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A. (Den)Psychosocial
Interpretation:
Analysis:
B. (Ryan)Elimination
Interpretation:
Analysis:
C. (Nikka)Rest and Sleep
Interpretation:
Analysis:
D. (Jae)Safe Environment
Interpretation:
Analysis:
E. (Aya)Oxygenation
Interpretation:
Analysis:
F. (Jae)Nutrition Metabolic
Interpretation:
Analysis:
IV. ACTIVITIES OF DAILY LIVING (Darwin and zhar)
Before During
Interpretation
ADL Hospitalizatio Hospitalizatio
and Analysis
n n
Nutrition
Elimination
Exercise
Hygiene
Substance Abuse
Sleep and Rest
Sexual Activity
Interpret
Actual
Norms ation and
Findings
Analysis
General Appearance
1. Posture/Gait
2. Skin color
3. Personal
Hygiene/ Grooming
4. Nutritional
status
5. Age
appropriateness
6. Verbal
behavior
7. Non-verbal
behavior
Measurements
1. Temperature
2. Pulse rate
3. Respiratory
rate
4. Blood pressure
5. Weight
6. Height
Interpret
Body Part Actual
Norms ation and
(Technique used) findings
Analysis
General Survey
1. Body built, Proportionate, varies with lifestyle
height and weight
2. Posture, gait , Relaxed, erect posture; coordinated
standing, sitting movement
and walking
3. Overall hygiene Clean, neat
and grooming
4. Body and No body odor or minor body odor
breathe odor relative to work or exercise; no breath
color
5. Sign of distress No signs of distress
in posture of facial
expression
6. Obvious signs Healthy appearance
of health or illness
7. Clients attitude Cooperative, able to follow
instructions
8. Clients Appropriate to situation
affect /mood ;
appropriateness
9. Quality and Understandable, moderate pace; clear
Quantity of speech tone and inflection; exhibits thought
association
10. Relevance and Logical sequence; makes sense; has
organization of sense of reality
thought
Skin
11. Skin color and Varies from light to deep brown; from
uniformity ruddy pink to light pink; from yellow
overtones to olive. Uniform
12. Presence of No edema
edema
13. Skin lesion Freckles, some birthmarks, some flat
according to and raised nevi; no abrasions or other
location, lesions
distribution, color,
configuration, size
shape, type of
structure
14. Skin moisture Moisture in skin folds and the axillae
(varies with environmental
temperature and humidity, body
temperature, and activity)
15. Skin Uniform; within normal range
temperature
16. Skin turgor When pinched, skin springs back to
previous state; may be slower in
elders
Fingernails
17. Fingernail Convex curvature; angle of nail plate
plate shape, about 160°
curvatures and
angle
18. Fingernail and Highly vascular and pink in light-
toe nail bed color skinned clients; dark-skinned clients
may have brown or black
pigmentation in longitudinal streaks
19. Fingernail and Smooth texture
toenail texture
20. Tissues Intact epidermis
surrounding the
nails
21. Blanch test Prompt return of pink or usual color
capillary refill (generally less than 4 seconds)
Skull
22. Skull size, Rounded (normocephalic and
shape or symmetry symmetric, with frontal, parietal, and
occipital prominences); smooth skull
contour
23. Nodules, Smooth, uniform consistency; absence
masses and of nodules or masses
depression
Scalp
24. Color and Uniform in color (light brown)
appearance
25. Areas of No tenderness
tenderness
Hair
26. Hair evenness Thick hair, Evenly distributed
of growth, thickness
or thinness
27. Hair texture Silky Resilient hair
and oiliness over
the scalp
Face
28. Facial features, Coordinated movement, Symmetric or
symmetry of facial slightly asymmetric facial features;
movement palpebral fissures equal in size;
symmetric nasolabial folds
Eyebrows
29. Hair Hair evenly distributed; skin intact,
distribution, eyebrows symmetrically aligned;
alignment , skin equal movement
quality and
movement
Eyelashes
30. Hair equally distributed; curled slightly
distribution and outward
direction of curl
Eyelids
31. Surface Skin intact; no discharge; no
characteristic, discoloration,
position in relation Lids close symmetrically,
to cornea, ability to Approximately 15 to 20 involuntary
blink and frequency blinks per minute; bilateral blinking,
of blinking When lids open, no visible sclera
above corneas, and upper and lower
borders of cornea are slightly covered
Conjunctiva
32. Bulbar Transparent; capillaries sometimes
conjunctivae (lying evident; sclera appears white (darker
over the cornea ) or yellowish and with small brown
for color, texture macules in dark-skinned clients)
and presence of
lesion
33. Palpebral Shiny, smooth, and pink or red
conjunctivae (lying
over the cornea for
color, texture, and
presence of lesion
Sclera
34. Color and
clarity White in color
Cornea
35. Clarity and Smooth, transparent, details of the iris
texture is visible
Iris
36. Shape Brown, Flat and oval
Pupil
37. Color, shape Black, Smooth border
and symmetry
Buccal Mucosa
58. Color, Uniform in color, moist, smooth, soft,
moisture, texture glistening and elastic.
and presence of
lesions
Teeth
59. Color, number, White, smooth, shiny, tooth enamel
texture and
presence of
dentures
Gums
60. Color and Pink, moist, shiny, no retraction of
condition gums