Student      					                                                         Client's Initials     
Date     					                                                         Age     
										Medical Diagnosis     

Nursing I - Assignment # 3  -  ASSESSMENT    (DATA COLLECTION)
PHYSIOLOGICAL:
OXYGEN: Cardiovascular
Skin warm to touch?     
Skin color      
Color of nail beds      
Temperature         Location       
Radial pulse rate       Rhythm      
Apical pulse rate      Rhythm       
BP: Location      Position      
Pedal pulses         Pulse ox      

	Respiratory
Respiratory rate          Rhythm      
Audible breath sounds       
Dyspnea  -  at rest      on exertion  
Cough        Sputum      
Smokes      Packs per day      
Medications      
 Laboratory data       
Equipment in use (O2 ,     Respiratory Rx)      
Additional data:      
	
FLUIDS AND ELECTROLYTES:
Skin turgor   -  Normal      Poor 
Tongue and lips     
Mucous membranes      
Fluid intake for previous 24 hrs      mLs
Fluid restriction     
(Note amt q 24 hrs & distribution q shift)
Additional data:      
     	
Presence of thirst       
 Nausea or vomiting    
Presence of edema    
Medication      
Laboratory data         
Equipment in use                                                                                                         

	
NUTRITION:
Ht         Wt      
Ordered diet      
Preferred foods      
% of meal consumed      
Dietary supplement       
Assistance with meals      

	
Dentures?     Upper         Lower         Partial 
Recent change in weight?      
Problem chewing?     Swallowing?     Heartburn?    Indigestion?   
Medications       
Laboratory data        
Equipment in use (N/G tube, PEG tube, G tube, etc.)      
Additional data:       
	
ELIMINATION:
Urinary:
  Amount        Color        Frequency     
 Bathroom   Commode  Bedpan   Incontinent
 Urine output for previous 24 hrs      mL
Bowel: Amount        Color       Frequency     
            Normal for client     Constipated 
            Diarrhea      Incontinent  	
Bowel sounds           Abdominal distention 
Medications      
 Laboratory data       
 Equipment in use       
Additional data:      
	
MOBILITY AND ACTIVITY:
Muscle strength - Handgrips equal  
                            Foot pushes equal
ROM -  Normal     Limited     Severely limited 
Ability to move in bed - Self    Assist   Immobile
OOB  -  Chair       Wheelchair      Geri-chair 
Ability to transfer - Self      Assist      
Distance able to ambulate         Gait     	Fall Assessment Score     
Fall risk - High       Moderate         Low 
Physical therapy working with client?      
Medications      
Laboratory data      
Equipment in use (assistive devices)      
Additional data:       
	
REST, SLEEP AND PAIN:
Reported quality of sleep in hospital      
C/O Pain   -
     Location      
     Intensity      
     Duration       	
Observable signs of pain - Grimacing     Posturing       Moaning 
Medications       
Pain scale      
Additional data:       

SAFETY AND SECURITY:
Vision:
     Able to see without glasses      Needs glasses 
     Able to read own menu 
     Watches TV from       ft
     Medications     
Hearing:
      Responds to normal voice tones 
      Hearing aid       Deaf 
Speech:
      Clear     Garbled    Incomprehensible 

Mental status:
     Alert      Lethargic        Unresponsive 
     Oriented to  - Person      Time      Place 
     Medications            

Braden/Norton Score              	Skin integrity:
Intact 
Reddened       Location       
Balancing erythema     Non-balancing erythema 
Incision/Lesion/Wound      Location       
Approx. size in cms      
Appearance     
Treatment (dressings, etc/)      
Medications     

Allergies     
Laboratory data      

Environment:      
Physical surroundings      
Additional data:          

	

LOVE AND BELONGING:
Client report of family/friends     

Indicators - Cards    Flowers Family pictures 

	Next of kin (chart)     
Religious affiliation     
Additional data:      

SELF-ESTEEM:
Family role     
Occupation     
Interest in appearance     

	 Grooming equipment at bedside:
Brush/comb       Toothbrush        Toothpaste
Other personal toiletries 
Additional data:      

SELF-ACTUALIZATION:
Client report of satisfaction with life     

Independence     
Creativity     
	
Additional data:       	

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

Nursing I Internet Assignment 3