2-12
Area of Concern
Assessment Criteria
General Appearance
Is 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?
Behavior
Does 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?
Position
Does 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?
Skin
Is 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?
Eyes
Are 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?
Ears
Does 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?
Nose
Is 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?
Mouth
Does 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
