AREAS OF GENERAL APPEARANCE AND BEHAVIORAL ASSESSMENT
a. Demographic Data. You begin the assessment by collecting personal
information, which includes name, age, sex, marital status, race, and religion. This
identifies the patient and provides important demographic data.
b. Body Build. Observe the patient's general appearance and health state in
relation to his age and lifestyle. Determine the patient's height, weight, and vital signs at
c. Posture and Gait. Observe whether the patient is erect or slouched, steady or
unsteady. Posture can indicate mood. For example, a slumped position may reflect
depression; too rigid and upright a position may indicate anxiety.
d. Hygiene and Grooming. Look for cleanliness of nails, hair, skin, and overall
appearance. Usually, you can assess these gradually while observing other parts of the
body for data. Observe the skin for color, texture, temperature, and lesions. Lesions
warrant particular attention during assessment. Some primary skin lesions are:
Nodule--a solid mass extending into the dermis.
Tumor--a solid mass larger than a nodule.
Cyst--an encapsulated fluid-filled mass in the dermis or subcutaneous
Wheal--a relatively reddened, flat, localized collection of fluid. An example
(5) Vesicle--circumscribed elevation containing serous fluid or blood. An
example is chickenpox.
Bulla-- large fluid-filled vesicle. An example is a second-degree burn.
Pustule--a vesicle or bulla filled with pus. An example is acne.
e. Dress. Observe the patient's clothing in relation to age, climate, socioeconomic
status, and culture. Notice whether the clothing is clean, properly buttoned, or zipped.
The patient's dress may reflect the cold intolerance of hypothyroidism. Slippers or untied
shoelaces suggest edema.
f. Body and Breath Odors. Malodorous body or breath may indicate pulmonary
infections, uremia, or liver failure. A breath odor of acetone may be due to diabetes.
Although odors give important clues, avoid the common mistake of assuming that alcohol
on a patient's breath explains neurologic or mental status findings. Alcoholic breath does
not necessarily mean alcoholism.