain – location, intensity, rate on scale of 0-10</p><p>Past experience of fainting or feeling dizzy</p><p>Presence of lower leg swelling</p><p>Respiratory status</p><p>Nasal flaring</p><p>Respirations -- labored, non-labored, rate, rhythm, depth, chest expansion</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Assess if on oxygen therapy (how many liters per minute)</p><p>History of asthma, use of inhaler</p><p>Breath sounds</p><p>Normal sounds – bronchial, bronchovesicular, vesicular</p><p>Adventitious sounds –sibilant and sonorous wheezes, fine and </p><p> course crackles, pleural friction rub, stridor, rhonchi</p><p>Presence of a cough – productive, nonproductive, frequency</p><p>Expectoration of secretions (sputum) – COCA (Color, Odor, Consistency </p><p> and Amount)</p><p>ABG lab values</p><p>Wounds, Scars, drains, tubes, dressings, ostomies</p><p>Type of drain (Hemovac, Jackson-Pratt, Penrose)</p><p>Skin sutures, skin staples, WoundVac</p><p>Document location, size, and amount of drainage or discharge, signs of </p><p> inflammation</p><p>Breasts</p><p>Size and symmetry</p><p>Note any obvious masses, dimpling, or inflammation</p><p>Nipples and areola</p><p>Symmetrical in size, shape and color</p><p>Note discharge from the nipples</p><p>Assess axillary lymph nodes – enlargement, tenderness</p><p>Does client perform breast self-exams</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Date of last mammogram</p><p>Abdominal assessment</p><p>Gastrointestinal status </p><p>Assess if client is passing flatus, experiencing constipation, diarrhea, </p><p> cramping, nausea, vomiting, GERD, heartburn, belching</p><p>Nasogastric tube </p><p>Assess placement of NG placement</p><p>Assess NG tube for intactness, continuous or intermittent suction, </p><p>COCA NG drainage </p><p>Presence of rashes and scars</p><p>Abdominal appearance </p><p>Abdominal girth </p><p>Flat, rounded, distended, soft, firm, hard, board-like</p><p>Symmetry</p><p>Visible signs of peristalsis or pulsations</p><p>Abdominal auscultation in all 4 quadrants </p><p>Bowel sounds -- active, hypoactive, hyperactive</p><p>Abdominal light palpation – for lesions, masses, and pain </p><p>Genitourinary assessment </p><p>Urinary output (COCA)</p><p>Presence of catheter (foley, use of straight cath)</p><p>Presence of pubic area enlargement or fullness</p><p>Presence of urinary meatus inflammation or discharge</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Affect of present illness on sexual activity</p><p>Lesions or ulcerations indicating sexually transmitted infections</p><p>Voiding pattern and any recent changes</p><p>Female:</p><p>Number of pregnancies</p><p>Use of birth control</p><p>Menstrual cycle history</p><p>Present sexual activity</p><p>Protection during intercourse</p><p>Date of last Pap test</p><p>Male:</p><p>Inspect penis, urethral meatus, foreskin and scotum</p><p>Performance of testicular self-examination</p><p>History of urinary tract infections, kidney stones, change in the urinary </p><p> stream, or painful urination or nocturia</p><p>Musculoskeletal and extremity assessment</p><p>Symmetry and strength of major muscle groups</p><p>Range of movement when changing position – active and passive ROM</p><p>Observe client’s movement and posture when walking across the room – gait </p><p> assessment</p><p>Observe the client’s gross motor movements and posture when sitting up in bed to</p><p> assess gross motor movement and posture</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Assess muscle strength – using grade system, hand grasp, arm strength </p><p> assessment and lower extremity assessment, pedal push and pull</p><p>Palpate muscles to identify swelling, tone, or specific changes in the shape of the </p><p> muscles</p><p>Hand grasps and foot pushes</p><p>Assess client’s coordination skills </p><p>Assess strength and symmetry of major muscle groups</p><p>Use of aids for ambulation</p><p>Lower extremity assessment</p><p>Determine color, loss of feeling</p><p>Loss of hair</p><p>Change in temperature within the extremity and from one extremity to the other</p><p>Presence of varicose veins, ulcers, and edema</p><p>Presence of leg pain, cramps, or muscle weakness</p><p>Difficulty or pain when walking or performing routine daily activities</p><p>Observe for stiffness, crepitus, or fatigue during ambulation</p><p>© 2011 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.</p>