Lecture 1: General Survey, Assessment Techniques, & Nursing Fundamentals
General Survey & Types of Physical Assessments
General Survey Definition:
The initial "first impression" check performed the moment a nurse enters a patient's room.
Serves to observe overall appearance, posture, breathing, and safety cues prior to beginning a detailed physical assessment.
Types of Physical Assessments:
Admission Assessment: A deep, complete, top-to-bottom health history and physical examination performed when a patient first enters the facility.
Shift Assessment: A quick, focused check performed at the start of a shift to note changes from the previous shift.
Head-to-Toe Assessment: A systematic, top-to-bottom scan across all body systems to determine overall current status.
Focused Assessment: An examination limited to one specific problem area (e.g., examining only the mouth and jaw for a patient complaining of a toothache).
The Four Physical Examination Techniques
Technique Sequence: Physical examinations must always be conducted in the exact order below:
1. Inspection (Looking, Listening, Smelling):
Always serves as the first step.
Uses sight, sound, and smell to observe color, size, symmetry, body shape, and movement.
Tools needed: Light source, penlight, otoscope, or ophthalmoscope.
2. Palpation (Feeling with Hands):
Light Palpation: Uses finger pads to press down () to check surface texture, tenderness, moisture, and temperature.
Deep Palpation: Uses one or both hands to press down to feel deep internal organs or abnormal masses.
Hand Placement Guide:
Back of Hand (Dorsal surface): Best for checking temperature.
Base of Fingers / Palm edge (Ulnar surface): Best for feeling vibrations.
Finger Pads: Best for checking pulses, tissue texture, size, and fluid.
Golden Rule: Always palpate painful or tender areas last.
3. Percussion (Tapping the Body):
Involves tapping on skin to determine if underlying organs are solid, filled with fluid, or filled with air.
Used for checking organ size and reflexes.
4. Auscultation (Listening with a Stethoscope):
Diaphragm (Flat Side): Pressed firmly against the skin to hear high-pitched sounds (breath sounds, normal heart sounds, bowel sounds).
Bell (Cupped Side): Placed lightly on the skin to hear low-pitched sounds (heart murmurs, abnormal blood flow).
Bedside Clinical Evaluations & Pain Mnemonics
The 10-Second Quick Survey:
A mental checklist performed upon entering the patient room:
FACE: Assess whether the patient is awake, grimacing in pain, if their skin is pale or flushed, and whether their face is symmetrical.
POSTURE: Observe whether they are sitting comfortably upright, or hunched over / guarding a painful area.
TUBES IN: Trace all IV lines and feeding tubes from the wall/pump to the patient. Verify lines are open, labeled, and flowing correctly.
DRAINS OUT: Trace catheter and wound drain tubes from the patient to the collection bag. Ensure fluids are draining properly and note color/amount.
ENVIRONMENT: Check for room clutter, safety hazards, strange odors, or unconsumed food trays.
Mental Status & Pain Assessment Tools:
Folstein Mini-Mental State Examination (MMSE): A quick point cognitive test. A score above indicates normal mental functioning.
COLDSPA / OLDCARTS Pain Mnemonics:
C / C (Character / Characteristics): What does the pain feel like—sharp, dull, aching?
O / O (Onset): When did it start?
L / L (Location): Where is it?
D / D (Duration): How long does it last?
S / S (Severity): Pain rating from .
P / A (Pattern / Aggravating-Alleviating factors): What makes it better or worse?
A / R (Associated factors / Radiation): Does the pain spread anywhere else?
Professional Standards, Ethics, & Bedside Safety Routine
Patient Rights & HIPAA:
Confidentiality: Patient health information is strictly private and cannot be shared without written consent.
Need-to-Know Standard: Healthcare workers may only access medical records for patients directly under their care.
Legal Exceptions: Patient data can only be shared without consent in rare legal circumstances (e.g., public health reporting, medical research approved by a review board, or fraud investigations).
Bedside Entry Routine (Safety & Professionalism):
1. Knock on the door before entering.
2. Wash hands (hand hygiene) and put on clean gloves.
3. Introduce yourself: State your name, title, and purpose (e.g., "Hello, my name is… and I am a student nurse…").
4. Identify the patient ways: Check their ID wristband, ask them to state their name and date of birth, or verify with staff.
5. Provide privacy & comfort: Close curtains/doors, cover the patient with a sheet, and ask if they need to use the bathroom before starting.
Health History Collection & Documentation
Health History ("The Patient's Story"):
Biographical Data: Name, age, gender, race, primary language.
Reason for Seeking Care: The main symptom bringing them in (e.g., pain, fever, nausea, shortness of breath).
Past Medical & Family History: Chronic illnesses, previous surgeries, and hereditary conditions.
Lifestyle & Practices: Medications, dietary habits, smoking/alcohol history, and cultural background.
Subjective vs. Objective Data:
Subjective Data: Everything the patient or family tells you verbally (e.g., "My lower back hurts" or "I feel tired").
Objective Data: Everything measured, observed, or tested directly by the nurse (e.g., Blood Pressure , Temperature , pale skin).
Electronic Health Record (EHR / SimChart):
Legal, permanent document used to record patient findings, guide care plans, justify insurance billing, and communicate patient changes to the rest of the care team.
Key Fields Include:
Patient age, gender, race, room/bed number.
Primary admitting diagnosis and secondary diagnoses.
Code status and Advance Directives.
Isolation / Contact precautions and allergy alerts.