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COMPREHENSIVE NURSING ASSESSMENT TOOL

CLIENT HISTORY

I. GENERAL HISTORY OF CLIENT

Name___________________________________________________________Age___________Sex_________

Racial and ethnic data________________________________________________________________________

Marital status_______________________________________________________________________________

Number and ages of


children/siblings____________________________________________________________

Living arrangements__________________________________________________________________________

Occupation_________________________________________________________________________________

Education__________________________________________________________________________________

Religious affiliation___________________________________________________________________________

II. PRESENTING PROBLEM

A. Statement in the client’s own words of why he or she is hospitalized or seeking help

___________________________________________________________________________________________

___________________________________________________________________________________________

B. Recent difficulties/alterations
in_____________________________________________________________

1. Relationships

2. Usual level of functioning

3. Behavior

4. Perceptions or cognitive abilities

C. Increased feeling of
_______________________________________________________________________

1. Depression

2. Anxiety

3. Hopelessness
4. Being overwhelmed

5. Suspiciousness

6. Confusion

D. Somatic changes, such as


__________________________________________________________________

1. Constipation

2. Insomnia

3. Lethargy

4. Weight loss or gain

5. Palpitations

III. RELEVANT HISTORY – PERSONAL

A. Previous hospitalizations and


illnesses________________________________________________________

B. Educational
background___________________________________________________________________

C. Occupational
background__________________________________________________________________

1. If employed, where?______________________________________________________________________

2. How long at that job?_____________________________________________________________________

3. Previous positions and reasons for


leaving____________________________________________________

4. Special skills____________________________________________________________________________

D. Social patterns

1. Describe friends_________________________________________________________________________

2. Describe a usual day_____________________________________________________________________

E. Sexual patterns
1. Sexually active?_________________________________________________________________________

2. Sexual orientation_______________________________________________________________________

3. Sexual difficulties________________________________________________________________________

4. Practice safe sex or birth


control____________________________________________________________

F. Interests and abilities

1. What does the client do in his or her spare time?


_______________________________________________

2. What is the client good at?


_________________________________________________________________

3. What gives the client pleasure?


_____________________________________________________________

G. Substance use and abuse

1. What medication does the client take?


_______________________________________________________

How often?________________________How much?______________________________________________

2. What herbal or over the counter medications does the client take?
________________________________

How often?________________________How much?______________________________________________

3. What psychotropic drugs does the client take?


________________________________________________

How often?________________________How much?______________________________________________

4. How many drinks of alcohol does the client take per day?
_______________________________________

Per week__________________________________________________________________________________

5. Does the client identify use of drugs as a problem?


_____________________________________________

H. How does the client cope with stress?


_______________________________________________________
1. What does the client do when he or she gets upset?
___________________________________________

2. Whom can the client talk to?______________________________________________________________

3. What usually helps to relieve stress?


________________________________________________________

4. What did the client try this time?


___________________________________________________________

IV. RELEVANT HISTORY – FAMILY

A. Childhood

1. Who was important to the client growing up?


__________________________________________________

2. Was there physical or sexual abuse?


__________________________________________________________

3. Did the parents drink or use drugs?


___________________________________________________________

4. Who was in the home when the client was growing up?
___________________________________________

B. Adolescence

1. How would the client describe his or her feelings in adolescence?


___________________________________

2. Describe the client’s peer group at that


time.____________________________________________________

C. Use of drugs

1. Was there use or abuse of drugs by any family member?


___________________________________________

Prescription_______________________Street_____________________By whom?
______________________

2. What was the effect on the family?


____________________________________________________________
D. Family physical or mental problems

1. Is there any family history of violence or physical or sexual abuse?


___________________________________

2. Who in the family had physical or mental problems?


______________________________________________

3. Describe the problems_______________________________________________________________________

4. How did they affect the family?


________________________________________________________________

E. Was there an unusual or outstanding event the client would like to mention?
___________________________

____________________________________________________________________________________________

MENTAL AND EMOTIONAL STATUS

A. Appearance

Physical handicaps__________________________________________________________________________

Dress: Appropriate__________________________Sloppy____________________________

Grooming: Neat____________________________Poor______________________________

Eye contact held___________________________Posture____________________________

B. Behavior

Restless__________________Agitated___________________Rapid________________Slurred__________
___

Mannerisms_____________________Facial
expressions________________________Other________________

C. Speech

Clear_________________Mumbled______________Rapid________________Lethargic________________
___

Constant________________Mute or silent____________________Barriers in
communications_____________

D. Mood
What mood does the client convey?
_____________________________________________________________

__________________________________________________________________________________________

E. Affect

Is the client’s affect bland, apathetic, dramatic, bizarre, or appropriate? Describe.

__________________________________________________________________________________________

F. Thought process

1. Characteristics

Flights of ideas_________Looseness of association__________Blocking________________

Concrete thinking_____________Confabulation________________

Describe the characteristics of the client’s


responses____________________________________________

_______________________________________________________________________________________

2. Cognitive ability

Proverbs: Concrete___________Abstract_____________

Serial sevens: How far does the client go?_____________Can the client do simple math?
__________

What seems to be the reason for poor concentration?


__________________________________________

Orientation to time?_____________Place?________________Person?____________________

G. Thought content

1. Central theme: what is important to the client?


________________________________________________

Describe_______________________________________________________________________________

2. Self-concept: How does the client view himself or herself?


_______________________________________

______________________________________________________________________________________
3. Insight: Does the client have hallucinations?__________Delusions?________________

Obsessions?_____________Rituals?_____________Phobias?_____________Grandiosity?
____________

Religiosity?_____________Worthlessness?_______________

Describe______________________________________________________________________________

H. Spiritual assessment

1. What importance does religion or spirituality have in the client’s life?


_____________________________

_____________________________________________________________________________________

2. Do the client’s religious or spiritual beliefs influence the way the client takes care of
himself or herself or his or her illness?________ How?
_________________________________________________________________

3. Who or what supplies the client with hope?


____________________________________________________

I. Cultural influences

1. With what cultural group does the client identify?


_______________________________________________

2. Has the client tried any cultural remedies or practices for his or her condition? If so, what?
_____________

_______________________________________________________________________________________

3. Does the client use any alternative or complementary medicines/herbs/practices?


____________________

_______________________________________________________________________________________