2-12Area of Concern Assessment CriteriaGeneral AppearanceIs the patient• of average build, short, tall, thin, or obese?• well-groomed?• apparently in pain?• walking with a limp, wearing a cast, walking on crutches, or wearing a prosthetic extremity?BehaviorDoes the patient• appear worried, nervous, excited, depressed, angry, disoriented, confused, or unconscious?• refuse to talk?• communicate thoughts in a logical order or erratically?• lisp, stutter, or have slurred speech?• appear sullen, bored, aggressive, friendly, or cooperative?• sleep well or arouse early?• sleep poorly, moan, talk, or cry out when sleeping?• join ward activities?• react well toward other patients, staff, and visitors?PositionDoes the patient• remain in one position in bed?• have difficulty breathing while in any position?• use just one pillow or require more pillows to sleep well?• move about in bed without difficulty?SkinIs the patient’s skin• flushed, pale, cyanotic (bluish hue), hot, moist, clammy, cool, or dry?• bruised, scarred, lacerated, scratched, or showing a rash, lumps, or ulcerations?• showing signs of pressure, redness, mottling, edema, or pitting edema?• appearing shiny or stretched?• perspiring profusely?• infested with lice?EyesAre the patient’s• eyelids swollen, bruised, discolored, or dropping?• sclera (whites of eyes) clear, dull, yellow, or bloodshot?• pupils constricted or dilated, equal in size, react equally to light?• eyes tearing or showing signs of inflammation or discharge?• complaints about pain; burning; itching; sensitivity to light; or blurred, double, or lack of vision?EarsDoes the patient• hear well bilaterally?• hold or pull on his ears?• complain of a buzzing or ringing sound?• have a discharge or wax accumulation?• complain of pain?NoseIs the patient’s• nose bruised, bleeding, or difficult to breathe through?• nose excessively dry or dripping?Are the patient’s nares (nasal openings) equal in size?Is the patient sniffling excessively?MouthDoes the patient’s• mouth appear excessively dry?• breath smell sweet, sour, or of alcohol?• tongue appear dry, moist, clean, coated, cracked, red, or swollen?• gums appear inflamed, ulcerated, swollen, or discolored?• teeth appear white, discolored, broken, or absent?Does the patient• wear dentures, braces, or partial plates?• complain of mouth pain or ulcerations?• complain of an unpleasant taste?Table 2–1.—Self-Questioning Techniques for Patient Assessment and Reporting
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