GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2

I. MENTAL STATUS
a. State of Mental
Consciousness

b. Orientation
a. Attention span
b. Ability to understand
II. STATUS OF SPECIAL SENSES
a. Auditory perception
b. Visual perception
c. Speech perception

GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2
d. Tactile perception
e. Olfactory perception
II. MOTOR ABILITY
a. Current mobility
b. Posture
c. Range of Motion
d. Muscle and nervous
status

e. Loss of extremities
a. Ranges
V. RESPIRATORY STATUS


GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2
a. Character
b. Use of respiratory aids
c. Interfere with
respiration

d. Abdominal respiratory
opening

. CIRCULATORY STATUS
a. Characteristics of
arterial pulse

b. Apical-radial pulse
c. Blood pressure
d. Pulse pressure

GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2
e. Mean Arterial Pressure
f. Intravenous fluid
VII. NUTRITIONAL STATUS
a. Condition of buccal
cavity

b. Digestion of food
c. Weight
VIII. ELIMINATION STATUS
a. Bowel
b. Bladder
c. Abnormalities
IX. FEMALE REPRODUCTIVE STATUS

GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2
a. Age of menarche
b. Patterns of menses
. STATUS OF SKIN AND APPENDAGES
a. Skin
b. Hair
c. Nails
XI, STATE OF PHYSICAL REST AND COMFORT
a. Sleep/rest pattern
b. Presence of discomfort
c. Use of supportive aids
XII. EMOTIONAL STATUS

GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2
a. Emotional reaction
b. Body image
c. Ability to relate others
XIII. NURSING DIAGNOSIS