Client Assessment Tool

The Client Assessment Tool provides a comprehensive guide for use when completing a
client assessment in the clinical setting. The Client Assessment Tool can be downloaded
or printed from the Online Companion and taken to the clinical site for assessing a
client's physical and psychosocial needs. You are encouraged to write pertinent client
assessment data on the assessment tool. You can add write-in space or delete items as
required by your clinical setting and individual needs. (NOTE: Each nursing program can
determine the extent of assessment each student will perform.)
Health History
Demographic information
Reason for seeking health care
Perception of health status

Does client have fears or concerns about health status at this time?

Previous illnesses, hospitalizations, and surgeries

Client/Family medical history hypertension, diabetes, cancer, alcoholism
Immunizations/exposure to communicable diseases
Allergies
Current medications anticoagulants
Developmental level - (Refer to Ericksons Stages of Psychosocial Developmental)
Psychosocial history

Self-concept/self-esteem

Sources of stress

Ability to cope

Sociocultural history

Home environment

Family situation

Clients role in family

Recreational drug use

Complementary/alternative therapy use

Use of herbal supplements

Activities of daily living

Describe clients lifestyle

Capacity for self-care

Use/History of alcohol, drug abuse, smoking, chewing tobacco, snuff

Receival Notes
How did you find the client?

Was client asleep or awake

Easily aroused?

Was the client alert

Client subjective statements

Physical examination
Head-to-Toe assessment
Vital signs
Temperature
Pulse
Respirations

Blood pressure
Pulse oximetry
Pain
Height
Weight/body mass index
Head and neck assessment
Hair and scalp
Eyes
PERRLA
Snellen test
Use of contacts and/or glasses
Presence of drooping eyebrows and eyelids
Color of sclera and conjunctiva
Presence of drainage
Pupil size in millimeters
Nose
Note presence of deformity, inflammation, or prior trauma
Check patency of nostrils
Ask if has experienced nosebleeds, dryness, or decrease in sense of smell
Lips and mouth
Color, symmetry, moisture, or lesions
Breath odors
Inspect oral mucosa -- check color, moisture, and free of lesions

Inspect tongue to determine clients hydration

Enuciation of words
Voice changes hoarseness
Dental hygiene practices
History of tobacco usage
Neck
Full range of motion
Enlargement of lymph nodes or thyroid gland
Pulsations in the neck
Jugular vein distention
Mental and neurological status and affect
Assess short term and long term memory
Level of orientation to person, place and time
Responsive to environment
Check coordination skills - ability to touch the tip of the nose with a finger and
the tip of the nurses finger as it is moved to different locations
Skin assessment
Skin Turgor < 3 sec
Assess boney prominences for redness, swelling, pain, skin breakdown,
Assess incision for signs and symptoms of infection, intactness, drainage,
approximation, assess sutures and/or staples,

Presence of an IV location, assessment for signs and symptoms of infection,

infiltration, and discomfort at the IV site, how much fluid remaining in IV
bag, what type of fluid and the rate
Color
Moisture/dryness
Edema
+0 no edema
+1 indentation of 2 mm (0 inches), disappears rapidly
(trace)
+2 pitting of 4 mm ( inch), disappears in 10 to
15 seconds (mild)
+3 pitting of 6 mm (1 inch), lasts 1 to 2 minutes
(moderate)
+4 pitting of 8 mm or more (greater than 1 inch), lasts 2 to
5 minutes (severe)
Thoracic Assessment
Cardiovascular status
Apical pulse
Blood perfusion of peripheral vessels and skin
Note changes in skin temperature, color, and sensations
Note changes in pulses -- radial, dorsalis pedis, and posterior
tibialis pulses
Capillary refill
Assess toes for warmth and color
Compare peripheral pulses bilaterally and note changes in strength
and quality
Personal exercise habits

Past chest pain

Shortness of breath
Describe pain location, intensity, rate on scale of 0-10
Past experience of fainting or feeling dizzy
Presence of lower leg swelling
Respiratory status
Nasal flaring
Respirations -- labored, non-labored, rate, rhythm, depth, chest expansion
Assess if on oxygen therapy (how many liters per minute)
History of asthma, use of inhaler
Breath sounds
Normal sounds bronchial, bronchovesicular, vesicular
Adventitious sounds sibilant and sonorous wheezes, fine and
course crackles, pleural friction rub, stridor, rhonchi
Presence of a cough productive, nonproductive, frequency
Expectoration of secretions (sputum) COCA (Color, Odor, Consistency
and Amount)
ABG lab values
Wounds, Scars, drains, tubes, dressings, ostomies
Type of drain (Hemovac, Jackson-Pratt, Penrose)
Skin sutures, skin staples, WoundVac
Document location, size, and amount of drainage or discharge, signs of
inflammation

Breasts
Size and symmetry
Note any obvious masses, dimpling, or inflammation
Nipples and areola
Symmetrical in size, shape and color
Note discharge from the nipples
Assess axillary lymph nodes enlargement, tenderness
Does client perform breast self-exams
Date of last mammogram
Abdominal assessment
Gastrointestinal status
Assess if client is passing flatus, experiencing constipation, diarrhea,
cramping, nausea, vomiting, GERD, heartburn, belching
Nasogastric tube
Assess placement of NG placement
Assess NG tube for intactness, continuous or intermittent suction,
COCA NG drainage
Presence of rashes and scars
Abdominal appearance
Abdominal girth
Flat, rounded, distended, soft, firm, hard, board-like
Symmetry
Visible signs of peristalsis or pulsations

Abdominal auscultation in all 4 quadrants

Bowel sounds -- active, hypoactive, hyperactive
Abdominal light palpation for lesions, masses, and pain
Genitourinary assessment
Urinary output (COCA)
Presence of catheter (foley, use of straight cath)
Presence of pubic area enlargement or fullness
Presence of urinary meatus inflammation or discharge
Affect of present illness on sexual activity
Lesions or ulcerations indicating sexually transmitted infections
Voiding pattern and any recent changes
Female:
Number of pregnancies
Use of birth control
Menstrual cycle history
Present sexual activity
Protection during intercourse
Date of last Pap test
Male:
Inspect penis, urethral meatus, foreskin and scotum
Performance of testicular self-examination
History of urinary tract infections, kidney stones, change in the urinary
stream, or painful urination or nocturia

Musculoskeletal and extremity assessment

Symmetry and strength of major muscle groups
Range of movement when changing position active and passive ROM
Observe clients movement and posture when walking across the room gait
assessment
Observe the clients gross motor movements and posture when sitting up in bed to
assess gross motor movement and posture
Assess muscle strength using grade system, hand grasp, arm strength
assessment and lower extremity assessment, pedal push and pull
Palpate muscles to identify swelling, tone, or specific changes in the shape of the
muscles
Hand grasps and foot pushes
Assess clients coordination skills
Assess strength and symmetry of major muscle groups
Use of aids for ambulation
Lower extremity assessment
Determine color, loss of feeling
Loss of hair
Change in temperature within the extremity and from one extremity to the other
Presence of varicose veins, ulcers, and edema
Presence of leg pain, cramps, or muscle weakness
Difficulty or pain when walking or performing routine daily activities
Observe for stiffness, crepitus, or fatigue during ambulation

5 Ps: Power, Paresthesia, Pulsation, Pallor,

Lab Values
Diagnostic Tests
Nursing Care Plan