Health Assessment, part 2: Physical Assessment Steps, Beginning an Assessment, & General Survey
by Meris Shuwarger March 31, 2023 Updated: August 10, 2023 5 min read
Full transcript and video captions coming soon!
Hi. I'm Meris, and in this video, I'm going to be covering some key concepts from health assessment, including the physical assessment steps, how to begin an assessment, and how to perform a general survey. I'm going to be following along using our health assessment flashcards, so if you already have a set of your own, I would invite you to follow along with me, and if not, check them out on our website, LevelUpRN.com. All right. Let's go ahead and get started. First up, we are talking about the actual steps in performing a physical assessment. And if you see here in our deck, we actually have a nice numbered list for you. So I'm just going to kind of go through this. And just keep in mind that your school may follow slightly different steps. You may find it easier or a better flow to follow these steps in a different order, and that's okay as long as you are operating within your school or your facility policy. These are just a general guideline. So first, we're going to start by introducing ourselves, performing hand hygiene. We're going to do our general survey, which we'll talk about here soon. We'll then assess vital signs, pain assessment. We'll move on to skin assessment. Then we will assess the head, neck, eyes, ears, nose, mouth, and throat. We'll then move on to the anterior and posterior chest. We'll do the abdominal assessment, the musculoskeletal assessment, the neurologic assessment, and then we will go ahead and end the assessment and provide for safety. So that's in general how you're going to flow through a physical assessment.
Now let's talk about beginning assessment. And we have some key steps here in some bold red text, which you know if it's bold and red, that means it's important; you got to know it. So again, this is a nice numbered list telling you the order in which to do things. We're always going to perform hand hygiene before entering a room, again, whatever that means for your patient. So if they are just on universal or standard precautions, we're just going to use foaming hand sanitizer or soap and water, whichever you would prefer, but if they have certain types of isolation requirements, we will follow those hand hygiene guidelines. We'll make our presence known. This is one of my pet peeves as a nurse and as a patient is knock on that door before you go in. You wouldn't like it if somebody just barged in on you, and it's the same idea. Respect your patient's privacy. So announce yourself before you go in. You're going to introduce yourself and state your job title. So I always say, "Hi, my name is Meris. I'm going to be one of the nurses helping to take care of you today. I'm here to perform an assessment. I'm going to get some information from you, and I'll grab your vital signs as well." So then tell them about how long it's going to take, "All of this should take roughly 5 to 10 minutes. And at the end, I'll make sure that you're comfortable, and I address any of your additional needs at that time." That way they know kind of how things are going to flow. And then before we do anything ever, we are going to identify our patient using two appropriate patient identifiers. So some examples of valid patient identifiers would be their name, their date of birth, medical record number, and phone number. Yes. What is not a valid identifier would be just part of their name, like just their first name or their last name, their room number. Things of that nature, not a valid patient identifier. So that is super duper important before you do anything, including your assessment. And again, I like to chart in real time. I like to open my patient's chart, and then when I'm talking to them after performing the assessment, I'm going to kind of be charting that. I want to make sure I'm charting on the right patient because there is nothing worse than realizing you've made a mistake. You've charted your entire assessment on the wrong patient. You have to undo it all and do a chart correction, so just make sure to do that patient identification before you begin.
All right. Now let's talk about the general survey. This is the first step in actually performing the assessment itself. And here we're talking about physical appearance, body structure, and mobility and behavior. So I want to actually skip to the bottom of this card really quickly. We have a cool chicken hint here to help you remember that in your general survey, you only assess what you could tell about a patient if you saw them at the grocery store. General survey, grocery store. So I'm not laying hands on my patients during the general survey. I am not taking their vital signs. I'm not listening to their heart and lungs. I'm not doing anything that I would not do to somebody in the grocery store. But what I can tell about somebody at the grocery store is pretty straightforward. I can see their physical appearance. What do they look like? What's their age? What kinds of facial features do they have? Do they appear to be in distress? That one you can tell right away, right? Level of consciousness. Are they alert or are they sleeping or drowsy? That kind of a thing. Body structure and mobility. What's their gait like? I can see somebody at the grocery store. I can assess what their gait is like, what their posture is like, their general range of motion. Certainly not down to specific angles and things like that, but I can tell on the whole what your range of motion is. Use of assistive devices, nutritional status, any kind of obvious deformities, trauma, injury, that I can tell during my general survey and at the grocery store. And lastly, their behavior. Here's where we're going to assess their mood and their affect. We'll see if they're making eye contact, what their speech is like because remember, I could tell what somebody's speech is like at the grocery store, right? I could hear that. What their level of dress is like. Are they dressing appropriately for the weather? Are they well-groomed? So that general survey is just that big overall impression. What do I see? What am I hearing? What do I smell? All of those things are things that I could tell at the grocery store and that is going to be a component of my general survey.
All right. I've got some quiz questions for you to test your knowledge of key facts I provided in this video. Which of the following are acceptable as patient identifiers: name, phone number, room number, birth date? Name, date of birth, and phone number are all valid patient identifiers. However, a patient's room number is not acceptable as a patient identifier. Which of the following would the nurse not assess during a general survey: mood, gait, lung sounds, vital signs, level of consciousness? The nurse would assess all of those except for lung sounds and vital signs, which are not a component of the general survey. I hope that review was helpful for you. If it was, I would love to hear your comments. Any ways that you have to remember things, I definitely want to hear those too. Thank you so much for studying with me. You're doing a great job. Happy studying.
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