By Maria Edwards,2014-10-17 13:29
15 views 0


    I. GENERAL ATTITUDE AND BEHAVIOR Behavior: Cooperative ڤ Passive ڤ Domineering ڤ Withdrawn ڤ Restless ڤ Dramatic ڤ Hostile ڤ Intimidating ڤ Suspicious ڤ Uncooperative ڤ Other:________________________

    Appearance: Unkempt ڤ Disheveled ڤ Clean ڤ Neat ڤ Unusual ڤ

    Attire: Appropriate ڤ Seductive ڤ Loud ڤ Meticulous ڤ Untidy ڤ Atypical ڤ Facial Expression: Unremarkable ڤ Sad ڤ Angry ڤ Perplexed ڤ Fearful ڤ Elated ڤ Immobile ڤ Grimacing ڤ Atypical ڤ

    Gait: Normal ڤ Parkinsonian ڤ Ataxic ڤ Shuffling ڤ Unusual ڤ


    Motor Activity: Unremarkable ڤ Agitated ڤ Hypoactive ڤ Tremor ڤ Tic ڤ Hyperactive ڤ Pacing ڤ Handwringing ڤ Mannerisms ڤ


    Productivity: Spontaneous ڤ Verbose ڤ Pressured ڤ Slow ڤ Soft ڤ Mute ڤ Atypical ڤ Progression: Logical ڤ Association ڤ Loose Association ڤ Circumstantiality ڤ Perseveration ڤ Halting ڤ Incoherent ڤ Fragmented ڤ Tangential ڤ Flight of Ideas ڤ Ruminations ڤ Confabulation ڤ Neologism ڤ

    Language: Normal ڤ Childlike ڤ Peculiar ڤ Stilted ڤ

    III. Emotional State/Reaction

    Affect: Unremarkable ڤ Indifferent ڤ Fearful ڤ Angry ڤ Euphoric ڤ Anxious ڤ Sad ڤ Range: Normal ڤ Labile ڤ Constricted ڤ

    Depth: Normal ڤ Shallow ڤ Increased ڤ

    Vegetative Sx of Depression:

    Depressed mood ڤ Loss of interest or pleasure ڤ Appetitie Disturbance ڤ Sleep Disturbance

    ڤ Psychomotor Agitation or Retardation ڤ Fatigue or Loss of energy ڤ Decreased concentration ڤ Feelings of worthlessness or guilt ڤ Diurnal mood variation ڤ Suicidal/Homicidal: Denies ڤ Ideation ڤ Plan ڤ Attempt ڤ

     IV. MENTAL TREND AND THOUGHT CONTENT Perception: Unremarkable ڤ Depersonalization ڤ Derealization ڤ Dissociation ڤ Hallucinations: Auditory ڤ Visual ڤ Tactile ڤ Olfactory ڤ Gustatory ڤ

    Cognitive Style: Obsessive ڤ Self Deprecatory ڤ Intellectualized ڤ Autistic ڤ Global (Histrionic) ڤ Other: ______________________________ Cognitive Content: Obsessions ڤ Phobias ڤ Compulsive Rituals ڤ Religiosity ڤ Ideas of Reference ڤ Bizarre Ideas ڤ Self Depreciations ڤ Delusions ڤ Nihilistic ڤ Somatic ڤ Grandiose ڤ Paranoid ڤ Guilt ڤ

    V. SENSORIUM, MENTAL GRASP AND CAPACITY Consciousness: Alert ڤ Clouded ڤ Fluctuating ڤ Stuporous ڤ

    Orientation: Normal ڤ Mild ڤ Moderate ڤ Severe ڤ Disorientation to: Time ڤ Place ڤ Person ڤ Situation ڤ

    Memory: Intact ڤ Mild ڤ Moderate ڤ Severe ڤ Memory Deficits ڤ Immediate ڤ Recent ڤ Remote ڤ

    Digit span: Forward: Good ڤ Poor ڤ Backward: Good ڤ Poor ڤ

    Disorders of: Counting ڤ Calculation ڤ Reading ڤ Writing ڤ Attention ڤ Concentration ڤ Comprehension ڤ

    General Knowledge: Good ڤ Poor ڤ Consistent with education ڤ Inconsistent with education

    ڤ Personalized ڤ Superficial ڤ Pseudoabstraction ڤ

    Intelligence: Normal ڤ Below ڤ Above Normal ڤ

    Insight: Good ڤ Fair ڤ Poor ڤ None ڤ

    Judgment: Good ڤ Fair ڤ Poor ڤ None ڤ






    This guide is a basic outline of areas to consider when assessing a client. It is not meant to be inclusive of each area needing consideration. Items will need to be added to each category as assessment skills and theoretical base is expanded. When assessing a client, add or delete areas as appropriate for age, growth and developmental stages, presenting conditions, and nursing situation (points for grading are listed in parentheses).


     Date of Interview ___________________

     Name of Client ____________________ Age ____ Gender____


     Place of Birth _____________________ Culture _____________ Race _________

     City of Residence __________________ Marital Status: S M W D Family______

     Occupation _______________________ Education


     Transportation ________________________ Religion


     Information obtained from: Client ________ Other


II. CHIEF COMPLAINT (CC): (3 points)

     S: Client’s statement about why he/she is seeking health care at this time; should

    be brief.


    A. Usual Health:

     S: Client’s summary

    B. Chronological Story of Symptoms:

     S: Date of onset; manner (gradual or sudden); duration; precipitating factors.

    Course since onset: location; quality; quantity; setting; associated

    phenomena; alleviating or aggravating factors; family history related to

    present complaint.

    C. Negative Information:

     S: Any negative information regarding the chief complaint that is as significant

    as the positive information.

    D. Relevant Family History:

     S: Any problem similar to chief complaint in blood relatives.

     E. Disability Assessment:

     S: Effect on activities of daily living (ADL); physical, psychological, sociological

    and financial impacts of problems(s).

IV. PAST HISTORY: (14 points)

     A. Health Perception:

     S: Client’s perception.

     B. Childhood Illnesses:

     S: (i.e., measles, rubella, mumps, whooping cough, chicken pox,

    rheumatic fever, scarlet fever, polio, diphtheria).

     C. Adult Illnesses:

     S: (Tuberculosis, hepatitis, diabetes, hypertension, myocardial

    infarction, tropical or parasitic diseases, other infections).

     D. Psychiatric Illnesses:

     S: (Mood disorders, psychiatric intervention with dates(s);

    hospitalizations and date(s).

     E. Accidents and Injuries:

     S: (Dates; disability limitation; blood transfusion).

     F. Operations:

     S: (Dates; hospital or outpatient and name of facility; diagnosis and

    complications; blood transfusions including reactions, date and number

    of units).

     G. Hospitalizations:

     S: (If not previously noted).

     V. CURRENT HEALTH STATUS: (10 points)

     A. Allergies:

     S: (Medications; environmental; foods; other).

     B. Immunizations:

     S: (Smallpox, polio, diphtheria, pertussis and tetanus toxoid, influenza,

    choler, typhus, typhoid, Bacille Calmette-Guerin (BCG), hepatitis,

    pneumonia; unusual reactions to immunizations; tetanus or other

    antitoxin made with horse serum).

    C. Screening Tests:

     S: (Hematocrit, urinalysis, tuberculin tests, Pap smears, mammogram,

    stools for occult blood, and cholesterol tests; list dates and results).

D. Environmental Hazards:

     S: (Home, school, work).

E. Use of Safety Measures:

     S: (Seat belts, work related measures, safety measures in the home,


F. Exercise and Leisure Activities:

     S: (Type and frequency).

G. Sleep Patterns:

     S: (Time goes to bed; awakens during night; daytime naps; difficulties in

    falling asleep or staying asleep).

H. Diet/Nutritional Data:

     S: (Dietary intake for 24-hour period; dietary restrictions or


I. Current Medications:

     S: (Home remedies; prescription and nonprescription drugs;

    vitamin/mineral supplements and borrowed medications).

J. Tobacco, Alcohol, Drugs, and Related substances:

     S: (Type of cigarettes and frequency of use, chewing tobacco/snuff;

    street drugs; type of alcohol and frequency; other).

     VI. FAMILY HISTORY: (10 points)

     S: (Covers three (3) generations and includes age and health, or age and

    cause of death, of each immediate family member. Use a

    genogram/pedigree diagram/family tree to illustrate family status.

    Determine if any of the following conditions have occurred within the

    family: diabetes, tuberculosis, heart disease, high blood pressure,

    stroke, kidney disease, cancer, arthritis, anemia, thyroid disease,

    asthma, sexually transmitted disease, headaches, epilepsy, mental

    illness, alcoholism, drug addiction, hematologic disorders (hemophilia,

    sickle cell anemia, thalassemia, hemolytic jaundice), Huntington’s

    chorea, arteriosclerosis, gout, obesity, and symptoms like those of the



A. Home Situation and Significant Others:

    S: Persons with whom client lives; client’s position within the family;

    recent family crisis, or changes; significant others.

B. Daily Life:

    S: Rest-Sleep-Activity (RSA) patterns, social activities, recent

    changes in daily activities; special weekend activities.

C. Life Cycle Events:

    S: Marriage, divorce, recent move or job change, marriage of

    children—any event which might significantly impact on client’s health

    or health seeking behavior.

D. Environment:

    S: Home, community, work, and recent changes in those

    environments; foreign travel.

    E. Occupational History:

    S: Jobs held, job satisfaction, current place of employment. Exposure

    to health hazars.

F. Economic Status and Resources:

    S: Source of income, perception of adequacy of income, effect of

    illness on economic status.

G. Educational Level:

    S: Highest degree or grade attained.

H. Patterns of Health Care:

    S: Private and public primary care agencies, dental care, preventive

    care, emergency care.


A. Cognitive Abilities:

     S: Level of education learning patterns, and memory.

     B. Responses to Illness and Health:

     S: Reaction to illness, coping patterns, value of health.

C. Response to Care:

     S: Client’s perceptions, compliance in past.

D. Cultural Implications for Care:

     S: Client’s religious beliefs related to health care.

    IX. REVIEW OF SYSTEMS (ROS): (40 points)

A. General

     S: Usual state of health, chills, fever, sweats, weakness, malaise,

    fatigue, recent and significant gain or loss of weight.

     O: Height and weight, vital signs (TPR; B/P in both arms in at least 2

    positions); appearance relative to age; apparent state of health,

    awareness, personal appearance, emotional status, nutritional

    status, affect, response, cooperation.

     INFANTS: Head and chest circumference.

B. Skin, Hair, and Nails:

     S: Skin: Color, temperature or texture changes, pruritus, care habits.

     Hair: Alopecia, texture changes, care habits (dye hair,

    permanents, frequency of shampooing).

     Nails: Changes in appearance or texture, care habits.

     O: Skin: Color, turgor, texture, pigmentation, eruptions, lesions,

    rashes, edema, scars, nevi, petechiae, ecchymoses,

    telangiectasia, moisture.

     Hair & Scalp: Quality, distribution, color, texture, presence of lesions or


     Nails: Color of beds, capillary refill, texture, clubbing, adherence to

    nail bed, splinter hemorrhages.

C. Head and Face:

     S: Dizziness, injuries, pain, syncope, headaches, masses.

     O: Cranium: Contour, tenderness, masses.

     INFANTS: Fontanels and type of hair.

     Face: Symmetry, movements, sinuses, Cranial Nerve V

    (CNV), CNVII.

D. Eyes:

     S: Visual acuity, with and without corrective lenses; cataracts,

    changes in visual fields or vision, diplopia, excessive tearing,

    glaucoma; date of last ophthalmologic exam; visual disturbances,

    infections, pain, photophobia, pruritus, unusual discharge or


     O: Visual acuity (Snellen chart or hand held card), fields (draw

    defect if present), alignment of eyes, extra ocular movements

    (EOM’s), alignment of eyelids, movement of eyelids (ptosis),

    conjunctiva, sclera, cornea, anterior chamber, iris, pupils equally

    round, react to light and accommodation (PERRLA), lens,

    lacrimal apparatus, ophthalmological apparatus. Test

    appropriate cranial nerve(s) and state tests used.

E. Ears:

     S: Use of prosthetic devices, hearing ability, tinnitus, discharge,

    epistaxis, frequency of colds, sinus infections, sneezing,


     O: Auricle, canal, otoscopic, exam (tympanic membrane description),

    Rinne’ and Weber, discharge, mastoid tenderness. Test

    appropriate cranial nerve(s).

F. Nose and Sinuses:

     S: Olfactory ability, pain in infraorbital or sinus areas, discharge,

    epistaxis, frequency of colds, sinus infections, sneezing,


     O: Patency of each nostril, olfaction, turbinates and mucous

    membranes, transillumination of sinuses. Test appropriate

    cranial nerve(s).

G. Mouth and Throat:

    S: Pattern of dental care; dental problems, bleeding or swelling of

    gums, change in taste, dryness, excessive salivation, lesions,

    sore throats, hoarseness, voice changes.

    O: Buccal mucosa, gums, teeth/dentures, floor of mouth, hard and

    soft palate, tonsilar areas, posterior pharyngeal wall, tongue,

    breath, lesions, parotid duct.

     CHILDREN: Note teeth pattern.

H. Neck:

     S: Pain with movement or palpation, swelling.

     O: Symmetry, tracheal position, thyroid gland, masses, bruits.

I. Breasts:

    S: Self-examination pattern, masses, discharge, tenderness.

    O: Symmetry, axillary nodes, supraclavicular nodes, infraclavicular

    nodes, nipples, discharge, masses, dimpling, tenderness to

    palpation, gynecomastia.

     NEWBORN: size of breast nodule.

J. Respiration System and Chest:

    S: Smoking hx., cough, dyspnea, orthopnea, hemoptysis, sputnum,

    stridor, wheezing, paroxysmal nocturnal dyspnea (PND); date of

    last roentgenogram.

    O: Shape and symmetry of thorax, respiratory rate and rhythm,

    respiratory movements and use of accessory muscles of

    respiration, intercostals retractions, Palpation: tactile fremitus,

    tenderness, masses, thoracic expansion, costovertebral ans

    spine tenderness. Percussion: diaphragmatic excursion.

    Auscultation: breath sounds, adventitious sounds, egophony,

    bronchophony, whispered pectoriloquy.

K. Cardiovascular System:

    S: Hypertension (HTN), edema, pain, unusual sensations; exercise

    history, exercise tolerance; date of last ECG.

     O: Position in which heart was examined: Lying, sitting, left lateral,

    recumbent. Inspection: bulging, depressions, pulsations.

    Palpation: thrusts, heaves, thrills, friction rubs, Point of Maximum

    Intensity (PMI). Auscultation: S, S, murmurs and extra sounds. 12

    Pulses: temporal, temporal, carotid-rate, rhythm, equality,

    amplitude, thrills, bruits, JVP. Palpate peripheral pulses:

    brachial, radial, femoral, popliteal, dorsalis pedis and posterior

    tibialis; Hct. and Hbg.

    L. Abdomen/Gastrointestinal System:

    S: Appetite, dysphagia, thirst; nausea, vomiting, diarrhea (NVD);

    indigestion, abdominal pain; bowel habits; change in stool color;

    dyschezia; flatulence; rectal discomfort; rectal bleeding;

    hemorrhoids; nutrition-typical day’s diet.

O: Inspection: Scars, size, shape, symmetry, muscular

     development, diastasis, distention, movements.

     Auscultation: Peristaltic sounds, bruits.

     Palpation: Masses, tenderness, tone of muscalature;

    liver size, tenderness; CVA tenderness, palpable

    spleen, palpable kidney, distention of urinary


     Percussion: Liver-size at MCL, spleen, masses, shifting


     INFANT: Movement of umbilicus.

     PREGNANT CLIENT: Changes in

    abdomen/fundal height measurement.

    M. Genitourinary:

    S: Anuria, change in stream, dysuria, incontinence, nocturia,

    oliguria, polyuria, hematuria, pyuria, frequency, flank pain,

    suprapubic pain.

     Female: Menstrual hx., age at menarche; regularity, frequency,

    and duration of periods; amount of bleeding, bleeding between

    periods or after intercourse, last menstrual period; dysmenorrhea,

    premenstrual tension, age at menopause, menopausal

    symptoms, postmenopausal bleeding. (If born prior to 1971,

    exposure to DES diethylstilbestrol) from maternal use during

    pregnancy). Vaginal discharge, itching, sores, lumps, sexually

    transmitted diseases and treatments; obstetrical hx., number of

    pregnancies, deliveries, abortions (abortions and induced),

    complications; contraceptive hx., birth control methods; sexual

    activity, preference, satisfaction or problems; date of last pap


     O: Female: External hair distribution, labia, bartholin’s, urethral

    meatus, Skene’s glands (BUS); hymen, introitus; vaginal

    observation-rectocele, urethrocele, cystocele, tissue, discharge,


     Bimanual exam: cervix, uterus, adnexa.

     Rectovaginal exam: hemorrhoids, sphincter tone, lesions,

    fissures, uterus, cul-de-sac, septum.

     Male: Penis: circumcised, lesions;

     Scrotum: size, skin, testes, epididymis, spermatic cords, masses;

     Prostate gland: size, shape, consistency, tenderness;

     Inguinal area: hernia, inguinal and femoral nodes; rectal exam.

     CHILDREN: hygiene, secondary sex characteristics (Tanner

    Rating Scale).

     PREGNANT CLIENT: Changes related to pregnancy.

    N. Extremities and Musculoskeletal:

    S: Extremities: Coldness, discoloration;

     Muscles: Cramping, weakness;

     Bones and Joints: Stiffness, erythema, edema.

    O: General assessment: size, shape, masses, symmetry, hair

    distribution, color, temperature, edema, varicosities, tenderness,

    lesions, Homan’s sign, contractures, epitrochlear lymph nodes.

     Muscles: Cramping, weakness;

    Back: posture, tenderness, movement-extension, lateral bending,


    Pulses: amplitude and character of peripheral pulses, including

    radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsal


    Infants: measure; inspect sole creases, webbing, and number of

    toes and fingers.

    Bones and Joints: Range of motion of fingers, wrists, elbows,

    shoulders, spine, toes, ankles, knees, hips; swelling, warmth,

    tenderness, redness, deformity.

    O. Neurologic:

    S: General behavior change, mood change, anxiety, nervousness,

    seizures, speech, changes in cognitive ability, motor difficulty,

    i.e., ataxia, imbalance, tremors, spasm, tic, paresis, paralysis;

    sensory-pain, paresthesia.

     O: Mental status, appearance, behavior, speech, mood, thought

    processes, cognitive function (insight, vocabulary, abstract

    reasoning, serial sevens, judgment), sensorium (orientation,

    recent and remote memory), coping behaviors, cranial nerves,

    coordination, sensory-touch, pain position, vibration, two-point

    discrimination; Babinski’s sign, Romberg’s sign, deep tendon

    reflexes (DTR’s).

    P. Hematologic:

    S: Bleeding, bruising, past hx., of blood transfusion, exposure to

    radiation or toxic agents, joint pain.

    O: Bleeding, petechiae, bruising.

    Q. Lymphatic:

    S: Lymph nodes: Enlarged, tender, suppuration.

    O: Lymph nodes: Location, size, shape, consistency, mobility.

    R. Endocrine:

    S: Intolerance to heat or cold; thyroid gland enlargement or

    tenderness, unexplained weight change, diabetes, polydipsia,

    polyuria, changes in facial or body hair, increased hat and glove

    size, skin striae.

    O: (State theorists used in this part of the assessment, e.g., Erikson

    for individuals; Duvall for families).

Adapted from:

     thBates, B., (1991). A guide to physical examination and history taking. (5 ed.). Philadelphia: J.B.


     thMalasanos, L., Barkaukas, V., & Stoltenberg-Allen, K. (1990). Health assessment. (4 ed.). St. Louis:

    C.V. Mosby.

     ndSeidel, H., Ball, J., Dains, J., & Benedict, G. (1991). Mosby’s guide to physical examination. (2 ed.). St.

    Louis: C.V. Mosby.

Report this document

For any questions or suggestions please email