2. Introduction
Assessment begins when the nurse First
meets the client.
The nurse determines the reason the client
is seeking health care.
The examination begins with a general
survey that includes observation of general
appearance and behavior, vital signs, and
height and weight measurements.
3. A general survey provides information
about characteristics of an illness, a
client’s hygiene and body image,
emotional state, recent changes in
weight, and development status.
4. General appearance and behavior
Assessment of appearance and behavior
begins while nurse prepare the client for
examination.
The review of general appearance and
behavior includes the following…
5. Gender and race
A person’s gegender affects the type of
examination performed and the manner
in which assessments are made.
Different physical features are related to
gender and race.
Certain illness are more likely to affect a
specific gender or race :example
6. Age : age influence normal physical
characteristics.
Signs of distress : There may be obvious
signs or symptoms indicating pain,
difficulty breathing, or anxiety.
7. Body type
The nurse observe if a client appears
trim and muscular, obese or excessively
thin. Body type can reflect the level of
health, age and life style.
8. Body movements
Observe whether movements are
purposeful and note if there are any
tremors involving the extremities.
Determine if any body parts are
immobile.
9. Hygiene and grooming
The client’s level of cleanliness is noted by
observing the appearance of the hair, skin,
and fingernails
Dress : culture, lifestyle, socioeconomic
level, and personal preprance affect the type
of clothes worn. Note if the type of clothing
worn is appropriate for the temperature and
weather conditions.
10. Body odour
An unpleasant body odour may result
from physical exercise, poor hygiene or
certain disease states. Poor oral hygiene
may cause bad breath.
11. Affect and mood
Affect is a person’s feelings as they
appear to others. A person’s mood or
emotional state is expressed verbally or
nonverbally. Note if Verbal
expressionexpressions match nonverbal
behavior and observe if the client’s mood
is appropriate for the situation.
12. Speech
Normal speech is understandable and
moderately placed and shows an
association with the person’s thoughts.
Note if the client talks rapidly or slowly.
13. Client abuse
Abuse of children, women, and older
adults is growing and serious health
problem.
14. Substance abuse
Health care provider’s recognition of
clients who abuse, alcohol, prescribed
medications, or illegal drugs is typically
poor.