General Survey and Measurement

General Survey and Measurement General Survey Physical Appearance Age: examine if the client appears their stated age Sex: examine if the client’s sexual development is appropriate for their stated age and sex. Pay particular attention to individuals who are transgender, carefully noting the stage of transformation. Level of Consciousness: examine if the client is alert and oriented to person, time, place, and situation. Correctly chart their orientation. This can be examined by asking the client some questions and noting if they respond appropriately. Skin Color: examine the client to make sure that their skin color is consistent with their ethnicity. Make sure that their tone is even, their skin is intact without any obvious lesions, and make note of any tattoos and piercings they may have. Facial Features: facial features should be symmetrical with movement. Note any slight or overt deviations from normal and the specific side of the face affected. Overall Appearance: it is important to note if your client is in any type of distress, and depending on the distress determine appropriate actions. Body Structure Stature: this assessment focuses on whether the client’s height appears normal based on the age and other genetic factors. Nutrition: Does the client’s weight appear normal for their age, height, and body build? What is the body fat distribution? Symmetry: examine whether the body parts look symmetrical bilaterally, and relative in proportion to each other. Deviations from normal should be noted and specified. Position: positions can reveal a lot of information about a client’s general wellbeing. Note whether they are sitting comfortably with arms relaxed and resting on their side, and head turned to the examiner. Posture: is the client standing comfortably, erect, and appropriate for their age? Note their plumb line from top to bottom. A few exceptions for toddlers and older adults who may have protuberant abdomens and kyphosis respectively. Body Build and Contour a. Arm span: compare fingertip to fingertip and make sure they are equal in height. b. Body length: should be roughly equal from crown to pubis, and from pubis to sole. Obvious Physical Deformities: examine the client to detect any obvious physical deformities such as congenital or acquired defects. Mobility Gait: things to assess include the following: are feet approximately shoulders apart? Is the walk smooth and even? Is the foot placement accurate? Can the client maintain balance and proper posture without assistance? Do they have any other associated movement such as symmetric arm swing? Range of Motion: examine full mobility of each joint. Do they have active range of motion or it is just passive? Is the joint movement deliberate accurate, smooth, and coordinated? Behavior Facial expressions: the client should maintain eye contact; exhibit facial expressions appropriate for situation, and matches though processes. Always make considerations for cultural appropriateness. Mood and Affect: note for any agitation. Is the client comfortable and cooperative with the exam? Examine the client’s affect e.g. are they anxious, depressed, etc. Speech: examine for articulation, which is the ability to form words. Be mindful of people who may not have English as their first language. Seek interpreter as appropriate. Speech pattern: may include things like fluency and pace of talking. Examine whether the client can clearly convey ideas and thoughts. Be mindful of education level and any health literacy issues. Dress: is the dress appropriate for the occasion and situation? If the dress is culturally appropriate, it should not be labeled as inappropriate just because it may not necessarily fit into main stream dress codes. Personal Hygiene: assess whether the client is clean and well groomed. Note any cultural considerations such as cultures that may not support the use of deodorants etc. Measurement Weight Use standardized balance or electronic scale Remove shoes or any heavy outer clothing Weigh at same time every day Record the weight in Kgs and Lbs. (if using one, be consistent with each measurement). Height Use wall mounted device The person should be shoeless Ask the person to look ahead Feet, shoulders and buttocks should be in contact with the hard surface. Body Mass Index Practical marker of optimal health weight for body height Can indicate obesity or malnutrition More accurate measure of total body fat Healthy range is between 19 and 25 Formula: BMI = 703 x weight (lbs.) / [height (in)]2 Waist circumference Excess abdominal fat is a risk factor for many disease processes such as diabetes, hypertension, and cardiovascular accidents. Excessive weight around the waist is more dangerous that around the hips and can be a risk factor for heart disease Measurement should be done in individuals standing uprightly and then measured at the top of the iliac crest. Should be less than 35 inches in women and less than 40 inches in men.