general survey edited
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Assessment Normal Findings Deviations from normal
Observe body build,height , weight in rel. toage, lifestyle, and health
Proportionate, varieswith lifestyle
Excessively thin or obese
Posture and gait,
standing ,sitting andwalking
Relaxed, erect
posture, coordinatedmovement
Tense, slouched, bent
posture, uncoordinatedmovement; tremors
Overall hygiene andgrooming
Clean , neat Dirty, unkempt
Body and breath odor inrel. to activity level
No body odor / minorbody odor relative towork/exercise; nobreath odor
Foul body odor; ammoniaodor; acetone breath odor;foul breath (halitosis)
Signs of distress inposture or facialexpression
No distress noted Bending over because ofabdominal pain, wincing,frowning or laboredbreathing
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Assessment Normal Findings Deviations fromnormal
Signs of health orillness (e.g. skin color
or breathing)
Healthy appearance Pallor; weakness;lesions
Clients attitude Cooperative, able tofollow instructions
Negative, hostile,withdrawn
Affect/ mood; assessthe appropriateness ofthe clients responses
Appropriate tosituation
Inappropriate tosituation
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Assessment Normal Findings Deviations fromnormal
Quantity of speech(amount and pace),quality (loudness,clarity), organization(coherence of thought,overgeneralization,vagueness)
Understandable, moderatepace; clear tone; exhibitsthought association
Rapid /slow pace; overlyloud or soft; usesgeneralizations;
lacks association
Listen to relevance andorganization of
thoughts
Logical sequence; makessense; has sense of reality
Illogical sequence; flightof ideas; confusion;
vaque
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Chair scaleChair scaleChair scaleChair scale Bed scaleBed scaleBed scaleBed scale
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