ASSESSING APPEARANCE AND MENTAL STATUS

Planning

Equipment

Delegation Due to substantial knowledge and skill required, Assessment of general appearance And mental status is not delegated to unlicensed Assistive personnel (UAP). However, many aspects are

None

Observed during usual care and maybe recorded by persons Other than the nurse. Abnormal findings must be validated and interpreted by the nurse.

IMPLEMENTATION

Performance

1. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he/she can cooperate. Discuss how he or she can cooperate. Discuss how the result will be use in planning further care or treatments. 2. Performing hand hygiene and observed appropriate infection control procedure. 3. Provide for client privacy.

ASSESSMENT DEVIATION FROM NORMAL 4. Observed body build, height, and weight and relation to the clients age, lifestyle, and health.

NORMAL FINDINGS Proportional varies with smoking

5. Observed clients posture and Gait, standing, sitting, and walking.

Erect posture, coordinated Movement, Relaxed

6. Observed clients overall hygiene And grooming. Relate this to the Persons activities prior to the Assessment.

Clean, Neat

7. Note body and breathe odor in Relation to activity level.

No body odor or minor Body odor; no breath odor

8. Observed for sign of distress in Posture or facial expression.

No distress noted

9. Note obvious signs of health or illness (e.g., in skin color or breathing)

Healthy appearance

10. Assess the clients attitude.

Cooperative, able to

follow instructions 11. Note the clients affects/mood; Assess the appropriateness of the Clients responses. Appropriate to situation

12. Listen for quantity of speech

Understandable; clear

(amount and pace), quality (loudness, tone, exhibits thought Clarity,inflection), and organization (coherence of thought, overgeneralization, Vagueness). association

13. Listen for relevance and organization of thoughts.

Logical sequence; makes Sense; has sense of reality

14 Document findings in the client record using hand written or electronic forms and checklist supplemented by narrative notes when appropriate. _______________________________________________________________________ EVALUATION Perform a detailed follow-up examination of other individual systems based on findings that deviated from expected or normal from the client. Relate findings to previous assessment data if available. Report significant deviation from normal to the primary care provider. ASSESSING THE SKIN PLANNING

 Review characteristics of primary and secondary skin lesions if necessary. Ensure that adequate lighting is avaible.

Delagation Due to substantial knowledge and skill Required, assessment of the skin is not Deligated to UAP. However, the skin is Observed during usual care and these Persons should record their findings. Abnormal findings must be validated And interpreted by the nurse.

Equipment Millimeter ruler Clean gloves Magnifying glass

IMPLEMENTATION

Performance

1. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he/she can cooperate. Discuss how he or she can cooperate. Discuss how the result will be use in planning further care or treatments. 2. Performing hand hygiene and observed appropriate infection control procedure. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: pain or itching: presence and spread of lesions, bruises, abrasion, pigmentation spots; previous experience with skin problems; associated clinical signs; family history; presence of problems on

other family members; related systemic conditions; use of medications, lotions, home remedies; excessively dry or moist feel to the skin; tendency to bruise easily; association of the problem to season of the year, stress, occupation, medication ,recent travel, housing and so on; recent contact with allergens, e.g., metal paint.

ASSESSMENT FROM NORMAL 5. Inspect the skin Color (best assessed Under natural light And on areas not Exposed to the sun).

NORMAL FINDINGS Deep brown

DEVIATION

6. Inspect uniformity Of skin color.

Generally uniform except In areas exposed to the sun; Areas of lighter pigmentation (palms, lips, nail beds)

7. Assess edema, if Present (i.e location, Color, temperature, Shape, and the degree to which the skin remains indented or pitted when pressed by

No edema

a finger). Measuring the circumference of the extremity with a millimeter tape may be useful for future comparison.

8. Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or draining. Palpate lesions to determine shape and texture. Describe lesions

birthmark in right lower quadrant of abdomen; no lesions

according to location, distribution, color, configuration, size, shape, type, or structure.

9. Observed and palpate skin moisture.

moisture in skin folds And axillae

10. Palpate skin temperature. Compared the two feet and the two hands, using the back of your fingers.

Uniform; within normal range

11. Note the skin turgor (fullness or elasticity) by lifting and pinching the skin on an extremity.

when pinched, skin springs back to previous state

12. Document findings in the client record using forms or checklist supplemented by narrative notes when appropriate. Draw location of skin lesions on body surface diagrams.

____________________________________________________________________

EVALUATION

Compare findings to previous skin assessment data if available to determine if lesions or abnormalities are changing. report significant deviation from normal to the primary care provider.

ASSESSING THE HAIR PLANNING EQUIPMENT

Delegation Assessment of the hair is not delegated to UAP. However, many aspects are observed during usual care and may be recorded by persons other than the

Clean gloves

nurse. Abnormal findings must be validated and interpreted by the nurse.

_______________________________________________________________________ IMPLEMENATION

Performance

1. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he/she can cooperate. Discuss how he or she can cooperate. Discuss how the result will be use in planning further care or treatments. 2. Performing hand hygiene and observed appropriate infection control procedure. 3. Provide for client privacy. 4. inquire if the client has any history of the following: recent use of hair dyes, rinses, or curling , or straightening preparation; recent chemotherapy(if alopecia is present) ; presence of disease , such as hypothyroidism, which can be associated with dry, brittle hair.

ASSESSMENT FROM NORMAL 5. Inspect the evenness

NORMAL FINDINGS Evenly distributed hair

DEVIATION

of growth over the scalp.

6. Inspect hair thickness or Thin hair thinness.

7. Inspect hair texture and Silky, resilient hair oiliness.

8. Note presence of infection No infection or or infestation by parting the hair in several areas, checking behind the ears and along the hairline at the neck. infestations

9. Inspect amount of body hair. Variable 10. Document findings in the clients record using forms or checklists supplemented by narrative notes when appropriate. ____________________________________________________________________ EVALUATION Report significant deviation from normal to the primary care provider. ASSESSING THE NAILS PLANNING Delegation EQUIPMENT None

assessment the nails is not delegated to UAP. However, many aspect are observed during usual care and may be record findings by person other than the nurse. Abnormal findings must be validated and interpreted by the nurse. _______________________________________________________________________

IMPLEMANTATION

Performance

1. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he/she can cooperate. Discuss how he or she can cooperate. Discuss how the result will be use in planning further care or treatments. 2. Performing hand hygiene and observed appropriate infection control procedure. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: presence of diabetes mellitus, peripheral circulatory disease, previous injury , or severe illness.

ASSESSMENT FROM NORMAL 5. Inspect fingernail plate shape to determined its

NORMAL FINDINGS convex curvature; angle of name plate

DEVIATION

curvature and angle.

About 160 degrees

6. Inspect fingernail and toenail texture.

Smooth texture

7. Inspect fingernail and toenail bed color.

Pinkish

8. Inspect surroundings nails.

Intact epidermis

9. Perform blanch test of capillary refill. press two or more nails between your thumb and

Prompt return of Pink in 2 seconds

index finger; look for blanching and return of pink color to nail bed.

10. Document findings in the clients record using forms or checklists supplemented by narrative notes when appropriate. ____________________________________________________________________

EVALUATION

 Perform a detailed follow-up examination of other individual system based on findings that deviated from expected or normal form the client.