General Survey Form
Imaging Conduct a general survey on 65 years old female client. Perform this as an inspection only and document the findings in short phrases. Also, identify actual or potential risks for the client
Objective: Conduct a general survey on your 65 years old client. The purpose of this interaction is to observation the following and include all contents below in details. In include subjective data and objective data.
1. 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)
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
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
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.”
5. Describe two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
WRITE FROM NURSE PROSPTIVE
APA FORMATE AND IN TEXT CITATION
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