General Survey Health Assessment(ANSWERED)

QUESTION

Purpose of Assignment:

Learning to make purposeful observations is an essential skill for a nurse. The general survey is the observation a nurse makes during the initial client interaction. The nurse must provide nonbiased, descriptive documentation of these observations.

Course Competency:

Identify the foundations of health assessment.

Instructions:

Content:

• Use the provided form as a guide to the information that should be collected.
• Short descriptive paragraph of findings. Remember, this is objective information, so only what you observe. Avoid stating why you know or think something is.
• Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:

• Standard American English (correct grammar, punctuation, etc.)

Resources:

Bates video: http://batesvisualguide.com.ezproxy.rasmussen.edu/MultimediaPlayer.aspx?multimediaid=6091198) view to 2:35 minutes

 

General Survey Form

Objective: Conduct a General survey on a person of your choice. The purpose of this interaction is observation only.

Physical Appearance/Hygiene:

1. 1. General appearance:
   2. Gender
   3. Apparent age
   4. Ethnic group
   5. Appears overall healthy
   6. Well-groomed or disheveled (Note the general color of skin and hygiene)

Body Structure and Movement (Observe general stature):

1. 1. Height appropriate for apparent age
   2. Appears well nourished
   3. Weight suitable for the height
   4. Position or posture (comfortable and relaxed)
   5. Obvious deformities
   6. Walks with ease
   7. Gait balanced and smooth
   8. Limitations to range of motion
   9. Involuntary movements
   10. Using assistive devices

Emotional/Mental Status and Behavior:

Level of alertness

Appear well rested or tired

Converse appropriately

Behavior appropriate for the situation

Dress suitable for the weather

Document observations with detailed responses in a narrative format. For example, if a client appears tired provide a description adequate for the reader to visualize the client, “Client is alert and appears tired, slumped in a chair with eyes half closed.”

Describe two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

 

ANSWER

General Survey Form

Objective: Conduct a General survey on a person of your choice. The purpose of this interaction is observation only.

Physical Appearance/Hygiene:

1. 1. General appearance: Middle-class, well-groomed, thinly-looking, and inattentive.
   2. Gender: male
   3. Apparent age: 78 years
   4. Ethnic group: White
   5. Appears overall healthy: The interviewee seems to be healthy. He had no signs of pain or distress
   6. Well-groomed or disheveled (Note the general color of skin and hygiene): He is well-groomed: his clothes were neat and ironed, hair and nails were well-kept, no breathe or body odor, or visible skin lesions, rashes, turgor, or lumps.

Body Structure and Movement (Observe general stature):

1. 1. Height appropriate for apparent age: yes, appears 5’9” – 5’11”.
   2. Appears well nourished: The patient does not look well nourished: she is quite thin.
   3. Weight suitable for the height: He looks underweight for her height evidenced by thin stature with prominent bones.
   4. Position or posture (comfortable and relaxed): The patient posture is forward-leaning and shoulders are slumped.
   5. Obvious deformities: None
   6. Walks with ease: Patient walking pattern is unstable and uneven
   7. Gait balanced and smooth: Gait is wide-based and his arms held outward
   8. Limitations to range of motion: The patient is stiff when he turns around
   9. Involuntary movements: No involuntary motor activities were observed, i.e., no tremors were observed.
   10. Using assistive devices: Patient uses a cane to walk
       Emotional/Mental Status and Behavior:

Level of alertness: The client was inattentive and disinterested in the interview.

Appear well rested or tired: He seemed tired and drowsy

Converse appropriately: Patient’s responses were slow (he sometimes took moments to answer questions) but his speech was clear and coherent.

Behavior appropriate for the situation: The client was sometimes uncooperative and cross during the interview

Dress suitable for the weather: Clothes were appropriate for the weather and occasion

Question on Documenting

Document observations with detailed responses in a narrative format. For example, if a client appears tired provide a description adequate for the reader to visualize the client, “Client is alert and appears tired, slumped in a chair with eyes half closed.”

The patient has a thin-looking stature with prominent bones, suggesting he may be underweight or malnourished. He was inattentive, agitated (rude and cross), and seemed disinterested during the interview. He got distracted easily, making it difficult for him to concentrate during the interview. His responses were slow, and he sometimes looked confused. His gait is wide-based (his feet are wide apart) and unsteady. His shoulders were slumped, his arm swings were decreased, and he looked stiff when he turned. He used a cane as an assistive device.

Question on Describing

Describe two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

The client’s weight may affect his bone health. Subramaniam et al.’s (2019) study reported that underweight subjects have higher prevalence rates of osteoporosis than overweight individuals and those with a normal BMI. Weight loss is often accompanied by a reduced intake of essential nutrients, including calcium. The absence or reduced intake of calcium and other nutrients essential for maintaining bone health can contribute to low bone density and early bone loss, increasing the individual’s risk of bone fractures and osteoporosis.

The patient’s gait and posture also increased his risk of falling. Pua et al. (2020) indicate that reduced postural balance and gait decline increase patient fall risk. The authors indicate that falls are one of the leading causes of emergency department visits among older patients. Falls can also cause injury, broken bones, or even death. This patient’s impaired postural balance and declining gait increase his risk of falling.

References

Pua, Y. H., Ong, P. H., Clark, R. A., Matcher, D. B., & Lim, E. C. W. (2017). Falls efficacy, postural balance, and risk for falls in older adults with falls-related emergency department visits: prospective cohort study. BMC geriatrics, 17(1), 1-7.

Subramaniam, S., Chan, C. Y., Soelaiman, I. N., Mohamed, N., Muhammad, N., Ahmad, F., … & Chin, K. Y. (2019). Prevalence and predictors of osteoporosis among the Chinese population in Klang Valley, Malaysia. Applied Sciences, 9(9), 1820. https://www.mdpi.com/2076-3417/9/9/1820/pdf

 

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