NCM 101 RLE

ASSESSMENT GUIDE OF A NORMAL

CLIENT
I.  Personal Data
II.  Family Background
III.  General Assessment
IV.  Motor Ability Status
V.  Nutrition Status
VI. Elimination Status
VII. Reproductive Status
VIII. Circulatory Status
 ASSESSMENT GUIDE OF A NORMAL
CLIENT
IX. Respiratory Status
X. State of Physical Rest and Comfort
XI. Emotional Status
XII. State of Skin Appendages
XIII. Health Maintenance Activities
XIV. List of Problems Identified
 I. Biographical/Personal Data
•  provide you with direct information related
to a current health problem, alert you to
risk factors for health problems, and
point out the need for referrals.
•  Y o u r p a t i e n t ’ s a b i l i t y t o p r o v i d e
biographical data accurately reflects his or
her mental status.
 I. Biographical/Personal Data
•  Patient’s name •  Educational level
•  Address, •  Occupation
•  Phone number •  S o c i a l s e c u r i t y
•  Contact person number/ health
•  Age/birth date insurance.
•  Place of birth
•  Gender
•  Religion
•  Marital status
I. Biographical/Personal Data
•  Person who provided the history and her or his
reliability as well as the person who referred the
patient.
•  Information on advance directives may also be
obtained for hospital admissions. Also note any
special considerations, such as the use of an
interpreter.
 II. FAMILY BACKGROUND
A.  Family Structure •  Grandparent Family
•  Nuclear •  Adolescent Family
•  Extended •  Foster Family
•  Single Parent •  Cohabiting Family
Family
•  Gay and Lesbian
•  Childless Family Family
•  Two Career Family •  Cohabiting Family
•  Step/blended •  Single Adults living
Family Alone
 II. FAMILY BACKGROUND
B. Role in Family
•  A family role is the position one has
within the family household.
•  One's role encompasses how much
power the individual holds within
the family system and their
responsibilities, as well as their impact on
other family members.
 II. FAMILY BACKGROUND
c. Ethnic Group
•  the ties are reckoned by blood and traced
through the family tree.
d. Herido-familial disease
•  A familial disease is hereditary, passed on
from one generation to the next.
e. Immunization History