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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Negative, hostile,withdrawn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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