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Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
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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.
9. Undertake a health history, as per Skill 2-1.
10. Assess the patient’s physical appearance.
(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?
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