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Student Name:__________________________ HENRY FORD COMMUNITY COLLEGE NURSING DIVISION

Date:__________________________________ CLIENT ASSESSMENT GUIDE

Nsg 126, 155, 221, 222 CUES: Client Initials: Age: Sex: Date of this SCR

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: SCR

Present Medical Diagnosis:

Surgery this admission: (include date) BIOLOGICAL FACTORS:

Chronic Diseases: SCR

Past Surgeries: (dates)

Medications taken at home: (include dosages, if known) Allergies: (write in red) Patterns and Habits related to Physical Health: SCR Values: Rank your health: Good, Fair, Bad

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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: T: P: R: SpO2 Pain: Ht: Wt: ____ ____ ____ ____ + Skin/Nails/Hair SCR:

S:

O:

Chart Data: Braden Scale Score + Neurological System:

S: SCR: O: *Hand grips *PERRL_________________

*Orientation to person ____________________, place______________, time________________ Chart Data:

Heinrich Fall Assessment + Sensory System :( sight, smell, hearing, taste and touch):

S:

O: SCR:

Chart Data: + Musculo - Skeletal System:

S: SCR:

O:

Chart Data: *ordered activity level_________________________ + Respiratory System:

S: SCR:

O:

Chart Data: CHEST X-RAY ++ABGs

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+ Cardiovascular System: S: SCR

O:

Chart Data: EKG (summary statement)

+ Hematologic System:

S: SCR

O:

Chart Data: ++HGB: ++HCT: ++WBC: ++Transfusions + Gastrointestinal System:

S: SCR

O:

Chart Data: I: O: Diet Orders

++Na ++K ++CO2 ++Protein/Albumin: + Genitourinary System:

S: SCR

O: Chart Data:

+ Endocrine System:

S: SCR

O: Chart Data: ++Blood Sugar:

++Thyroid Studies ++PSA

PSYCHOLOGICAL FACTORS: Appearance: SCR O: Affect: S: O: Behavior: S: O:

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PSYCHOLOGICAL FACTORS: (Cont.) Chart Data:

Communication: SCR O: (nonverbal) O: (verbal)

Chart Data: Perceptions: S: (about illness) S: (current stressors) S: (priorities)

Chart Data:

Cognition: O: Attention O: Memory SCR DEVELOPMENTAL DATA: SCR

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: SCR Race: National Origin:

Type of Residence: (Home, Apartment, Nursing Home) Religious/Spiritual Beliefs: Occupation: Education: Insurance: Does the client have any financial concerns? Marital Status: Number of children: Ages: Roles client has in family: Relationship and Support System: Home Environment:

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