Checklists for Clinical Nursing Skills

15

skill 2-2 Performing a general survey (continued)

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12. Assess the patient’s behaviour. (a) Are their facial expressions appropriate for the situation? (b) Do they maintain eye contact, based on cultural norms? (c) Do they appear comfortable and relaxed with you? (d) Is their speech clear and understandable? 13. Observe the patient’s hygiene and grooming. (a) Is their clothing appropriate for the climate? (b) Do their clothes fit well? Are the clothes clean and appropriate for the person’s culture and age group? (c) Does the person appear clean and well groomed, appropriate for their age and culture? 14. Assess the patient’s mobility. (a) Is their gait smooth, even, well-balanced and coordinated? (b) Is joint mobility smooth and coordinated with a general full range of motion (ROM)? (c) Are involuntary movements evident? 15. Assess for pain. (Refer to Chapter 10 on comfort.) 16. Have the patient remove their shoes and heavy outer clothing. Weigh the patient using scales. Compare the measurement with previous weight measurements. 17. With shoes off, and standing erect, measure the patient’s height using a wall-mounted measuring device or measuring pole. Compare height and weight with recommended averages on a standardised chart. 18. Use the patient’s weight and height measurements to calculate the body mass index (BMI). Body mass index = weight in kilograms height in metres 2 19. Using a tape measure, measure the patient’s waist circumference. Place the tape measure snugly around the patient’s waist at the level of the umbilicus. 20. Measure the patient’s temperature, pulse, respirations, blood pressure and oxygen saturation. (Refer to Chapter 1 on vital signs and Chapter 14 on oxygenation for specific techniques.) 21. Continue with assessments of specific body systems as appropriate or indicated.

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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.