Assessment
Observe body build, height , weight in rel. to age, lifestyle, and health Posture and gait, standing ,sitting and walking Overall hygiene and grooming Body and breath odor in rel. to activity level
Normal Findings
Proportionate, varies with lifestyle
Deviations from normal
Excessively thin or obese
Relaxed, erect posture, coordinated movement Clean , neat No body odor / minor body odor relative to work/exercise; no breath odor No distress noted
Tense, slouched, bent posture, uncoordinated movement; tremors Dirty, unkempt Foul body odor; ammonia odor; acetone breath odor; foul breath (halitosis) Bending over because of abdominal pain, wincing, frowning or labored breathing
Signs of distress in posture or facial expression
Assessment
Signs of health or illness (e.g. skin color or breathing) Clients attitude
Normal Findings
Healthy appearance
Deviations from normal
Pallor; weakness; lesions
Cooperative, able to follow instructions
Negative, hostile, withdrawn Inappropriate to situation
Affect/ mood; assess Appropriate to the appropriateness of situation the clients responses
Assessment
Quantity of speech (amount and pace), quality (loudness, clarity), organization (coherence of thought, overgeneralization, vagueness) Listen to relevance and organization of thoughts
Normal Findings
Understandable, moderate pace; clear tone; exhibits thought association
Deviations from normal
Rapid /slow pace; overly loud or soft; uses generalizations; lacks association
Logical sequence; makes sense; has sense of reality
Illogical sequence; flight of ideas; confusion; vaque
Chair scale
Bed scale