general survey

Question 1

general survey

Answer 1

what the nurse observes, physical appearance, body structure, mobility, behavior

Question 2

physical appearance

Answer 2

• age
• sex
• level of consciousness
• skin color
• facial features
• overall appearance (presence/absence of distress?)

Question 3

age

Answer 3

does patient appear his/her stated age?

Question 4

sex

Answer 4

is sexual development appropriate for gender/age?

Question 5

level of consciousness

Answer 5

is person alert and oriented? attend to questions and respond appropriately?

Question 6

skin color

Answer 6

is color tone even? pigmentation varies with genetic background, is skin intact with no obvious lesion?

Question 7

facial features

Answer 7

are features symmetric with movement?

Question 8

overall appearance

Answer 8

provide general statement r/t presence/absence of distress

Question 9

jaundice

Answer 9

yellowing of skin; more melanin may produce subtle discoloration

Question 10

cyanosis

Answer 10

blue discoloration; more melanin tends to appear purple

Question 11

erythema

Answer 11

redness; more melanin tends to appear purple

Question 12

pallor

Answer 12

pale/whiteness; palmar creases usually reduced in darkness

Question 13

body structure

Answer 13

stature, nutrition, symmetry, posture, position

Question 14

stature

Answer 14

does height appear within normal range for age/genetic heritage?

Question 15

nutrition

Answer 15

does weight appear within normal range for height/body build? is body fat distribution even?

Question 16

symmetry

Answer 16

do body parts look equal bilaterally and are in relative proportion?

Question 17

posture

Answer 17

does the person stand comfortably erect as appropriate for age?

Question 18

position

Answer 18

describe the patient’s position during survey

Question 19

mobility

Answer 19

• range of motion
• gait (example foot placement, no involuntary movement)

Question 20

behavior

Answer 20

• facial expressions
• mood and affect
• speech
• dress
• hygiene

Question 21

facial expressions

Answer 21

• maintains eye contact
• appropriate to situation

Question 22

mood and affect

Answer 22

• person is comfortable and cooperative with examiner
• interacts pleasantly

Question 23

speech

Answer 23

• is articulation clear and understandable?
• are ideas conveyed clearly?
• word choice appropriate to culture and education

Question 24

dress

Answer 24

appropriate to climate? looks clean and fits body? appropriate to person’s culture and age group?

Question 25

personal hygiene

Answer 25

does person appear clean and groomed appropriately?

Question 26

weight measurements

Answer 26

use a standardized balance/electronic standing scale; record in lbs/kg

Question 27

height measurements

Answer 27

wall mounted device/ align headpiece with top of head - shoeless, heels against wall

Question 28

BMI measurement

Answer 28

practical marker of optimal weight for height and an indicator of obesity

Question 29

waist circumference measurement

Answer 29

assess body fat distribution as an indicator of health risk measured in inches below ribcage and above iliac crest; women 35 and men 40

Question 30

unexpected in body weight and proportion

Answer 30

dwarfism, gigantism, anorexia, endogenous obesity, marfan syndrome, elderly

Question 31

indication for emergency assessment

Answer 31

acute change in mental status, bleeding, seizing, respiratory distress, abnormality in vital signs, diaphoresis