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2. Close doors and put screen. - The lack of privacy makes the
R: To provide privacy. - Patient shows that he is patient feel anxious and conscious
comfortable since at the same time which can lead to
inaccuracy of findings.
privacy is provided and
could help encourage the
patient. - Patient shows signs that he feels
ashamed or embarrassed
- When dignity is
present people feel in
control, valued,
confident, comfortable
and able to make
decisions for themselves.
Thinking
Behavior Thought Content
•Eye contact: normal •Suicidal ideation
•Fearful
Thinking •Homicidal ideation
Thought Processes
Thought Content
● Future oriented
5. Observe the client’s level The client is fully awake and Client has lowered LOC and shows
of consciousness (LOC) and alert: eyes are open and follow irritability, short attention span, or unable
orientation. Ask the client topeople or objects. The client is to follow simple commands or answer
state his/her own name, attentive to questions and simple questions. At lowered LOC, he or
current location, and responds promptly and accurately she may respond to physical stimuli only
approximate day, month, or to commands; he or she moves (such as deep pain). The lowest extreme is
year. willingly. If the client has been deep coma, when the eyes are closed and
R: Responses indicate the sleeping, he or she responds to the client fails to respond to verbal or
client’s brain function. LOC verbal or physical stimuli and physical stimuli, with no voluntary
is the degree of awareness of demonstrates wakefulness and movements. If LOC is below full awareness
environmental stimuli. It alertness. The client is aware of but above coma, objectively note the
varies from full wakefulness who he or she is (orientation to client’s eye movements, respond to
and alertness to coma. person), where he or she is commands and type of movement:
Orientation is a measure of (orientation to place), when it is voluntary, withdrawal to stimuli or
cognitive function or the (orientation to time) withdrawal to noxious stimuli (pain) only.
ability to think and reason.
6.Observe client’s ability to The client is able to follow Abnormal findings include dysphasia
think, remember, process commands and repeat and (difficulty in understanding or expressing
information and remember information. He or she language), dysarthria (inability to speak),
communicate. is able to see and identify objects memory loss, disorientation, or
R: These processes indicate within the room. hallucinations. The client may also be
cognitive functioning. Inspect voluntarily mute (in psychiatry).
articulation on speech style
and contents of speaking.
7.Observe the client’s ability The client can hear even though
to see, hear, smell and the speaker turns away. He or she The client cannot hear low or very high
distinguish tactile sensations. identifies objects or reads a clock tones and must look directly at the speaker
in the room, and distinguishes to distinguish what is being said. He or she
between sharp and soft objects. cannot read a clock or distinguish sharp
The nose is centered; the ears are from soft. Eyes, ears, nose, or mouth are
symmetrical on the sides of the asymmetrically placed. Redness or swelling
head; the lids open and close in appears around the eyelids or eyes.
command. Excessive tears, exudate (abnormal
drainage from eyes or ears), or
conjunctivitis (redness of eyes) is present.
Blood pressure
Temperature: 97.8°F to 99.1°F ● Greater than 120 is hypertension
(36.5°C to 37.3°C)/average ● BP falls to 90 mm Hg and below
98.6°F (37°C) is hypotension
Breathing
● If higher than 20 breaths per
minute, patient may have
hyperoxia which is excessive
oxygen supply
● If lower than 12 breaths per
minute patient may have hypoxia
which is insufficient oxygen
B. Skin Assessment Asses SKIN SKIN
integumentary structures ● skin is not dry or oily ● Dry, oil, excessive sweating
(skin,hair, nails) and there is no ● Vascular lesions or erythema
and function excessive sweating
SKIN NAILS
Inspection and Palpation
15. Inspect the back and ● No vascular lesions or ● blemishes or discolour
palms of the client’s hands
erythema are observed ● Cracks
for skin color. Compare the
right and left sides. Make ● Skin and nails occur changes
similar inspection of feet NAILS
and toes, comparing the ●
right and left sides R: Pink and transparent HAIR
Extremities indicate without blemishes or ● Brittle, hair fall
peripheral cardiovascular discolouring
function
●
Smooth and
paliable,convex
without cracks
●
Curves are pulling
away from the corners
●
Skin around nails
shows no changes and
nails looks well cared
HAIR
●
No recent changes of
characteristics of the
hair
●
16. Palpate the skin on the Skin is smooth, there is no S kin is not smooth may be scaliness in the
back and palms of the client’s scaliness and the skin thickness is texture and skin is not supple
hands for moisture,texture. normal
Skin is normally free of lesions There are two categories of skin lesions that
20. Inspect the skin for except for common freckles or are known; primary and secondary skin
lesions. Note the appearance, age-related changes such as skin lesions. Primary Lesions: this includes
size location, presence, and tags or senile keratosis, cherry skin conditions that are apparent at birth or
appearance of drainage. angiomas and atrophic warts. are developed over an individual’s lifetime
R : Locate abnormal cell such as:
growths or trauma that
suggests abnormal
physiologic processes.
Pediculosis capitis
-head lice; signaled by tiny, white, oval
eggs (nits) that adhere to the hair shaft.
24. Inspect the scaly, lumps, - - clump together to form white or
nevi or other lesions. grey flakes of dandruff
- shade of brown to black,
congenital melanocytic nevi can
The scalp is normally be reddish.
-
smooth and inelastic
with even coloration.
By carefully separating
strands of hair,
thoroughly examine the
scalp for lumps,nevi or
other lesions. The
- scaly, lumps, and other
lesions should be
present, if lumps and
bruises are found, ask if
the patient has
experience recent head
traumas.
EYES
28. Position: Eyeballs are symmetrical in size If the reflex on one eye is more medial, the
Stand in front of the client and position. The eyeballs are in patient may have e xotropia; if more lateral,
and inspect both eyes for the same plane as eyebrow and the patient may have e sotropia . To
position and alignment. maxilla. evaluate position, inspect for outward
deviation, called e xophthalmos.
34. Pupils: The eyes do not turn inwards or Pupils are unequal in size and are not
Inspect the size, shape, and outwards and there is no visible symmetrical in shape and position.
compare symmetry. prominence. Both pupils should
be the same shape and size.
35. Pupillary response to The pupils constrict to direct The pupil is abnormal if it fails to dilate to
light: illumination (direct response) and the dark or fails to constrict to light or
● Ask the client to to illumination of the opposite accommodation.
look into distance eye (consensual response). The
and light a penlight pupil dilates in the dark. Both
from the side of the pupils constrict when the eye is
eye. focused on a near object
(accommodative response).
● Remove it on the
other side to observe
how pupil reacts.
● Repeat other side
with same procedure.
36. Coordination of eye Both eyes should be able to Both or one of the eyes will have difficulty
movements: smoothly follow the object focusing on the object and following its
● Hold an object at a without difficulty. path. Eye movements can be asymmetrical.
distance from the client.
● Ask him/her to
keep his/her head
still and follow the
object with the eyes
only.
● Move the object
towards his/her right
and left eye, then
towards the ceiling
and floor.
37. Convergence test: The eyes move together and be ● Isolated lesions of a cranial nerve
● Ask the client to able to easily and smoothly ● Strabismus - “cross-eyes” present
follow your finger or follow the finger. or eye movement asymmetrical.
a pencil as you move
it in towards the
● Eyelids are dropping or have
bridge of the nose. asymmetrical movements.
38. Snellen Eye Chart Test: Pupils are able to see objects both ● Diplopia (double vision) or
● Use the Snellen near and far away. blurring of vision.
Eye Chart, which
includes objects, Pupils are equal, round and
letters or numbers of responsive to light. ● Pupils are unequal and/or
different sizes in unresponsive or sluggishly
rows, under well- responsive to light .
light.
● Position the client
20 ft from the chart
and ask the client to
identify the items.
● Compare the visual
acuity of the client
with normal vision.
EAR & HEARING Auditory canal Pinna and Post Auricular Area
● Some hair, often with ● Obvious deformities or abnormal
39. Using otoscope, yellow to brown cartilaginous fragments
hold the helix, gently pull the cerumen. ● Scars or skin changes
pinna upward and backward
toward the occiput. o Including for skin malignancies ●
40. Gently insert the Tympanic Membrane Signs of inflammation
otoscope and examine the ● Lateral process of
ear. malleus o An inflamed mastoid may push
● Cone of light the pinna forward
● Perforations
● Tympanosclerosis
● Red and bulging membrane
● Retraction of the membrane
41. Inspect the pinna, external Pinna - abnormal shape or position of the
canal, tympanic membrane, outer ear (pinna or auricle).
landmarks External Canal - Patient has
(lobules, helix, antihelix, external otitis which is an acute infection of
tragus, triangular fossa, Pinna - no deformity or skin
the ear canal skin caused by bacteria
mastoid process) changes.
Tympanic Membrane - Patient
External Canal - has some hair,
positive for myringitis because of inflamed
often lined with yellow to brown
TM
wax. Tympanic Membrane -
pearly grey, shiny, translucent,
with no bulging or retraction.
Lateral process of malleus.
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