General Survey Form 2021/22

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) 28 year old Caucasian male appears to be well-nourished with an athletic build. He is well-kept and dressed appropriately for the setting and outdoor temperatures. Does not present any concerns of pain or discomfort. Hands and nails appear stained with a cut on the right thumb, possibly due to his occupation as an auto mechanic. Skin is warm to the touch, with no discolorations or bruising. 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 Client is 6 feet 2 inches tall and weighs 188 pounds. He seems comfortable and relaxed with an erect posture in his recliner and displays no involuntary movements. He shows no signs of obvious deformities and walks with ease upon greeting me. Client doesn’t utilize any assistive devices and doesn’t have any concerns regarding range of motion. Facial features are symmetrical with no apparent involuntary movements or facial twitching. 3. 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 He is oriented to person, place, and time. Client’s recent and remote memory are intact. He is able to recall who was president in the year 2000 and is able to recite who the two presidential candidates currently are. He is able to maintain eye contact while conversing. Client appears well rested and alert. He is able to converse fluently without speech complications. 6/29/2020 This study source was downloaded by from CourseH on :42:43 GMT -06:00 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.” “Client is in an upright posture in his recliner, appears alert and well-rested with eyes open while watching tv. He’s dressed in jeans and a t-shirt. He shaves his head due to male patterned baldness.” 5. Describe two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. An actual risk is that the cut on his right thumb could be infected. It appears red and swollen. Client states the wound doesn’t cause him pain. A potential risk is if client isn’t seen by a practitioner regarding the wound on his right thumb, the infection could potentially reach the blood stream and cause sepsis. He doesn’t present with any other abnormalities or causes for concern.