Student:                                                                                               	 Client’s Initials:   
	
Date:                                                                                                                                  	Age:    	

Nursing I - Assignment #2  -  ASSESSMENT   (DATA COLLECTION)
PHYSIOLOGICAL
OXYGEN:   Cardiovascular                                                                                 Respiratory
Skin warm to touch:   Head & Torso   Arms & Hands   Legs & Feet        Respiratory rate__________   Rhythm__________
Color of nail beds_____________________                                                          Skin color____________________________________
Temperature: _______      Location________________                                        Breath sounds_________________________________
Radial pulse rate_____ Rhythm_____      Apical pulse rate:      Rhythm _____         
Blood pressure: Location __________    Position__________
Pulse ox__________
Medications:                                                                                                            Medications:

Additional data:
	
FLUIDS AND ELECTROLYTES
Skin turgor over sternum:    
Tongue & Lips:    
Amount of liquids taken at  one meal:   (approx.)________ ml                              Additional data: 

Medications:                                                                                                            
	
NUTRITION
General appearance: Obese”    Average”    Thin”                                             Dentures: Upper”    Lower”    Partial”    Has own teeth”
Ordered diet:__________________________________                                       Problem chewing?”      Swallowing?”
% of meal consumed: ___________________                                                       Equipment in use (G/tube, PEG tube, etc.):
Ht.____________      Wt.____________

Medications:                                                                                                            Additional data:
	
ELIMINATION:    Urinary                                                                                  Bowel
Incontinence: _________________________________                                        BM:     Large”   Moderate”    Small”
Bedpan”   Commode”   Toilet”                                                                                      Formed”    Hard”    Loose”

Medications:                                                                                               Additional data:
	
MOBILITY AND ACTIVITY
Muscle strength:   Handgrips equal”   Foot pushes equal”                                  OOB:   Chair”    Wheelchair”
ROM:    Full”   Limited”   Severely limited”                                               Ability to transfer:  Self”   Assist x ______      Hoyer”
Ability to move in bed:   Self”   Assisted”   Immobile”                                 Physical therapy:    Yes”    No”
Fall Assessment Score ________
Fall risk:                                                                                                     Additional data:
Medications:                                                                                               	

REST, SLEEP AND PAIN
Able to stay wake during morning care?    Yes”    No”
Complaints of fatigue when OOB?    Yes”    No”
Complaints of pain?  Yes”    No”          Location_____________     Intensity_____________    Duration____________
Pain scale ________________________

Medications:                                                                                                            Additional data:

	
                                                                                                           
SAFETY AND SECURITY                                                                     
Vision:      Able to see without glasses”     Needs glasses”                         Skin integrity:   Intact”     Pressure ulcers”
                  Blind”                                                                                        Location and size:______________________________________
                  Makes eye contact with caregiver from ______ feet                            _____________________________________________________
                                                                                                                        Treatment:  
Hearing:    Responds to normal voice tones”                                                      Turning schedule posted? ”
                  Hearing aid”      Deaf”                                                                     Preventive devices?_____________________________________

Speech:      Clear”     Garbled”     Incomprehensible”                                     Skin tears”     
                                                                                                                              Location and size:______________________________________
Mental status:   Alert”     Lethargic”     Unresponsive”                                   ____________________________________________________
                         Oriented to:   Person”    Time”    Place”                                Treatment:  
                                                                                                                              Protective sleeves?”
                                                                                                                        Allergies:_______________________________________________
                                                                                                                        Environment:____________________________________________
Medications:
                                                                                                                        Additional data:
 	
LOVE AND BELONGING
Client report of family/friends___________________________                  Next of kin (chart)________________________________________
___________________________________________________                  Religious affiliation_______________________________________ 
Indicators:  Cards”   Family pictures”   Drawings by grandchildren” 
    Other_____________________________________________                 Additional data:
	
SELF-ESTEEM
Family role__________________________________________                  Grooming equipment at bedside:    Brush/comb”
Occupation__________________________________________                      Toothbrush/toothpaste”     Other personal toiletries”
Interest in appearance_________________________________
                                                                                                                        Additional data:
	
SELF-ACTUALIZATION
Client report of satisfaction with life ______________________                 Additional data:
____________________________________________________
History on chart gives indications of goals met______________
____________________________________________________

ERIKSON’S STAGE OF DEVELOPMENT
The client is at the following developmental stage as evidenced by:

	

assessment Assignment 2 Nsg I

c:assessment-dc2