Physical Health Assessment

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Physical Health Assessment

General Survey Form

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

1. Physical Appearance/Hygiene:

a. General appearance:

b. Gender

c. Apparent age

d. Ethnic group

e. Appears overall healthy

f. Well-groomed or disheveled (Note the general color of skin and hygiene) Physical Health Assessment

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2. Body Structure and Movement (Observe general stature):

a. Height appropriate for apparent age

b. Appears well nourished

c. Weight suitable for the height

d. Position or posture (comfortable and relaxed)

e. Obvious deformities

f. Walks with ease

g. Gait balanced and smooth

h. Limitations to range of motion

i. Involuntary movements

j. Using assistive devices

 

3. Emotional/Mental Status and Behavior: Physical Health Assessment

Level of alertness

Appear well rested or tired

Converse appropriately

Behavior appropriate for the situation

Dress suitable for the weather

 

4. 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.”

 

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

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: Physical Health Assessment

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 Physical Health Assessment

 

Grading Rubric:

General Survey Grading Rubric – 20 possible points

Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Documented Observations

(16 Pts)

 Addressed all three categories. Omitted more than half the requested information in each area. Subjective information detected. Bias or explanation for findings evident.

Failure to address all three categories will result in zero points for this criterion.

 All three categories addressed. Sparse detail given in all areas. Answers majority of items as yes or no with little detail. Subjective information may be detected. Addressed all three categories with more than one word responses to each question provided. No bias or explanation for findings evident. All objective information. Clear detailed descriptions of observations in all three categories. No bias or explanation for findings evident. All objective information
  Points: 11 Points: 14 Points: 15 Points: 16
Actual or Potential Risk Factors

(4 pts)

 

 Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
  Points: 1 Points: 2 Points: 3 Points: 4