CLIENT ASSESSMENT DATA BASE
May report difficulty sleeping
Poor muscle tone/muscle wasting
May be jaundiced
Dysuria, urinary frequency, decreased urine output, hematuria
Nausea, vomiting, anorexia, weight loss.
Tongue may have visible lesion or sore (hairy leukoplakia seen in AIDS).
May report indigestion, altered taste.
Loss of subcutaneous fat.
Poor skin turgor.
Backache, flank pain, colicky pain noted with acute pyelonephritis.
Chest pain may occur with tuberculosis.
Severe itching, burning pain with lesions.
May complain of pruritus with active (infectious) hepatitis A or B.
Dyspnea with exertion.
Cough may be productive of thick/purulent/blood-tinged sputum or may be nonproductive.
Crackles (rales), wheezes, bronchial breath sounds; tubular breath sounds, diminished/absent breath sounds over areas
of pleural effusion or pneumothorax (tuberculosis).
Temperature elevation dependent on type of infection, e.g., low-grade in cystitis, high fever in pyelonephritis
Chills, night sweats
History of UTI
Positive cultures, elevated titers, positive screening for infectious disease
Exposure to body fluids or blood products through professional practice or through receiving a transfusion parenterally
as a patient; carrier of group B beta-hemolytic streptococci (GBS) or of hepatitis B virus (HbsAg, anti-HBcAg)
Exposure to infectious agents through employment/environmental contact
May have history of early trimester pregnancy loss(es).
May currently have, or have previous exposure to, numerous heterosexual/bisexual partners, which increases risk for
exposure to HIV and STDs; sexual partner may be hemophiliac, necessitating blood transfusions and placing him
at risk for acquisition of HIV.
Vaginal discharge may be frothy, gray-green (trichomonal infection); whitish (candidal infection); thin, watery,
yellow-gray, foul-smelling, “fishy” (