AREAS OF ASSESSMENT 1.

) Appearance and Mental Status Inspect for the following: *Body built , height and weight (age, lifestyle and health) *Clients posture, gait, standing, sitting and walking *Overall hygiene and grooming (clients activities) *Note for body odors (activity level) *Signs of distress in facial expressions *Signs of illness or health *Clients attitude *Clients affect of mood (in appropriate with its responses) *Quality/quantity of speech organization

NORMAL FINDINGS

SIGNIFICANT DEVIATIONS OF NORMAL FINDINGS

ACTUAL FINDINGS

IMPLICATIONS

Normal build: Height and weight are in normal proportions.

Thin, Underweight; Overweight or Obese

Relaxed and standing erect. The body is coordinated with its movement Clean, neat, personal hygiene and grooming, culturally appropriate

Curvature in the body posture (affecting due to bone problems), knockknee and bow leg.

No known body odors (acetone breath, armpit odor) Not stressful, feels relax and confident Healthy and well coordinated Cooperative, active, always smiling, feels confident, attentive Attentive

Appears neglected; dirty clothing, offensive smell (unshaved in some cultures) Acetone breath, armpit odor Stressful, irritated and cannot stand from one position to another Unwell, Sick, Feels painful Inactive, not cooperative, negative emotions, irritable Not cooperative Very loud and very soft Cannot understand the words and interpreting it Change from one topic to another

Normal loudness and softness and clarity of the speech Having sense while interviewing

*Relevance of thoughts or messages 2.) Skull and face Inspect for the following: *Skull size, shape and symmetry *Skull nodules or masses and depressions *Facial features *Eyes for edema and hollowness *Symmetry of facial movements: Elevated eyebrows, frown, lower eyebrows, close the eyes tightly, puff the cheeks, and smile show the teeth 3.) Nails Inspect for the following: *Fingernail plate

Round in shape, with prominences in the frontal and occipital area. No tenderness noted upon palpation. No nodules nor depressions Normal facial features No edema or hollowness Symmetrical facial alignment and movement

Different shape, without prominences in nomocephalic area Having tenderness, nodules and depressions Changing in some part of facial features With edema and hollowness Asymmetrical facial movements and alignment

Curved nails are

Less than 160 or

determining the curvature and angle *Fingernail and toenail texture *Fingernail and toenail bed color *Tissues surrounding nails

normal with approximately 160 Surface is smooth, and slightly rounded or flat Pink-cast in lightskinned and brown in dark-skinned Capillary refill present (should return to normal2-3 sec). Uniform nail thickness throughout; no splintering or brittle edges

approximately 180

Rough and rounded

Brown-cast nails

Capillary refill of 1.5 seconds

4.) Hair Inspect for the following: *Evenness of growth over the scalp Normal growth in according to age and culture Maybe thick or thin, coarse or smooth.

Abnormal growth of hair Excessive thickness (hypothyroidism) Excessive thinness (hyperthyroidism)

*Hair thickness or thinness

*Hair texture and oiliness Brittle, dry and oily *Presence of infections behind the ears and along the hairline at the neck *Amount of body hair Normal 5.) Skin Inspect for the following: *Skin color *Uniformity of skin color Skin is uniform *Assess for edema (if present) *Inspect or palpate skin lesions (apply gloves) *Palpate skin moisture *Palpate skin temperature With edema No edema With skin lesions No skin lesions present except for freckles, birthmarks or moles which maybe flat or elevated Skin is dry with a minimum of perspiration. Warm and equal bilaterally. Hands and skin slightly cooler than the rest of the body Should return to original contour rapidly 6.) Eyes Inspect for the following: Whitish pink or brown color Cyanotic color Neither brittle nor dry and not oily No infections Excessive amount of body hair With infections

Excessive dryness and moist Hypothermia and Hyperthermia

*Note skin turgor

Did not return to its original contour or slowly returning to its original form

EXTERNAL EYE STRUCTURES *Eyebrows for hair distribution and alignment (ask client to raise and lower the eyebrows) *Eyelashes for evenness or distribution even the direction of the curl *Eyelids for surface characteristics. Inspect lower eyelids while clients eyes are close Normal distribution and symmetrical alignment of eyebrows Eyelashes turn out and away from the eyeball. Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open. No drooping of upper eyelids. Meets completely when eyes are closed. Symmetrical Asymmetrical alignment of eyebrows

Eyelashes rubbing on eyeball PTOSIS (drooping of upper eyelids) Does not completely meet when eyes are closed. Asymmetrical Clear color without presence of capillaries Dry With foreign objects and ulcers

*Bulbar conjunctiva for color, texture and presence of lesions

Pinkish or red in color. Presence of many capillaries. Moist No ulcers No foreign objects Lacrimal gland is normally non palpable. No tenderness on palpation.

*Palpate lacrimal gland

Palpable and with tenderness

*Corneal sensitivity *Anterior chamber for transparency *Pupils color, shape and symmetry of size *Pupils direct and consensual reaction to light. Determine the function of CN III and CN IV PUPIL REACTION TO LIGHT *Response of the illuminated pupil. Response REACTION TO ACCOMODATION *Pupil response VISUAL FIELDS 70 *Left eye (Temporal field) *Left eye (Upward Field) *Downward field *Nasal field Can directly follow the movements symmetrically Normal 20/20 vision ASSESSING SIX OCULAR MOVEMENTS VISUAL ACUITY Visual disability Cannot follow directly. Asymmetrical to each other Above/ Less than 90 50 Above/ Less than 50 90 Above/ Less than 90 70 Above/ Less than 90 Unresponsive Responsive to the light. Constricts Unresponsive to the light. Does not constricts Black, rounded and 3cm symmetrical size Any color, not rounded and above 3cm asymmetrical size

7.) Nose and Sinuses Inspect for the following: NOSE *Shape, size, color and flaring or discharge from the nares *Areas of tenderness, masses and displacement of bone cartilage *Patency of both nasal cavities (close mouth) Each nostril patent *Exert pressure from one naris to another *Patency of opposite naris *Nasal cavities (using flashlight) No pain or discomfort during palpation *Presence of redness, swellings, growth and discharge *Nasal septum between nasal chambers No tenderness FACIAL SINUSES *Palpate the maxillary and frontal tenderness 8.) EARS and HEARINGS Inspect for the following: AURICLES *Shape, size, color, position Bean-liked shape Central position. Proportional Flesh color of the rest of the skin Indefinite shape Not align in central position. Not proportional Not matches with the color of skin Tenderness In pain or discomfort during palpation Symmetrical, midline of the face Asymmetrical, midline of the face Swelling, bleeding, lesions, or masses.

Without swelling, bleeding, lesions, or masses.

Each nostril does not patent

*Texture, elasticity and areas of tenderness

No redness, lesions, swelling, tenderness Should not complain of pain or tenderness

Redness, lesions, swelling, tenderness In pain or tenderness

EXTERNAL EAR CANAL and TYMPANIC MEMBRANE *External ear canal for cerumen, skin lesions, pus and blood *Tympanic membrane for color and gloss GROSS HEARING ACUITY *Response to normal voice tones

*Result of watch tick tests TUNING FORK TESTS *Webers Test *Rinne Test 9.) MOUTH and OROPHARYNX Inspect for the following: LIPS and BUCCAL MUCOSA *Symmetry of contour, color, texture. (purse lips)

Lips and membranes are pink and moist, rough without lesions. Symmetrical; moves freely.

Lips and membranes are pale and dry, smooth with lesions. Asymmetrical; moves freely. In white skinned people it will be possible to detect paleness, cyanotic

INNER LIPS and FRONT TEETH *Any lesions for size, tenderness and consistency

No swelling. Moist

*Teeth and gums BUCCAL MUCOSA and BACK TEETH *Number of teeth, color, state of fillings, dental caries and tartar GUMS *Bleeding, color, retraction of teeth, edema, lesions. Gum texture *Dentures, inspecting the condition and particularly broken and worn areas TONGUE/FLOOR OF THE MOUTH *Position, color, texture *Tongue movement

Strong teeth, white and smooth without any discharge and healthy pinkish colored gums Complete teeth (32 teeth) without tartar. White colored

No swelling. Dryness, cracks & ulcers in all cultures. Inflamed, swollen, bleeding, lesions, trauma Weak teeth with any discharge and unhealthy pale colored gums

Incomplete teeth. Yellowish teeth

Gums have pale-red strippled surface. No swelling. No edema and lesions Without broken and worn areas Breath smells fresh.

Gums have pale strippled surface. With swelling, edema and lesions

With broken and worn areas Breath smells fresh.

Tongue is midline. *Inspect for any nodules and lumps SALIVARY GLANDS *Swelling and redness PALATES and UVULA *Hard and soft palate color, shape, texture and presence of bony prominences *Uvula position and mobility (saying ah!) No swelling and redness Swelling and redness Hard palate is smooth and soft palate is rough with presence of bony prominences Moves upward, downward and sideward No nodules and lumps With nodules and lumps Tongue is not in the midline. Cannot move in all sides

Hard palate is not smooth and soft palate is not rough without presence of bony

OROPHARYNX and TONSILS *Color and texture

prominences Well-aligned Not properly aligned Pinkish Red (signs of inflammation eg: tonsillitis)

10.) NECK Inspect for the following: NECK MUSCLES *SCM and traps abnormal swelling or masses *Head movement Chin to chest Head back to move chin upward Head to side of shoulder Equal strength *Muscle strength Unequal strength Shrugging the shoulder TRACHEA *Lateral deviations Palpable Positioned in the line and straight. (Central) Less than 40 No swelling or masses Coordinated, smooth movement and no discomfort Laterally flexes 40 Less than 40 60 hyper extends Laterally rotates 70 Less than 60 hyper extends With swelling or masses Not coordinated, rough movement and with discomfort, tremor and limited movements

Enlarged palpable. Neck tumor, enlargement of lymph nodes

THYROID GLAND *Smoothness, enlargement, masses and nodules

Lobes may not be palpated. Absence of nodules and masses and bruit

Salivatory nodules, presence of bruit