GENERAL APPEARANCE AND MENTAL STATUS

Clients name: GMM Date assessed: January 3, 2010 Initial v/s Temperature: 36.9 C - axillary Pulse rate: 65 beats / min., regular, weak, palpable - radial artery Respiratory rate: 13 breaths / min., regular, deep, quiet and effortless Blood pressure: 110 / 90 mmHg Height: 152 cm. Weight: 57 kg. BMI: 24.68 - normal Time assessed: 9:00 am

ASSESSMENT

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

1. BODY BUILT: Observe body built, height, and weight in relation to the clients age, lifestyle, and health.

Proportionate, varies with lifestyle ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

Weight within range for height, age, body size. Firm and well developed muscles. Mesomorph body built. Body built proportionate to height and weight. Firm and equal distribution of fat and muscle mass.

Normal

2. POSTURE AND GAIT: Observe clients Posture and gait, standing, sitting, and walking.

Relaxed, erect posture; coordinated movement ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

Posture is erect and comfortable for age. The same when standing, sitting and walking. Gait is rhythmic and coordinated with arms swinging at side.

Normal

3. HYGIENE AND GROOMING: Observe clients overall hygiene and grooming. Relate

Clean, neat; No body odor or minor body odor relative to work or exercise; no breath odor.

Overall hygiene is clean and neat. Wears appropriate clothing; clean and neat. Hair is well

these to the persons activities prior to the assessment. Note body and breath odor in relation to activity level.

( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

combed and neatly tied at the back. Nails are cut- short and clean. No body odor or minor body odor relative to work or exercise; no breath odor.

Normal

4. SIGN OF DISTRESS: Observe for signs of distress in posture or facial expression.

No distress noted ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

Facial features are symmetric with movement. No sign of distress. Calm and relax during assessment. Establishes and maintain good eye contact.

Normal

5. SIGN OF HEALTH AND ILLNESS: Note obvious signs of health or illness (e.g., in skin color or breathing).

Healthy appearance ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

No signs of illness. Appears healthy. Skin is uniform except in areas exposed to sun. Skin color is brown without obvious lesions.

Normal

6. ATTITUDE: Assess the clients attitude.

Cooperative, able to follow instructions. ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

The client is cooperative and able to follow instructions.

Normal

7. MOOD/AFFECT: Note the clients affect/ mood; assess the appropriateness of the clients responses.

Appropriate to situation ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

Affect is appropriate for the clients attitude. Smiles and frowns appropriately.

Normal

8. SPEECH: Listen for quantity of speech (amount and pace), and organization (coherence of thought,

Understandable, moderate pace; clear tone and inflection; exhibits thought association.

Speech is understandable, moderately paced with a clear tone and culturally appropriate.

overgeneralization, vagueness).

( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

Normal

9. CONSCIOUSNESS: Listen for relevance and organization of thoughts.

Logical sequence; makes sense; has sense of reality. ( ref: Fundamentals of Nursing, Berman/ Synder/ Kozier/ Erb, 2008,pp.572 )

Has a logical sequence when stating, has a sense of reality. Client is alert and oriented to what is happening at the time of interview, name, address and phone number and not stammering nor confused in talking.

Normal

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

GENERAL SURVEY

ESMAEL, EVA GLORIA C. BSNB05 GROUP II

PROF. JOHN ARBIE T. TATTAO, RN, MSN