NURS 507 Intro To Nursing Assessment
5.16 Exam Latest Update
Principles of Nursing Assessment - ANSWER Head-to-toe
Explain to the patient as you go
Think in terms of body systems
Be systematic - same way every time
Only expose area being assessed
Minimize position changes
Consider developmental and cultural aspects
Order of Assessment - ANSWER -Inspect (includes SMELL too!)
-Auscultate
-Palpate
-Percuss
(Look, Listen, and Feel)
steps to prepare: - ANSWER Gather your equipment
Review patient history, laboratory tests, procedures as needed
WASH YOUR HANDS!
ABC'S SAFETY, AND PAIN - ANSWER ABCs and Safety comes first!! ALWAYS!!
(this will be on the many exams)
A
B
C - ANSWER Airway
(Speaking, stridor, vomiting, swelling)
Breathing
(Skin color, breathing spontaneously, rate, pulse oximetry, chest movements)
Circulation
(Skin color and temperature, obvious bleeding
Safety
Pain)
What is a General Survey? - ANSWER The purpose of the general survey is to
quickly assess the overall status of the patient
, Assess Overall status
Assess for any distress or discomfort - ANSWER Apparent state of health
Body Structure
Level of consciousness
Skin Color
Personal Hygiene
Posture
Obvious physical deformities
Mood/Affect
Speech
Mobility
General Survey - ANSWER Apparent state of health
-Appears stated age
-Nutritional Status
-Appears well nourished or malnourished
Body structure
-Appears trim, muscular, obese, excessively thin
Level of Consciousness
-Alert and Oriented X 4
Person - Can they tell you their name?
Place - Can they tell you where they are?
Time - Can they tell you date, time of day, month?
Situation - What brought them into the health care facility?
general survey cont. - ANSWER skin color and status (congruent w race, signs
of obvious infection, infest, non-intact skin)
personal hygiene (dress & groom)
posture and gait (observe for erect, slumped, bent posture approp. for age;
observe gait if pt enters the rm- if they can walk, steadily)
assess for pain/discomf
Mental status assessments: - ANSWER All patients should be assessed for Level
of Consciousness (LOC):
A: Alert
V: responds to verbal stimulus
P: responds to pain
U: unresponsive
5.16 Exam Latest Update
Principles of Nursing Assessment - ANSWER Head-to-toe
Explain to the patient as you go
Think in terms of body systems
Be systematic - same way every time
Only expose area being assessed
Minimize position changes
Consider developmental and cultural aspects
Order of Assessment - ANSWER -Inspect (includes SMELL too!)
-Auscultate
-Palpate
-Percuss
(Look, Listen, and Feel)
steps to prepare: - ANSWER Gather your equipment
Review patient history, laboratory tests, procedures as needed
WASH YOUR HANDS!
ABC'S SAFETY, AND PAIN - ANSWER ABCs and Safety comes first!! ALWAYS!!
(this will be on the many exams)
A
B
C - ANSWER Airway
(Speaking, stridor, vomiting, swelling)
Breathing
(Skin color, breathing spontaneously, rate, pulse oximetry, chest movements)
Circulation
(Skin color and temperature, obvious bleeding
Safety
Pain)
What is a General Survey? - ANSWER The purpose of the general survey is to
quickly assess the overall status of the patient
, Assess Overall status
Assess for any distress or discomfort - ANSWER Apparent state of health
Body Structure
Level of consciousness
Skin Color
Personal Hygiene
Posture
Obvious physical deformities
Mood/Affect
Speech
Mobility
General Survey - ANSWER Apparent state of health
-Appears stated age
-Nutritional Status
-Appears well nourished or malnourished
Body structure
-Appears trim, muscular, obese, excessively thin
Level of Consciousness
-Alert and Oriented X 4
Person - Can they tell you their name?
Place - Can they tell you where they are?
Time - Can they tell you date, time of day, month?
Situation - What brought them into the health care facility?
general survey cont. - ANSWER skin color and status (congruent w race, signs
of obvious infection, infest, non-intact skin)
personal hygiene (dress & groom)
posture and gait (observe for erect, slumped, bent posture approp. for age;
observe gait if pt enters the rm- if they can walk, steadily)
assess for pain/discomf
Mental status assessments: - ANSWER All patients should be assessed for Level
of Consciousness (LOC):
A: Alert
V: responds to verbal stimulus
P: responds to pain
U: unresponsive
