CLIENT PROFILE AND ASSESSMENT

(REPRODUCTIVE HEALTH)

Student Name: ________________________________

Date: _____________________
I. CLIENT PROFILE: (subjective data)
Client Name (initials):

Date of Birth:

Occupation:
Age:

Birthplace:
Highest grade of formal education:

Sex:

Race:

Marital Status:

Statement of Present Problem and Duration:

(Reason for seeking medical attention & when problem started)

II. HEALTH HISTORY and REVIEW OF SYSTEMS:

A. CLIENT: (Use the words in italic as a prompt for system specific illness/disease, previous
hospitalizations that the student should inquire about. State what, when, and outcome. Do not leave any
section blank. If no problems, state none or client denies problems.)

Neurological: (headaches, migraines, weakness, ataxia, tics, tremors, seizures, vertigo, syncope,
diminished sense of smell, touch, sensation, taste, numbness, tingling, head injury, LOC, DTRs,
clonus, blurred vision)

Psychological: (depression, anxiety, eating disorder, schizophrenia, bipolar disorder, emotional

state)

Integumentary: (eczema, seborrhea, alopecia, skin color, skin temp.)

Eyes: (glaucoma, cataract, vision problems)

Ears/Nose/Throat & Neck: difficulty hearing, use of hearing aid, dental caries, bleeding gums, sinus
problems, epistaxis, resp. effort, breath sounds)

Respiratory: (COPD, emphysema, asthma, bronchitis, sarcoidosis, pneumonia, tuberculosis, SARS)

Cardiovascular: (heart problems, hypertension, chest pain, palpitations, MI, CAD, valvular disorder,
atherosclerosis, thrombophlebitis, varicose veins, capillary refill, lower extremities, edema/degree)

Gastrointestinal: (indigestion, ulcer, GERD, dysphagia, gallbladder disease, pancreatitis, bowel

disorders, hemorrhoids, constipation, diarrhea, incontinence, meal pattern, special needs, cultural
restrictions, appetite, nausea and vomiting, RUQ epigastric pain)

Urinary: (kidney disease, incontinence, lithiasis, nocturia, hematuria, urgency, retention)

Musculoskeletal: (muscle weakness, decreased ROM/mobility, joint pain/stiffness/swelling, leg

cramps, back pain, history of trauma)

Endocrine: (diabetes, thyroid disease, goiter)

Lymph Nodes: (lymphoma, Hodgkins disease)

Hematological: (leukemia, anemia, hemophilia, bruising, transfusions~when and why)

Immunological: (frequent infections, diminished immune status, HIV infection)

Surgical History: (what for, when, any complications or adverse reaction to anesthesia)

Prenatal Care: (month of 1st PN visit, prenatal classes attended, # of prenatal visits, antepartal
procedures/fetal well being testing, GTPAL, blood type)

Obstetrical History: (prenatal, antenatal, or postpartal complications)

Sexual History: (STIs, treatment, use of contraceptives, sexual orientation, and sexual practices)

Labor and Delivery Plans: (plans for labor & delivery, feeding preference, circumcision, tubal
ligation, pediatrician)

Labor and Delivery Information: (type of delivery, episiotomy/laceration, estimated date of

delivery, onset of labor, method membranes rupture, oxytocin, estimated blood loss, medication in
labor, fetal monitoring, operative procedures used, amniotic fluid characteristics)

Adolescent Screening: (grade in school, plans regarding school, family response to pregnancy, age
of father of baby, FOB involvement, other support)

Nutritional Screening: (problem with appetite, chewing/swallowing difficulties, weight gain or loss,
caffeine consumption)

Current Medications: (use attached medication list form)

Prescription:
Over-the-counter (OTC):
Herbals:
Allergies:

Immunization status: (tetanus, diphtheria, pneumonia, influenza)

Disabilities/Handicaps/Impairments:

Functional abilities related to:

Bathing

Dressing

Toileting

Mobility

Eating

Bowel & bladder function

B. FAMILY: (any serious, chronic or recurring illness or disease among immediate family members:
1st generation = parent, child, sibling, or 2nd generation= grandparent, aunt, uncle)

III. HUMAN DIMENSIONS:

A. Social:
Alcohol Use:
Tobacco Use:
Drug Use:

Work environment, past & present: (outdoor, office, healthcare, industrial, chemical exposure,
heavy equipment)

Home Environment:
Psychosocial: (lives alone, roommate, family)

Physical: (single family home, apartment, nursing home, is there adequate space & privacy)

Safety: (hazards present in the home)

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Support systems: (Interpersonal relationships/communication with others)

Physical or emotional abuse:

Hobbies/Leisure Activities, diversional activities in hospital:

Economic Status: (ability to meet financial obligations, provide for basic necessities and
healthcare)

Roles/Relationships: (parent, spouse, boy/girlfriend, stay at home parent, breadwinner)

Characteristic Patterns of Daily Living: (usual daily routine)

B. Spiritual:
Life Values: (what is important in life):

Sense of transcendence: (clients ability to accept illness and associated lifestyle

changes/limitations)

Self-actualization (clients ability to live a rewarding, enriched life; meet self-care needs):

Advance Directives / End of life Issues (clients feelings and beliefs about heroic measures to
prolong life, life
support through artificial means, and/or organ donation)

C. Cultural:
Perception of health & illness: (what is seen as a state of being healthy, to what degree must
health be altered for one to be considered ill)

Beliefs about illness: (curse, punishment, need for medications, blood product)
Reliance on folk medicine or home remedies: (Are such measures routinely used in lieu of
conventional healthcare, what are some common practices if any)

Attitudes about the body (is touching the body for any reason other than bathing/grooming
acceptable, i.e. self exams)

Communication:
First Language: English_____

Other (name) ______________________________

(if English is not 1st language, clients ability to express him/herself coherently through
spoken/written word, gestures, etc)

D. Emotional:
Recent experience and effects of significant loss (death, divorce, relocation)

Past suicidal ideations or attempts:

Clients self-report of feelings:
Self-image, level of self-esteem

Coping (strategies used and effectiveness)

Clients presentation: (sad, angry, anxious, flat, apathetic, optimistic, happy, etc.)

Appropriateness of presentation to current situation:

E. Prevention and Health Maintenance Activities:

Sleep pattern: (how many hours/24hour period, feel rested afterward, use of sleep aids)

Nutrition: (daily consumption of fruits, vegetables, whole grain foods, food storage and shopping
practices)

Exercise: (type and frequency)

Stress Management: (what techniques are used and effectiveness)

Use of Safety Devices: (walker, cane, seat belts, motorcycle/bicycle helmet, sports equipment etc)

Health Check-ups: (self breast or self testicular exams, PSA, Pap smear, vision and dental exams)

F. Developmental Stage:
Anticipated:
Actual:

G. Learning Needs:
Influence of maturation on learning: significant__

moderate__

little__

none__

Factors giving rise to education needs:_________________________________________

Factors that might influence ability to learn:_____________________________________
Readiness and motivation to learn:_____________________________________________

Potential barriers to learning:__________________________________________________

Learn Best By:____________________________________________________________
Learning Needs:___________________________________________________________

1V. DIAGNOSTIC TESTS and LABORATORY DATA

Diagnostic Test

Client Value

Normal Range

Interpretation

V. PHYSICAL EXAMINATION: (objective data)

General appearance:
Height: ___________

weight: _________lbs.

Vital Signs:

Pulse:

BP: (lying)

Temp:

(sitting)

_________kg

Respirations:
(standing)

Body type and stature (short, tall, thin, etc.)

Apparent age:

Posture:

Body movements/tremors:

Hair growth patterns:

Breath odor: Alcohol__
Fingernails:

Fruity__

Clean __ Dirty__

Bad breath__ Normal__

Filed__ Rough__

Hygiene/grooming: Clean__ Body odor__

Speech: Clear__ Unclear__

Neat__

Loud__ Soft__

Evidence of biting__
Disheveled__

Spontaneous__ Halting ___

NEUROLOGICAL STATUS:
Level of consciousness:
Awake, Alert _________
Orientation:

Time ________

Drowsy ___

Confused ____

Responsiveness to Stimuli:

Pupils:

Lethargic __________
Place __________
Combative ____

Unresponsive _________
Person ___________

Uncooperative ___ Cooperative ___

Verbal _________

Tactile _____________

Painful _________

None ______________

Equal _____ Unequal ______

Reaction to Light:

None ____

Sluggish ____ Brisk _____

Movement of Extremities:
Spontaneous ____

To Painful Stimuli _____

None _____

Equal _____ Unequal ____ Purposeful _____ Nonpurposeful _____ DTRs _____
Posturing (describe):
CARDIOVASCULAR STATUS:
Arterial Line _______/______mmHg
Mean Arterial Pressure (MAP) ____________
Heart Sounds: Normal/Regular ____

Palpitation ______

Irregular ___

Pulses: Apical ______ Radial _____ Brachial _____ Popliteal ______ Pedal ______
Capillary Refill: Normal (2 sec) _____

Slow (> 2 sec) _____

RESPIRATORY STATUS:
Pulse Ox ______%

Oxygen Rx ________________________

Breath Sounds: Present _R / L___

Absent _R / L__

Equal ______ Unequal _______

Rales _______ Rhonchi ______

Secretions ____

Color ___________

Chest Tube(s): Number________

Wheezing _____

Amount ___________ Consistency ___________

Suction________

Gravity _______

GASTROINTESTINAL STATUS:
Abdomen: Soft ___

Firm ___

Bowel Sounds: Present _______

Distended ___

Tender ___

Decreased __________

Date of Last Bowel Movement _________________

Blood in stool ___

N/V ______

Diet: Type _______________

Non-tender ____

Absent __________

Consistency ______________

Diarrhea ____
Amt Consumed _________% NPO _____

Nasogastric or Gastrostomy Tube: Type _________________ To Suction __________

Nasogastric or Gastrostomy Output: Amount________

Color __________

Guiac ______

Nasogastric or Gastrostomy feeding: Type, Amount, Freq. _______________________________

URINARY STATUS:
Output/shift ______cc

Self voiding ____ Indwelling Foley Catheter _____ In & Out ____

Incontinent _____ Urine Color ___________

Bladder Irrigation _____

Clarity ________

Sediment _________

Clots ______

Peripheral Line(s): How many ________ Catheter Type _________________

Location __________________________
Solution infusing ______________________________@ __________ml/hr
Central Line(s): How many ________ Location __________________________
Solution infusing ______________________________@ __________ml/hr
MUSCULOSKELETAL STATUS:
Pain ___

Swelling ___

Deformity ____

ROM: Limited _____________

Full ____

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SKIN STATUS:
Intact ____

Lesions ___

Warm ___

Cool ____

Dry ____

Diaphoretic _____

Turgor: Normal ____ Decreased ___

Edema: Present ____ Absent ____

Site __________________________ Degree

_____________
Color: Normal ___

Pale ___

Mucus Membranes: Dry ___

Cyanotic ___

Mottled ___

Jaundiced ___

Flushed ___

Moist ____

POSTPARTUM STATUS:
Breast_____________________________________________
Fundal Location______________________________________
Abdominal Incision___________________________________
Lochia Amount/Color/Amount___________________________
Episiotomy/Laceration_________________________________
Perineum____________________________________________
Lower Extremity______________________________________
PAIN: On 0 10 scale = __________
VI. Based on preceding subjective and objective data, determine where the client should be
positioned on the health/illness continuum and explain in the space below, why that placement is
appropriate.
Health

High-level
wellness

Risk factors to
functioning in
all dimensions

Severe
Illness

Illness
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The health-illness continuum, ranging from high-level wellness to severe illness, provides a method of identifying a clients level of health. Level of health is
a reflection of the clients level of functioning in all dimensions. (Potter, P. & Perry, A. (2003). Basic Nursing: Essentials for Practice, Pg 2. St.
Louis:Mosby.)

The client is placed as above because:

VII. Discharge Planning Needs

X. Prioritized List of Nursing Diagnoses (Based on Preceding Assessment Data)

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