Client’s Initials:
Student:
Date:
Age:
Nursing I - Assignment #2 - ASSESSMENT (DATA COLLECTION)PHYSIOLOGICAL
OXYGEN: Cardiovascular
Skin warm to touch: Head & Torso
Arms & Hands
Legs & Feet
Color of nail beds
Temperature:
Location
Radial pulse rate
Rhythm
Apical pulse rate:
Rhythm
Blood pressure: Location
Position
Pulse ox
Medications:
Respiratory
Respiratory rate
Rhythm
Skin color
Breath sounds

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:
Ordered diet:
% of meal consumed:
Ht.
Wt.
Dentures:
Problem
Equipment in use (G/tube, PEG tube, etc.):
Additional data:
Medications:
ELIMINATION:
Incontinence:

Urinary
Bowel
BM:
Additional data:
Medications:
MOBILITY AND ACTIVITY
Muscle strength: 
ROM: 
Ability to move in bed: 
Fall Assessment Score
Fall risk:
Medications:
REST, SLEEP AND PAIN
Able to stay wake during morning care?
Complaints of fatigue when OOB?
Complaints of pain?
Location
Duration
Pain scale
Medications:
OOB:
Ability to transfer:
Physical therapy:
Additional data:
Intensity
Additional data:
SAFETY AND SECURITY
Vision:
Able to see without glasses
Blind 

Needs glasses
Skin integrity: Intact
Location and
Pressure ulcers
size:
Makes eye contact with caregiver from
Hearing:
Responds to normal voice tones
Hearing aid
Deaf 
Speech:
Clear
Garbled
Treatment:
Turning schedule posted?
Preventive devices?

Incomprehensible
Mental status: Alert
Lethargic
Oriented to: Person
feet

Unresponsive 
Time
Place 
Skin tears
Location and size:
Treatment:
Protective sleeves?
Allergies:
Medications:
Environment:
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
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
History on chart gives indications of goals met
ERIKSON’S STAGE OF DEVELOPMENT
The client is at the following developmental stage as evidenced by:
Internet Nursing I Assignment 2
c:assessment-dc2
Additional data: