NCM 101-Thirteen Areas of Assessment A. Psychosocial Status Evaluation of an individual’s mental health and social well-being. It assesses the perception of self and the individual’s ability to function in the community. Normal • Feel comfortable with other people • Control tension and anxiety • Are able to meet the demands of life • Curb hate and guilt • Maintain a positive outlook • Value diversity • Feel good about themselves • Proper mind and body coordination Abnormal • Depressed with thoughts of suicide or harming others • Anxious • acts just a little peculiarly under normal situation • Changes in level of consciousness; • Restlessness • Listlessness • Confusion • disorientation, • sloppy clothes, body odor, dirty clothes • too tense or too relaxed. • altered speech and motor activity • Malaise • Confusion or disconnectedness • Sleep disturbances • Weight and appetite changes • Fatigue • lack of energy B. Mental and Emotional Status Assesses the function of the brain. The purpose is to evaluate mental functions and behaviors. A good mental status examination helps assess many mental health/central nervous system disease states. A good mental status examination can be used to monitor a patient’s severity of illness over time. Overall Assessment General appearance Normal • physical appearance appears stated age • dressed casually • Appropriate Facial expression • Tidy grooming • weight appears within normal range • normal body built or physical appearance • Stands comfortably erect • Dirty clothing • sloppy clothes • poor hygiene • dirty clothes Abnormal All could mean OBS or depression. • Very tidy or meticulous grooming (may mean obsessive-compulsive personality.) • appropriate facial expression. • Prominent physical abnormalities • Somnolent • Uncooperative • Apparent Physical appearance General behavior This is the: “First Impressions” category. Normal • open to questions • expressions appropriate to situation • relaxed • follows instructions well • responds appropriately to questions • direct eye contact • Belligerence • flat • Combativeness • Retardation • Furtive • Depressed • Angry • Sad Abnormal Orientation (general) Most nurses are familiar with this phase of brain function. Orientation is measured in time, person, and place. Normal • Respond Appropriately • alert Abnormal • disoriented • poor level of awareness in time,person and place Level of consciousness Normal • able to respond to stimuli at the same lower level of strength Abnormal • Clouded consciousness a state of reduced awareness whose main deficit is one of inattention. • Obtundation refers to moderate reduction in the patient's level of awareness such that stimuli of mild to moderate intensity fail to arouse • Stupor may be defined as unresponsiveness to all but the most vigorous of stimuli. The patient quickly drifts back into a deep sleep-like state on cessation of the stimulation. • Coma is unarousable unresponsiveness. The most vigorous of noxious stimuli may or may not elicit reflex motor responses. Mood and affect Normal • Comfortable • Cooperative • Interacts pleasantly Abnormal • Hostile • Distrustful • Suspicious • Crying C. Enviromental status Normal findings • Well ventilated • Spacious • Proper lightning and good ambience • free from pathogen • clean • free from unsafe objects • a safe environment free from accidents Abnormal findings • Crowded • Poor lightning • Noisy • Dirty D .Sensory a.Visual Normal • Non protruding • Pupils equally round reactive to light and accommodation • Intact ocular muscles using 6 cardinal positions • Can see objects in periphery • Both eyes coordinated ,move in unison with parallel alignment • 20/20 vision on Snellen-type chart • Equal palpebral fissure • Abnormal • Hazy , blurred and double vision • Swollen red eyes • Eye movements are not coordinated • Neither pupil constricts • Unequal response or absent response • Itching ,burning or heavy discharge in the eyes • Sudden development of persistent floaters • Changes in the color of Iris • Severe or sudden eye pain 2.Auditory Normal • Same color as the facial skin • Symmetrical • No lesions upon inspection • Free from cerumen ,skin lesions, pus and blood • Pearl gray color , semitransparent Tympanic membrane • Normal voice tunes audible • Sound is heard both ears or is localized at the center of the head (Weber negative) • Air-conducted (AC) hearing is greater than bone -conducted (BC) hearing AC>BC (Positive Rinne) Abnormal • Bluish color of earlobes , excessive redness • Asymmetrical • Presence of Lesion (cyst, flaky, scaly skin) tenderness when moved • Pink to red , yellow -amber ,blue or deep red and dull surface of Tympanic membrane • Normal voice times not audible ( request nurse to repeat words or statements ,leans toward the speaker ,cups the ears or speaks in loud tone voice • Sound is better heard in impaired ear indicating bone -conductive hearing loss or sound is heard better in ear without a problem , indicating a sensorineural disturbance (Weber Positive) • Bone conduction is equal to or longer than air conduction ,negative Rinne; indicates a conducive hearing loss • Difficulty in comprehending and following rapid speech • Difficulty localizing sound • Difficulty understanding spoken language in competing messages ,in noisy backgrounds • Being easy distracted • Poor performance on speech and language or psychoeducational tests in areas of auditory related skills. 3.Olfactory Normal • External nose has symmetrical shape and size • No discharge or flaring • Uniform color • Not tender upon light palpation • Free from lesions • Nasal septum in the midline & not perforated • Not tender upon palpation in the maxillary and frontal sinuses • Able to identify specific smell Abnormal • External nose has asymmetrical shape and size • Discharge from nares • Localized areas of redness or presence of lesions • Inability to distinguish specific smell or poor sense of smell • Presence of mucosa red, edematous • Abnormal discharge (pus) • Presence of lesions (polyps) • Septum deviated to the right or left • Tenderness in one or more sinuses • Persistent stuffy or blocked nose 4.Gustatory Normal • Pink color (some brown pigmentation on tongue borders in dark-skinned clients) in the surface of the tongue • Free from lesions • Raised papillae (taste buds) • Tongue can move freely and with strength • Smooth tongue base with prominent veins • able to discriminate sweet, sour, salty and bitter tastes from each other Abnormal • Inability to taste • Irritations in the soft and hard palate & from • Exostoses (bony growths) in the hard palate E. Motor Normal • patient is able to move and can move all her joints • all her extremities are intact. • While Clenching his /her teeth the strength of the muscle contraction should be equal bilaterally • Able to respond appropriately in corneal reflex • symmetry at rest and while he smiles, frowns, and raises his eyebrows • Increased muscle strength by attempting to open his eyes. Abnormal • asymmetry of muscle; unilateral atrophy will often indicate weakness. • Inability to put resistance in both extremities by pushing them down • Inability to let go when grasp your fingers in his fist Motor activity and speech rate Normal • Normal gait as a symmetric, rhythmic , well-balanced & characterized by alternating propulsive & retropulsive motions of the lower extremities • Normal speech rate • Spontaneous movement • altered speech rate ,rhythm (hypophonia of Pakinson’s disease) • halting speech • rapid and pressured speech • involuntary movement(Tremor, tics) • abnormal gait (example :propulsive, hemiplegic, ataxic) • unusual mannerisms • stereotypies • Slowness and loss of spontaneity in movement Abnormal F. Nutritional status Normal • Ideal body weight the optimal weight as recommended for optimal • Free from complications or illness • Turgid skin • Smooth and thick hair • Body fat is accordance to age and sex • Normal blood pressure level • Healthy cholesterol levels • Healthy skin and shiny hair • Clear vision • Mental alertness • Restful sleep • Regular bowel movements • Good muscle times • Healthy bones Abnormal • • Weakness and fatigue • Weight loss • Dry flaky skin • Poor skin turgidity • Sore that won’t heal • Thinning dry hair • Spoon-shaped brittle or ridged nails • Night -blindness • Cracks at the corner of the mouth • Red conjunctiva • Soft spongy bleeding gums • Swollen neck (goiter) • Beefy red tongue • Poor dentition • Edema • Shortness of breath • Cough • Third and fourth heart sounds • Tachycardia, murmur , hypotension • Bone pain • Muscle wasting • Altered mental status • Obesity G. Elimination status Normal • Normal voiding pattern • Normal urine output according to age • Free from associated risks such as infection & skin breakdown • Normal bowel movement • Soft & firm texture of the stool • Stool that is passed in one single piece or a few smaller pieces • stool color can range from light yellow to brown Abnormal: • Decreased frequency of defecation • Hard, dry & formed • Painful and difficult voiding • Involuntary urination • Involuntary leakage of urine • Decreased urinary output • Large production of urine • Straining at stool • Painful defecation • Feeling of fullness , discomfort in rectum and abdomen • Anorexia & nausea • Headache • Generalized malaise • Loss of appetite • Vomiting • Abdominal distention • Blood or coal stain in the stool H. Respiratory status Normal • Even and unlabored or effortless respirations • regular at a rate of 12 to 20 breaths per minute. • inspiration is half as long as expiration • Chest expansion is symmetrical. Clear airways • Comfort of stool passage • Stool soft and formed Abnormal • Complaints of shortness of breath (dyspnea) • Bluish or cyanotic appearance of the nail beds, lips, mucous membranes and skin • Restlessness, irritability, confusion, decreased level of consciousness • Pain during inspiration and expiration • Labored or difficult breathing • Orthopnea • Use of accessory muscles • Abnormal breath sounds such as wheezes, rhonchi or rales • Inability to breathe spontaneously • Thick, frothy, blood-tinged or copious sputum production • Paradoxical chest wall movement I. Circulatory status Normal • Pulses are normal according to age (Adult-60-100bpm) • Capillary refill time of two seconds or less • Normal usual skin tone bilaterally • Skin should be warm to touch • Improve tissue perfusion • Adequate cardiac output • Regular heart rhythms • Presence of peripheral pulse • Regular heart beats • Can perform activities without sign of difficulty • Proper body functioning Abnormal • Pallor or cyanosis • delayed capillary refill • Pulses (decreased or absent in distal extremity) • Shiny and pale skin • Cool and hot temperature on the localized part of the skin • Numbness or tingling in extremities • Shortness of breath • Dyspnea on exertion • Increased or decreased heart rate • S3 heart sound • Increased respiratory rate • Nocturia • Orthopnea • Distended neck veins • Decreased peripheral pulses • Decreased hair distribution • Chronic fatigue • Pitting edema on the feet and ankles • Dizziness J. Fluid and Electrolytes status Normal • Total body water 60% IBW of males 50-55% IBW of females • Normal sweating • Proper body functioning • Normal breathing pattern • Good skin turgor • Moist mouth and mucous membranes • Capillary refill is 1-2 seconds • Urinates regularly Abnormal • Peritonitis • Intestinal obstruction • Soft tissue inflammation/edema • Traumatic losses • Evidence of diminished volume • Tachycardia /Bradycardia • Narrowed pulse pressures • Hypotension • Thirst • Lethargy • Neurological dysfunction due to dehydration of brain cells • Decreased vascular volume • Diarrhea • Polyuria • Fever • Vomiting • Excessive sweating • Decreased capillary refill • Overhydration • Confusion, lethargy, apprehension • Muscle twitching • Headache • Seizures • Dry ,sticky mucous membranes • Tongue red,dry ,swollen Irritability K. Integumentary status Normal • Uniformity of skin color • Uniform hair pattern • Skin is turgor • Free from lesions • Smooth texture • Intact skin • Cyanosis • Edema • Ecchymosis Abnormal • Macule • papule cyanosis • jaundice • vitiligo • hirsutism • alopecia • Purple or bruised looking • skin • Paper-thin skin • Dark or reddened areas • Pressure ulcer • Rash • Infection, cellulitis Temperature status • Dry and over wetness skin (maceration) • Trauma • Skin tears • Breakdown • Incision • Burns L. Temperature Status Normal • Temperature is within the normal range which is 36.5-37.5 °C (98.5-99 °F ( Depends on the temperature route) • optimized metabolic processes and bodily functions. Abnormal • Drowsiness or very low energy • Bright red, cold skin (in infants) • Dizziness • Elevated Heart Rate • Fainting • Shivering • Slurred speech or mumbling • Clumsiness or lack of coordination • Fever • Headache • Muscle Cramps • Slow, shallow breathing • Weak pulse • Nausea • Profuse Sweating or Absence of Sweating M. Rest ,sleep & Comfort status Normal • Able to function well in daily • Wakes up feeling energetic or rejuvenated • Normal rhythm of sleep • Able to concentrate • Cope with daily stresses • Decreased susceptibility to infection • Increased cognitive functioning • No dependence on sleep aids Abnormal • Disturbed sleep • Aggression • Irritable • Anxious • Feeling sleepy during quiet times of the day • Feels tired • Difficult to initiate or persist • Negative moods • Emotionally irritable • Poor concentration • Difficulty making decisions • Depression • Impaired memory • Hallucinations • Increase Susceptibility to infection • Unrefreshing sleep • Wake up frequently during the night • Difficulty falling asleep
