These skills are related to: Health Assessment
Planning
- Assign: substantial knowledge and skill are required; this is not delegated to APs.
- Equipment: None
Implementation
- Prior to performing the assessment, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Discuss how the results will be used in planning further care or treatments.
- Perform hand hygiene and observe other appropriate infection prevention procedures.
- Provide for client privacy.
| Assessment | Normal Findings | Deviations from Normal |
|---|---|---|
| Observe for signs of distress in posture or facial expression. | No distress noted | Bending over because of abdominal pain, wincing, frowning, or labored breathing |
| Observe general body build, height, and weight. | Proportionate, varies with lifestyle | Excessively thin or obese. |
| Observe client’s posture and gait, standing, sitting, and walking. | Relaxed, erect posture; coordinated movement | Tense, slouched, bent posture; uncoordinated movement, tremors, unbalanced gait |
| Observe client’s overall hygiene and grooming. | Clean, neat | Dirty, unkempt |
| Note body and breath odor. | No body odor or minor body odor relative to work or exercise; no breath odor | Foul body odor; ammonia odor; acetone breath odor; foul breath |
| Note obvious signs of health or illness (e.g., in skin color or breathing). | Well developed, well nourished, intact skin, easy breathing | Pallor (paleness); weakness; lesions, cough |
| Assess the client’s attitude (frame of mind). | Cooperative, able to follow instructions | Negative, hostile, withdrawn, anxious |
| Note the client’s affect and mood; assess the appropriateness of the client’s responses. | Appropriate to situation | Inappropriate to situation, sudden mood change, paranoia |
| Listen for quantity of speech (amount and pace), quality (loudness, clarity, inflection). | Understandable, moderate pace; clear tone and inflection | Rapid or slow pace; overly loud or soft |
| Listen for relevance and organization of thoughts. | Logical sequence; makes sense; has sense of reality | Illogical sequence; flight of ideas; confusion; generalizations; vague |
Document findings in the client record using printed or electronic forms and checklists supplemented by narrative notes when appropriate. Perform a detailed follow-up examination of specific systems based on findings that deviated from expected or normal for the client. Relate findings to previous assessment data if available. Report significant deviations from expected or normal findings to the primary care provider.