Client Assessment Utilizing the Level II Physical Assessment Form
and the Adult Health Needs Analysis
The Level II Physical Assessment and Adult Health Needs Analysis are designed to provide the
foundational assessment for your clients. This information is then used to develop a care plan
individualized for that client and focused on their individual needs.
The Process:
1. Assessment begins the nursing process and thus, the process of assessing the client should begin
as soon as possible after assuming care. The Level II Physical Assessment Form is used to
direct your physical assessment of the medical-surgical patient.
2. The next step in assessing your client is completing the Adult Health Needs Analysis. It is
based on the thirteen functional health patterns.
If you believe that the client is effectively meeting his/her needs (i.e. that your assessment
is in agreement with the statement), place a check in the “Y” (yes) column.
If stressors are interfering with meeting client needs, place a check in the “N” (no)
column and add brief details supporting that choice. For example, the statement is
“hearing is normal”. Your client wears a hearing aide. Ask yourself “Is my client’s
hearing normal?” You answer no because she wears a hearing aide. Therefore, you check
“N” and write in the box “wears a hearing aide”.
If you believe that stressors could be potentially interfering with meeting client needs,
place a check in the “P” (potential) column and add brief details supporting that choice.
For example, the statement is “is able to digest/metabolize food.” Your patient
complained of nausea an hour ago, but has not vomited. You check “P” and write in the
box “had nausea but no vomiting”.
1
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https://www.coursehero.com/file/251426695/Level-2-Physical-Assessment-Assignment-1docx/
, HARFORD COMMUNITY COLLEGE
NURSING PROGRAM Level II Physical Assessment
Student Name: __________________________ Client Age: ______ Client Gender:________ Date: _______________ Time: _________
ASSESSMENT FINDINGS DESCRIPTION OF SIGNIFICANT/ABNORMAL FINDNGS
GENERAL SURVEY
Physical Comfort/Distress Facial expression:
(airway, breathing, circulation,
pain, facial expression, verbal Verbal complaints:
complaints)
Skin Characteristics Intact/Not Intact
Temperature: Normal/Warm/Cool
Lesions: yes/no
Discolorations: yes/no
Color (appropriate for ethnicity?
normal/pale/cyanotic
Turgor: good/fair/poor
Scars: Yes/No
Body Alignment/Position/ Gait: steady/unsteady/unable to assess
Posture/Gait
Body alignment?
Posture?
Safety Measures in Use List:
Hygiene/Grooming Adequate/Deficient
IV site(s) Location(s):_________________
Assessment:
2
and the Adult Health Needs Analysis
The Level II Physical Assessment and Adult Health Needs Analysis are designed to provide the
foundational assessment for your clients. This information is then used to develop a care plan
individualized for that client and focused on their individual needs.
The Process:
1. Assessment begins the nursing process and thus, the process of assessing the client should begin
as soon as possible after assuming care. The Level II Physical Assessment Form is used to
direct your physical assessment of the medical-surgical patient.
2. The next step in assessing your client is completing the Adult Health Needs Analysis. It is
based on the thirteen functional health patterns.
If you believe that the client is effectively meeting his/her needs (i.e. that your assessment
is in agreement with the statement), place a check in the “Y” (yes) column.
If stressors are interfering with meeting client needs, place a check in the “N” (no)
column and add brief details supporting that choice. For example, the statement is
“hearing is normal”. Your client wears a hearing aide. Ask yourself “Is my client’s
hearing normal?” You answer no because she wears a hearing aide. Therefore, you check
“N” and write in the box “wears a hearing aide”.
If you believe that stressors could be potentially interfering with meeting client needs,
place a check in the “P” (potential) column and add brief details supporting that choice.
For example, the statement is “is able to digest/metabolize food.” Your patient
complained of nausea an hour ago, but has not vomited. You check “P” and write in the
box “had nausea but no vomiting”.
1
This study source was downloaded by 100000901307859 from CourseHero.com on 10-21-2025 06:53:55 GMT -05:00
https://www.coursehero.com/file/251426695/Level-2-Physical-Assessment-Assignment-1docx/
, HARFORD COMMUNITY COLLEGE
NURSING PROGRAM Level II Physical Assessment
Student Name: __________________________ Client Age: ______ Client Gender:________ Date: _______________ Time: _________
ASSESSMENT FINDINGS DESCRIPTION OF SIGNIFICANT/ABNORMAL FINDNGS
GENERAL SURVEY
Physical Comfort/Distress Facial expression:
(airway, breathing, circulation,
pain, facial expression, verbal Verbal complaints:
complaints)
Skin Characteristics Intact/Not Intact
Temperature: Normal/Warm/Cool
Lesions: yes/no
Discolorations: yes/no
Color (appropriate for ethnicity?
normal/pale/cyanotic
Turgor: good/fair/poor
Scars: Yes/No
Body Alignment/Position/ Gait: steady/unsteady/unable to assess
Posture/Gait
Body alignment?
Posture?
Safety Measures in Use List:
Hygiene/Grooming Adequate/Deficient
IV site(s) Location(s):_________________
Assessment:
2
