ASSESSING THE APPEARANCE AND MENTAL STATUS
ASSESSMENT NORMAL FINDINGS
Observe for signs of
distress in posture or
facial expression.
Observe body build,
height, and weight.
Observe client’s posture
and gait, standing,
sitting, and walking.
Observe client’s overall
hygiene and grooming.
Note body and breath
odor.
Note obvious signs of
health or illness (e.g., in
skin color or breathing).
Note the client’s
affect/mood; assess the
appropriateness of the
client’s responses
Observe any birth
PATIENT’S
FINDINGS
No distress noted No deviation from the
normal findings.
Proportionate; BMI is No deviation from
within normal range normal findings.
(Weight: 52 lbs;
Height: 3.6 ft;
BMI: 20.7)
Erect posture; No deviation from the
coordinated movement normal findings.
Clean, neat No deviation from the
normal findings.
No body odor or minor No deviation from the
body odor; no breath odor normal findings.
Well developed, well No deviation from the
nourished, intact skin, normal findings.
easy breathing
Appropriate to situation Child is quite active
and playful, which is
just normal at her age.
(According to the
developmental stages
in Preschool children,
one of the behavioral
traits of them is being
active and playful.)
No birth defects No deviation from
 defects (dysmorphology) normal findings.
Note the OFC (Occipito OFC is within normal No deviation from the
frontal circumference). range (50-51 cm). normal findings (OFC:
50.7 cm)

ASSESSING THE SKIN AND LYMPHATIC

Inspect skin color (best Varies from light to deep No deviations from
assessed under natural brown; from ruddy pink to normal findings (skin
light and on areas not light pink; from yellow color is white).
exposed to the sun). overtones to olive
Inspect uniformity of skin Generally uniform except No deviations from the
color in areas exposed to the normal findings.
sun; areas of lighter
pigmentation (palms, lips,
nail beds)
Assess edema, if present No edema No deviations from the
(i.e., location, color, normal findings.
temperature, shape, and
the degree to which the
skin remains indented or
pitted when pressed by a
finger).
Inspect, palpate, and No abrasions or other No deviation from the
describe skin lesions. lesions normal findings.
Observe and palpate skin Smooth skin No deviation from the
texture and moisture normal findings.
Note skin turgor (fullness When pinched, skin No deviation from the
or elasticity) by lifting and springs back to previous normal findings.
pinching the skin on an state (is elastic).
extremity or on the
sternum.
Inspect for nevi, Mole/s in certain parts of No deviation from the
hemangiomas, and the body. No more normal findings.
mongiolian spots. mongolian spots. No
hemangiomas.
Palpate for any lymph No lymph node No deviation from the
nodes enlargement enlargement. normal findings.
(location, size,
consistency).