Assessment: General Survey

  1. Evaluate verbal and nonverbal behaviors.
  2. Determine level of consciousness and orientation.
  3. Obtain vital signs.
  4. Observe overall appearance.
  5. Rephrase questions as necessary.
  6. Ask patient short, focused questions if responses inappropriate.
  7. Offer simple commands or directions if unable to respond to orientation questions.
  8. Assess body posture and mobility.
  9. Evaluate speech patterns.
  10. Observe hygiene and grooming.
  11. Assess eyes:
  12. Position, color, movement.
  13. Near and far vision.
  14. Pupil size, shape, and equality.
  15. Pupillary reflexes.
  16. Assess hearing acuity and presence of hearing aid.
  17. Inspect nose for abnormalities.
  18. Verify integrity of nares for patients with indwelling tubes.
  19. Assess oral mucosa, tongue, teeth, and gums. Note presence and condition of dentures.
  20. Examine skin:
  21. Determine if patient has noted skin changes.
  22. Inspect skin surfaces symmetrically, note variations and lesions.
  23. Gently palpate and measure any lesions.
  24. Note color of face, oral mucosa, lips, conjunctiva, sclera, and nail beds.
  25. Using ungloved hand, palpate skin for moisture, texture, and temperature.
  26. Assess skin turgor.
  27. Inspect for pressure areas.
  28. Apply gloves, and inspect character of secretions.
  29. Apply clean gloves, and palpate IV site.
  30. Use the "six rights" to check IV fluids and medications.
  31. Assess affect and mood.
  32. Observe patient's interaction with others.
  33. Evaluate for signs of abuse.
  34. Record vital signs and alterations in patient's general appearance