Health Assessment General Survey

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Questions and Answers

What is the purpose of general survey?

The nurse looks at the client to capture a snapshot assessment, providing objective data and an introduction to history and physical that will follow.

What are the 4 components to assess in a general survey?

Physical appearance, body structure, mobility, behavior.

What should be observed regarding physical appearance during a general survey?

Age appearance, sex development, level of consciousness, skin color, facial features, signs of acute distress.

What key aspects should be assessed in body structure?

Stature, nutrition, symmetry, posture, and body build. Signup and view all the answers

What does mobility assessment include?

Gait and range of motion (ROM). Signup and view all the answers

What aspects of behavior should be noted during a general survey?

Facial expression, mood and affect, speech, dress, and personal hygiene. Signup and view all the answers

What is the purpose of the health history interview?

To obtain critical information about the client, establish rapport, and collect baseline data. Signup and view all the answers

What elements are included in a pain description?

Location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, and patient perception. Signup and view all the answers

What does PQRSTU stand for in pain assessment?

Provocative or palliative, quality or quantity, region/radiation, severity scale, timing, understand patient perception. Signup and view all the answers

What does the health history review of systems (ROS) include?

General overall health state, hair, skin, nails, HEENT, neck, breast/axillae, respiratory, cardiac, gastrointestinal, urinary, M/F genitalia, sexual, musculoskeletal, neurological, endocrine, hematological. Signup and view all the answers

What does HEEADSSS stand for in adolescent assessments?

Home environment, education and employment, eating, peer-related activities, drugs, sexuality, suicide/depression, safety from injury and violence. Signup and view all the answers

What does ABCT stand for in mental status assessment?

Appearance, behavior, cognition, thought process. Signup and view all the answers

When is a full mental status examination necessary?

If there are abnormalities in affect or behavior, family concerns about changes, brain lesions, aphasia, or symptoms of any psychiatric illness. Signup and view all the answers

What components of appearance should be noted?

Posture, body movements, dress, grooming/hygiene. Signup and view all the answers

What behaviors should be observed during assessment?

Level of consciousness, facial expression, speech, mood, and affect. Signup and view all the answers

What cognitive functions should be evaluated?

Orientation, attention span, memory (recent and remote), judgment, new learning. Signup and view all the answers

What do thought processes and perceptions include?

Thought processes, thought content, and thought perception. Signup and view all the answers

What is the mini mental exam used for?

To concentrate on cognitive functioning and detect dementia and delirium. Signup and view all the answers

What tool is used for children to detect developmental delays?

Denver II screening. Signup and view all the answers

Study Notes

General Survey Purpose

Conducted to gain a snapshot assessment of client’s overall health.
Provides objective data to support history and physical examinations.

Components of General Survey

Physical appearance
Body structure
Mobility
Behavior

Assessing Physical Appearance

Evaluate if the individual appears their stated age.
Assess sexual development appropriate to gender and age.
Determine level of consciousness: confused or drowsy.
Note skin color variations: pallor, cyanosis, jaundice, lesions.
Check facial symmetry during movement.
Identify any signs of acute distress.

Evaluating Body Structure

Stature should reflect normal height given age and genetic background.
Nutrition assessment includes weight: emaciated or obese.
Observe for symmetry and posture: signs of tension, stiffness, or slumping.
Body build may indicate missing extremities or abnormalities.

Observing Mobility

Gait patterns: staggering, stumbling, shuffling, or limping noted.
Assess range of motion (ROM) for functionality.

Analyzing Behavior

Facial expression assessment: flat, angry, sad, or anxious.
Evaluate mood and affect: cooperation, hostility, or emotional distress.
Speech should be clear, understandable, or may be monotone.
Dress may vary from appropriate to culturally specific to ill-fitting.
Personal hygiene reflects cleanliness and grooming standards for age.

Health History Interview Purpose

Critical information collection about the client.
Establish rapport with clients and families.
Gather baseline data for future assessments.

Pain Description Elements

Specific anatomical location required.
Character and quality of pain should be detailed.
Severity rated using an appropriate pain scale.
Note timing of pain occurrences and environmental factors.
Record any aggravating or relieving factors.
Patient perception included to understand their beliefs about the issue.

Pain Assessment Framework (PQRSTU)

Provocative or palliative factors.
Quality or quantity of pain experience.
Region or radiation of pain.
Severity scale used to rate pain intensity.
Timing of symptoms evaluated.
Understand patient perception for comprehensive care.

Review of Systems (ROS)

Comprehensive health assessment covering:
- General health
- Hair, skin, nails
- HEENT (Head, Eyes, Ears, Nose, Throat)
- Neck
- Breast/Axillary
- Respiratory, cardiac, gastrointestinal functions.
- Urinary, reproductive systems, musculoskeletal health.
- Neurological, endocrine, and hematological aspects.

Adolescent Health Assessment (HEEADSSS)

Home environment evaluation.
Education and employment insights.
Eating habits.
Peer-related activities.
Drug use assessment.
Exploration of sexuality issues.
Screening for suicidal thoughts and depression.
Safety from injury and violence considerations.

Mental Status Assessment via ABCT

Appearance to determine overall presentation.
Behavior observation for engagement and response.
Cognition assessment for memory and understanding.
Thought processes for logical communication.

Full Mental Status Assessment Indications

Abnormal behavior or affect noted.
Family concerns about behavioral changes.
Signs of brain lesions or aphasia.
Psychiatric illness symptoms present.

Aspects of Appearance

Posture and body movements are critical indicators.
Grooming and hygiene reflect self-care practices.

Assessing Behavior

Level of consciousness monitoring.
Evaluating facial expressions and emotional responses.
Speech clarity and emotional expression noted.

Cognitive Functions in Assessment

Orientation to person, place, and time.
Attention span metrics.
Memory evaluated for both recent and remote recall.
Judgment and new learning ability assessed using the 4 unrelated words test.

Evaluating Thought Processes and Perceptions

Coherence and logical consistency in speech.
Awareness of reality and thought content.
Screening for anxiety, depression, and suicidal ideation.

Mini Mental Status Exam

Focuses on cognitive functioning without mood evaluation.
Comprises a standardized set of 11 questions, taking 5 to 10 minutes to administer.
Useful for tracking cognitive changes over time; aids in detecting dementia and delirium.
Normal average score is 27; scores between 24 and 30 indicate no cognitive impairment.

Developmental Delay Detection in Children

The Denver II screening tool is utilized for assessing developmental milestones.

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Description

This quiz evaluates your understanding of the general survey process in health assessment. It covers components such as physical appearance, body structure, and mobility, which provide objective data to support clinical evaluations. Test your knowledge on how to assess various aspects of a patient's overall health effectively.