General Survey and Examination PDF

General Survey / Examination  General Survey: Starts at the first interaction and includes: o Observing body structure, grooming, hygiene, and facial expressions. o Assessing posture, mobility, and any assistive devices (e.g., wheelchairs). o Evaluating mood/affect and...

General Survey / Examination  General Survey: Starts at the first interaction and includes: o Observing body structure, grooming, hygiene, and facial expressions. o Assessing posture, mobility, and any assistive devices (e.g., wheelchairs). o Evaluating mood/affect and detecting signs of pain or distress. o Includes height, weight, and BMI measurements to assess nutritional status.  Examination: o Can be head-to-toe or system-based. o Document findings accurately for baseline data comparison. Focused / Comprehensive Assessment  Focused Assessment: o Addresses a specific issue (e.g., localized pain or symptoms like a rash). o Example: If a patient presents with chest pain, focus on cardiovascular and respiratory systems.  Comprehensive Assessment: o Includes health history, physical examination of all systems, and psychosocial aspects. o Typically conducted during initial visits or admissions. Priority  Priority Setting: o Use Maslow's hierarchy: Physiological needs > Safety > Love/Belonging > Esteem > Self- actualization. o ABC Rule: Address Airway, Breathing, and Circulation issues first. o Consider urgent vs non-urgent and the severity of conditions (e.g., a severe allergic reaction takes precedence over mild pain). Skin  Functions: o Protects against environmental damage and water loss. o Detects touch, pressure, pain, and temperature. o Synthesizes Vitamin D and regulates body temperature.  Risk Factors for Breakdown: o Immobility, poor nutrition, aging, and high BMI. o Prevention: Regular repositioning, proper hydration, and skin care.  Pressure Ulcers: o Stage I: Redness, intact skin. o Stage II: Open wound in epidermis/dermis. o Stage III: Damage to subcutaneous tissue. o Stage IV: Muscle and bone exposure.  Age Considerations: o Infants: Delicate, thin skin prone to temperature instability. o Older Adults: Thinning skin, decreased hydration, slower healing, and sensitivity to sunlight. Nails  Functions: Protect fingers/toes, aid in picking objects, scratching.  Normal Findings: Smooth, pink, firm nails with capillary refill