Checklists for Clinical Nursing Skills

14

Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-2 Performing a general survey

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed without the patient experiencing anxiety or discomfort, an overall impression of the patient is formulated, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.  1. Identify the patient.  2. Check the medical order or clinical pathway/care plan.  3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent.  4. Gather the necessary equipment. Equipment: scales, height measure, tape measure, stethoscope, sphygmomanometer, thermometer with probe covers, watch with second hand, oximeter, alcohol wipes.  5. Undertake a risk assessment, if indicated.  6. Perform hand hygiene.  7. Put on personal protective equipment (PPE), if indicated.  8. Ensure that patient privacy is maintained and the patient is comfortable. Ensure that interruptions are minimal. (a) Assess skin colour, temperature, moisture and turgor. (b) Observe whether they appear to be their stated age. (c) Note their mental status. Is the person alert and oriented, responsive to questions and responding appropriately? (d) Note whether the facial features are symmetrical. (e) Note any signs of acute distress, such as shortness of breath, pain or anxiousness. 11. Assess the patient’s body structure. (a) Does their height appear within the normal range for the stated age and genetic heritage? (b) Does their weight appear within the normal range for their height and body build? (c) Is body fat evenly distributed? (d) Do their body parts appear equal bilaterally and relatively proportionate? (e) Is their posture erect and appropriate for their age?  9. Undertake a health history, as per Skill 2-1. 10. Assess the patient’s physical appearance.

Comments

Excellent

Satisfactory

Needs practice

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Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.