I.

VITAL INFORMATION
Initials:
Age:
Sex:
Ethnic Group:
Marital Status:
Occupation:
Current Employment Status:
Insurance Coverage:
Date of Admission:
Diagnosis:
Reason for seeking Medical Assistance or Hospitalization:
Allergies:
Client’s Health History:
Family Health History:

II. NURSING ASSESSMENT

A. Socio – cultural
 How does the client view the current illness?
 What are the beliefs regarding health/healing practices?
 Religious and/or spiritual beliefs/practices?
 What is the client’s beliefs about family (e.g. structure, roles, loss, participation in
care, and decision – making)?
 Any special dietary considerations or preferences?
 Any language or communication difficulties?

B. Development
 Identify client’s status as it relates to Erikson’s developmental phases (e.g. old age),
psychosocial stage (e.g. late adulthood) and developmental tasks (e.g. letting go).
Describe observation made.
C. Psychological
 What is the client’s emotional state (e.g. depressed, shy, and angry)?
 How does the client seem to be coping with illness? Is the client using any defence
mechanisms? Any maladaptive response noted? Any fear or anxiety noted (e.g.
crying or excessive complaining)?
 Does the client seem disinterested or detached? Is the client able to express fears?
What is client’s perception regarding threats to body image and separation from
support system?

D. Physiological
1. Cerebral and Peripheral Innervation
 Level of consciousness (degree of alertness); degree of orientation to time,
place, and person? If confused, describe specific behavioural responses:
memory, difficulty speaking or swallowing, or organizing sentences?
Ability to follow directions? Are grips equal in strength? Test for strength
in lower extremities and describe. Any tremors or shaking? Lack of
coordination? Any numbers or tingling? Convulsion movements? Response
to sensation and painful stimuli? Hyperesthesia? Any fainting? Signs of
paralysis? Any change in guilt?
 Eyes: describe color of iris, sclera, and conjunctiva. Any evidence of
inflammation? Any mucus drainage or encrustations? Size and shape of
pupils? PERRLA? Consensual response? EOM? Strabismus? Describe any
evidence of visual ability or difficulty. Any edema of lids? Ptosis?
 Ears: Describe any evidence of actual hearing ability or difficulty.
Symmetry of placement? Size? Any wax build up, drainage, or debris?
Tinnitus? Vertigo?
 Diagnostic Studies: compare client values with normal values and describe
significance (e.g. LP, EEG, x – rays, CT Scan, myelogram, etc.)
2. Integumentary
 Hair: Color? Length? Any evidence of loss? Vermin? Flakes? Eruptions on
scalp? Dull or shiny? Texture distribution? Debris? Oil or dry?
 Nails: Color? Opacities? Shape (e.g. spoon nails, clubbing, etc.) length?
Any debris? Any ridges or cracks? Degree of brittleness? Growth pattern?
 Skin: describe the actual color of the skin. Describe how it feels: warm,
cool, moist, dry? Any eruptions or scales? Rashes (describe, if present)
turgor? Elasticity (describe)? Scaling? Discolorations? Scars? If present,
describe the scars as well as the surrounding tissue (e.g. edema, redness,
etc.), even if it is healed. Describe all wounds: size (in cm) and shape,
location, or drainage. If the drainage is present, describe amount color, odor,
condition of surrounding tissue, etc. Is there a break in the integument due
to I.V.’s? If present, describe the status of the site (e.g. any redness,
swelling, drainage, tenderness, or heat). All descriptions must be clear,
complete, and detailed.

3. Oxygenation
 Respiratory rate rhythm, depth? Identify client’s normal range (high and
low). How do your findings compare? Shape of chest? Is chest expansion
symmetrical? If not describe. Any shortness of breath, dyspnea,
orthopnoea? Use of accessory muscle? Nasal flaring? Is client a mouth
breather, chest breather, or abdominal breather? Any cyanosis? If present,
describe. Any cough? If present, when, how, frequent, type: dry or
productive (quantity, color, clarity of secretions produced)? Hemoptysis?
Respiratory chest pain? If present, when, severity, etc. assess for anterior,
posterior and bilateral breath sounds: what do you hear … rales, rhonchi,
wheezing, or friction rubs? Which lobes(s)? Is it heard upon inspiration,
expiration, or both? Is client receiving oxygen therapy? If so, amount?
Type? Per what method?
 Diagnostic studies: client’s values. Normal values and significance (e. g. x-
rays, sputum C and S, ABG, CBC with differential, lung scan, etc.).
4. Circulation
 Indicate and describe characteristics of all pulses, including apical (rate,
rhythm, strength); describe status of the vessel wall; pulse rate? Give
client’s normal rate (high & low) and compare your findings. Pulse deficit?
Blood pressure? Give client’s normal BP range (high & low) and make
comparison is there JVD? What are the results of your check for Homan’s
sign? Orthostatic hypotension? Any edema of extremities? If present, which
extremity (ies); describe specifically. Any chest pain (when? Severity?
Radiation? Describe specifically.) Palpitations? Capillary Filling Time
(must be less than 3 seconds)?
 Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. CVP, serum cholesterol, SGOT, SGPT, LDH,
CPK, cardiac cath, EKG, chest x-ray, etc.)

5. Hematological
 Any bleeding tendencies? Fatigue? Shortness of breath? Extreme
weakness? Skin color and turgor? Any palpable lymph nodes? Describe.
Transfusion required? If so, what type? Iron supplements required?
 Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. bone marrow aspiration, RBC, WBC, platelet
count, HCT, HGB, coagulation time, serum iron, etc.).

6. Immunological
 Any allergies? If so, describe the allergen and response. Childhood
diseases? Immunity: Active, Passive, Acquired, Natural, or Artificial,
Tonsils removed? Any swollen or tender lymph nodes? Any
immunosuppressive? Chemotherapy treatments?
 Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. Sedimentation rate, WBC, lymphocyte count, C
& S, biopsies, etc.).
7. Digestive and Bowel Elimination
 Digestive assessment: mouth and oral cavity: give complete description of
tongue, lips, mucous membranes: coated, chapped, cracked, lesions,
fissures, color and status of gums? Any bleeding, pigmentation, or
malodour? Describe condition of teeth: color, structure, any missing, or
dentures? Any throat soreness or discomfort? Abdomen: what is the
appearance ... distended, protrusions? Where? Symmetrical? Any visible
peristalsis? Venous pattern on abdominal wall? Any tenderness? If present,
describe. How does it feel to touch: firm or soft? Can you palpate any
masses (where, describe)? Bowel sounds present? Where (describe)?
Bruits? Any complaints of indigestion, nausea, or vomiting?
 Nutritional Status: Client’s height and weight. What does the client look
like with reference to nutritional status? Weight loss or gain? Fatigue?
Irritability? Lesions or eruptions on skin or mucous membranes? Pallor?
Type of diet ordered? Percentage of meals consumed? Usual intake pattern?
Intake pattern since hospitalization? Food preferences? Any NGT feedings
or TPN solutions?
 Elimination: Usual bowel habits prior to and since hospitalization? Stools:
characteristics, amount, shape, color, consistency, and odor?
 Diagnostics Studies: compare client’s values with normal values and
describe significance (e.g. HVT, HGB, total protein level, albumin, guiac,
x-ryas, amylase, endoscopy, liver function lab tests, etc.).

8. Metabolism
 Client’s temperature? Any intolerance to heat or cold? Changes in voice or
vision? Any weight changes? Any change in hair growth and texture?
Polydipsia? Polyuria? Polyphagia? Poor wound healing? Any fatigue?
Weakness: drowsiness? Palpitations? Nervousness? Irritability? Insomnia?
 Diagnostic Studies: compare client’s values with normal values and
describe significance (e.g. FBS, finger stick for glucose, serium TSH, serum
CA and Phos., (CT Scan, serum T3 and T4, radioactive iodine uptake, etc.).
9. Urinary Elimination
 Is client receiving I.V. therapy with electrolytes? What type? Any evidence
of electrolyte imbalance? Monitor client’s output pattern during your
clinical time. What is the amount and frequency of client’s usual output
pattern? Compare 8 hour and 24 hour intake and output patterns and
balance. Does the client experience intermittency, frequency, dribbling,
urgency, or retention (is there any distention at the suprapubic area)? Any
incontinence? If present, describe the urine; any discharge? Burning on
urination? Describe the urine: color, odor, and clarity? Any haematuria?
 Diagnostic Studies: Compare client’s values with normal values and
describe significance (e.g. serium electolytes, Co2, HCO3, UA, Bun,
creatinine. C & s, specific gravity, KUB, biopsies, IVP, etc.).

10. Reproductive
 Female: Describe appearance of vaginal mucus membranes and labia.
Complaints of pain or discomfort? Any discharge? If present, describe
color, consistency, odor, amount, associated, bleeding, spotting, pruritus or
irritation of the skin, etc. any malformations? Age of menarche? Last
normal menstrual period? Number of pregnancies? Number of live births
any abortions/ any breast tenderness or discharge?
 Male: development? Scars? Is client circumcised? Testes: relative size,
tenderness, or masses? Are both testicles descended? Any discharge? If
present, describe. Any malformations?
 Diagnostics Studies: Compare client’s values with normal values and
describe significance (e.g. biopsies, pap smear, mammography, urine
hormone levels, etc.).

11. Musculoskeletal
 Describe the overall muscle structure, build and tone. Any atrophy? If
present, where and to what degree? Any contractures? If so, which joints
specifically? Degree of ROM of all joints? If limited, then describe to what
 degree (e.g. can extend elbow only 30 degrees). Ability to move self? Gout?
Smoothness of movement? Lordosis? Scoliosis? Kyphosis? Ant fracture? If
present, state location, presence of therapeutic devices (e.g. traction, cast,
etc.). How is movement affected? Ant swelling of joints, redness,
tenderness, or local heat?
 Diagnostic Studies: Compare client’s values with normal values and
describe significance (e.g. x-rays, myelogram, arthogram, biopsy, serum
CA and Phos., etc.).
 PLEASE EMPHASIZED ON THE IDENTIFIED SRESSORS WITHIN THE FOUR
VARIABLES AND THE SUBSYSTEMSWITHIN THE PHYSIOLOGICAL VARIABLE

1. VITAL INFORMATION
Initials: Age: Sex: Room #: Admission Date:
Medical Diagnosis:

Surgical Procedures: (This hospitalization):

Reason for seeking medical assistance or hospitalization:

Allergies:

Lines of resistance – Defence/ Patient health history:

Family health history: