ASSESSMENT ACTUAL NORMAL INTERPRETAION AND
FINDINGS FINDINGS ANALYSIS
SKIN Pale, dry skin with Skin should be of Abnormal/Altered
bruising. normal color, well- Pale skin due to decreased
hydrated, and without hemoglobin levels, and
lesions or bruising. bruising due to low platelet
count due to bone marrow
suppression from
chemotherapy and radiation.
NAILS Brittle and ridged Nails should be Abnormal due to iron
nails smooth, pink, and deficiency anemia
firm.
FACE Pallor, particularly Skin tone should be Abnormal due to anemia
around the lips and consistent with the rest and decreased red blood cell
nose. of the body, with no count.
signs of pallor.
EYEBROWS Thinning of Full, evenly Abnormal due to
AND eyebrows and distributed eyebrows nutritional deficiencies or
EYELASHES eyelashes and eyelashes the effects of chemotherapy.
EYELIDS Appearance: The Appearance: Eyelids Paleness: Abnormal due to
patient's eyelids are should have a normal anemia, as they suggest
pale. skin tone consistent reduced blood flow and
Movement: Slight with the rest of the hemoglobin levels.
delay in blinking face and should not be
and droopy eyelids puffy. Ptosis: Abnormal due to
(ptosis). Movement: Blinking general muscle weakness or
should be regular and fatigue, common in patients
without delay, and undergoing intensive cancer
eyelids should not be treatments.
droopy.
EYES Pale conjunctivae Conjunctivae should Abnormal due to anemia
be pink and reduced hemoglobin
levels
PUPILS Normal pupil size Pupils equal, round, Normal
and reaction to reactive to light and
light accommodation
(PERRLA)
EARS Symmetrical, with Ears should be Normal
no lesions or symmetrical, with no
discharge lesions or discharge
NOSE Normal Nose should be Normal
appearance, no symmetrical, with
epistaxis clear nasal passages
(nosebleeds)
MOUTH Pale mucous Mucous membranes Abnormal
membranes, and should be pink and Pale mucous membranes is
angular cheilitis moist, tongue smooth due to anemia and
(cracks at the and moist, no cracks nutritional deficiencies,
corners of the or sores while angular cheilitis is
mouth) due to iron or vitamin
deficiencies
NECK No Neck should be Normal
lymphadenopathy supple, with no
(enlarged/swollen swollen lymph nodes
lymph nodes) or or thyroid
thyromegaly enlargement.
(enlarged thyroid).
HEART Regular heart rate Regular heart rate and Normal
and rhythm, no rhythm, no murmurs.
murmurs.
ABDOMEN Soft, non-tender, Abdomen should be Normal
no organ soft, non-tender, with
enlargement no organ enlargement
UPPER Pale skin, muscle Normal skin color, Abnormal due to anemia
EXTREMITIES wasting, and muscle tone, and and the catabolic effects of
weakness strength cancer and its treatments.
LOWER Pale skin, muscle Normal skin color, Abnormal due to reduced
EXTREMITIES wasting, and muscle tone, and activity and overall health
weakness strength; no edema status
NEUROLOGIC Patient is alert but Alert and oriented, no Abnormal due to decreased
reports dizziness dizziness oxygenation of brain tissues
from anemia.
MENTAL Oriented to time, Oriented to time, place Normal
STATUS place and person and person
CEREBRAL Normal motor Normal motor Normal
FUNCTION function, reflexes, function, reflexes, and
and no headaches no headaches
B. APPEARANCE OF MENTAL STATUS
ASSESSMENT ACTUAL NORMAL INTERPRETATION AND
FINDINGS FINDINGS ANALYSIS
Posture, Behavior, Posture: The Posture: Upright Altered.
Level of patient exhibits a and relaxed posture. The slouched posture and
Consciousness slouched posture, lethargic behavior are
appears physically Behavior: Engaged, indicative of physical
weakened, and has active, and exhaustion and weakness
reduced activity responsive behavior. commonly seen in anemia
levels. and cancer treatment. The
Level of patient's decreased
Behavior: The Consciousness: responsiveness can be
patient is lethargic, Fully alert, oriented, attributed to the overall
showing minimal and responsive fatigue and possible
spontaneous cognitive effects of anemia
movement and and chemotherapy.
appears fatigued.
Level of
Consciousness:
The patient is alert
but seems tired and
less responsive to
stimuli compared
to normal.
Speech and The patient speaks Clear, coherent, and Altered due to fatigue,
Language in a slow, soft fluent speech with cognitive effects of anemia,
voice normal volume and and possibly the impact of
rate. chemotherapy on cognitive
function.
Body Odor and No unusual body No unusual body Altered.
Activity Levels odor noted; odor, normal Low activity levels are
however, the activity levels for consistent with the patient’s
patient exhibits low the patient's age and reports of fatigue and
activity levels and condition. physical weakness. No
prefers to remain unusual body odor indicates
seated or lying that personal hygiene is
down. maintained despite reduced
activity.
Signs of Distress or The patient shows Relaxed facial Altered due to the physical
Facial Expressions signs of expressions with no effects of cancer, treatment
discomfort, such as signs of distress or side effects, and generalized
grimacing and discomfort. weakness from anemia
frequent frowning.
There are
occasional winces,
particularly when
moving
The patient Positive, engaged, Altered.
displays a and cooperative A subdued and withdrawn
generally subdued attitude attitude results from the
attitude, appears psychological burden of
somewhat chronic illness, cancer
withdrawn, and treatment, and the physical
exhibits occasional symptoms of anemia.
signs of frustration Frustration and sadness
or sadness. reflects the emotional
impact of dealing with a
long-term illness and its
associated treatments
