General Survey Flashcards
Initial appraisal of clients overall presentation and behaviors leads to focused assessments details
Head, hygiene, environment, introduction, identification, trust, and Rappaport
General survey overview of communication
Verbal nonverbal miscommunication
Steps to perform a general survey appearance
Behavior, indicators of abuse, neglect, human trafficking, body structure and mobility, measurement, height, weight, BMI, vital signs pain
Appearance expecting findings
Facial features expected symmetry
Emotional state expected, relaxed, smiling, responsive, direct eye, contact, level of consciousness, alert, and oriented skin should be warm in tack with even tones behavior/speech should be fluency pace, articulation normal, mood and affect should be pleasant and cooperated and personal hygiene should be grooming, clothing, hair, nails, older, and dental hygiene. Should all look clean.
Apparent unexpected findings
Facial features, unexpected are in expressionless asymmetry involuntary movements, swelling lesions, emotional state, unexpected, restless, grimacing, quiet, emotions, unexpected by contact, will be avoidance, unless culturally, appropriate squinting, and staring level of consciousness unexpected will be confusion Lethargy stupor obtundation comatose, skin, unexpected will look cool or hot diaphoresis clamminess tone, variations behavior, unexpected will be whispering, disarticulation, absence, abnormal tone, or pace mood and affect. Unexpected will be inappropriate response is flat or expressionless. Personal hygiene will be decreased grooming, clothing, hair, nails, older, and dental hygiene.
Body structure and mobility expected findings
Posture Relaxed, straight vertical line build expected should be normal height symmetry, nourishment, mobility, expected should be smooth. Gait normal range of motion range of motion expected is conscious, smooth coordinated movements.
Body structure and mobility, unexpected findings
Posture unexpected will be slump, rigid, fidgeting, build unexpected will be height out of range of symmetry, uneven, weight, distribution mobility, unexpected will be wide stance, staggering, stumbling, dragging, limping, and mobility, guarding, and inability to rise and sit without hands range of motion unexpected will be limitation’s pain and mobility coordinated movements, a symmetry of the joints and crepitus
Body structure and mobility, unexpected involuntary movements
Spasticity alteration in muscle tone, manifested as increase muscle tone tonicity for example, increase resistance, when attempting to passively extend a joint
Body structure and mobility, unexpected findings
Rigidity alternation in muscle tone, manifested as resistance to any manipulation of the joint
Body structure mobility, unexpected findings
Fasciculation alteration in muscle movement, seen as a continuous rabbit twitching of a muscle at rest
Body structure mobility, unexpected findings, involuntary movements
Myoclonus alteration in muscle movement, that is seen as a sudden, jerking of muscle examples include hiccups, seizure activity, and a single myoclonic jerk of the arm or leg when falling asleep
Body structure mobility, unexpected findings
Tick alteration in muscle movement, characterized by involuntary repetitive movement of a muscle group related to a neurological or psycho, genic cause examples, include grimaces, winks, and shoulder shrugs
Body structure mobility, and expected findings, involuntary movements
Trimmers alteration in muscle movement by opposing muscle groups, that result in arithmetic movement of one or more joints, trimmers can occur at rest, or when attempting voluntary and purposeful movement
Height, weight, and BMI measurements expected findings
BMI healthy weight is 18.5 to 24.9 kg/m
Height, weight, and BMI measurement unexpected findings
Weight gain, or loss on the way less than 18.5 kg/M overweight, 25 to 29.9 kg/M obesity, 30 and above.
