Step Response Rationale Normal findings Abnormal findings

1.Prior to performing Good morning, Ma’am. I to get the objective description If the patient is oriented If the patient is not responsive. And
the procedure, am …. I’ll be assessing and diagnostic clues. (Illness, to time, place, and if the person
introduce self and appearance and mental Severity, Values, Social person.
status. Rationale is…to Status, Personality of the
verify the client’s
get the obj. description patient, while getting the
identity using agency and diagnostic clues. mental status, it’s important
protocol. Explain to the (Illness, Severity, because you need to get data
client what you are Values, Social Status, about the emotional and
going to do, why it is Personality of the cognitive part of the patient.
necessary, and how he patient, while getting the
or she can participate. mental status, it’s
important because you Build trust and rapport
Discuss how the results
need to get data about
will be used in planning the emotional and
further care or cognitive part of the
treatments. patient.

Good afternoon, sir. My

name is … I am your
nurse for today, and ill
be doing assessment of
your … It’s very
important because I’ll be
getting subjective and
objective data that will
be used in the nursing
process. Is it okay, sir?

2. Perform hand hygiene Second thing I will be Proper hand hygiene Nosocomial infection - taking place
and observe other doing is handwashing decreases the proliferation of in a hospital, acquired in a hospital,
appropriate infection microorganisms, thus reducing especially in reference to an
infection risk. infection.
prevention procedures.
Increase patient safety

3. Provide for client I will provide client To prevent further harm and
privacy. privacy, I will close the discrimination
curtains and I will close
the door, but the locking, Effective Communication
I need to ask the patient