10/30/12

Performing a General Survey

Goal: The assessment is completed without the patient experiencing anxiety or discomfort, an overall impression of the patient is formulated, the findings are documented, and the appropriate referral is made to other healthcare professionals, as needed for further evaluation.

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient.

3. Close curtains around bed and the door to the room, if possible. Explain the purpose of the health examination and what you are going to do. Answer any questions.

4. Assess the patient’s physical appearance. Observe if the patient appears his or her stated age. Note the patient’s mental status. Is the person alert and oriented, responsive to questions and responding appropriately? Are the facial features symmetric? Note any signs of acute distress, such as shortness of breath, pain, or anxiousness.

5. Assess the patient’s body structure. Does the person’s height appear within normal range for stated age and genetic heritage? Does the person’s weight appear within
normal range for height and body build? Note if body fat is evenly distributed. Do body parts appear equal bilaterally and relatively proportionate? Is the patient’s posture erect and appropriate for age?

6. Assess the patient’s mobility. Is the patient’s gait smooth, even, well-balanced, and coordinated? Is joint mobility smooth and coordinated with a general full range of motion (ROM)? Are involuntary movements evident?

7. Assess the patient’s behavior. Are facial expressions appropriate for the situation? Does the patient maintain eye contact, based on cultural norms? Does the person appear comfortable and relaxed with you? Is the patient’s speech clear and understandable? Observe the person’s hygiene and grooming. Is the clothing appropriate for climate, fit well, appear clean, and appropriate for the person’s culture and age group? Does the person appear clean and well groomed, appropriate for age and culture?

8. Assess for pain. (Refer to Chapter 10, Comfort.)

9. Have the patient remove shoes and heavy outer clothing. Weigh the patient using a scale. Compare the measurement with previous weight measurements and recommended
range for height.

10. With shoes off, and standing erect, measure the patient’s height using a wall-mounted measuring device or measuring pole. Compare height and weight with recommended average weights on a standardized chart.

11. Use the patient’s weight and height measurements to calculate the patient’s BMI. weight in kilograms Body mass index height in meters2

12. Using the tape measure, measure the patient’s waist circumference. Place the tape measure snugly around the patient’s waist at the level of the umbilicus.

13. Measure the patient’s temperature, pulse, respirations, blood pressure, and oxygen saturation. (Refer to Chapter 1, Vital Signs, and Chapter 14, Oxygenation, for specific techniques.)

14. Remove PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems as appropriate or indicated. Initiate appropriate referral to other healthcare practitioners for further evaluation as indicated.

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