General Survey/ VS/ Hair, Scalp & Nails NURS 1710 - Fundamentals Skills General Survey includes the following pieces but is not required to be performed in this order: 1. Introduction of student RN to patient (assigned partner in skills for the rest of the semester) - Hello, my name is (state name). I am your student nurse for today. Before I begin my health history & assessment of your body systems, I would like to take and record your vital signs. *2. Measure Vital Signs (automatic only)- stating measurement of vital signs here but not performing 3. Inspection/ observation of facial, body language, approximate age, emotional & mental status -Use communication and begin scripting thoughts/ nursing language to describe assessment pieces in skills i.e. Woman presenting in office appears of middle age with normal body habitus. Pt. appears happy/ sad/ content/ angry/ facial grimacing/ flat affect etc. with arms resting comfortably in lap/ pacing clinical setting/ sobbing into hands etc. Pt. states “I’m in severe pain in my knee” while crying and holding husband’s hand etc. 4. Inspection/ observation of hygiene -Again, use communication to describe pt hygiene here, script your thoughts and use nursing language to describe assessment pieces per your Perry & Potter books i.e. pt appears well groomed with no odor noted. Inspection of pt. reveals no tremors or facial drooping. Facial skin appears pink, smooth with no obvious lesions or deformities noted. 5. Inspection of Orientation - i.e. What is your name? What is your date of birth? What year is it? Who is the president? Etc. - formulate your own pattern of thought/ questions to trigger your assessment with your patient and determine orientation to person, place, time, and situation - upon completion of this line of questioning, student RN will state: Pt. is alert and oriented x (whatever is determined), English speaking (or other language), and speech is easily comprehensible/ pt seems to be slurring words/ pt incomprehensible and continues to repeat phrases etc. *6. Health History begins- What brings you to the office today? Are you having any pain? Etc. 7. Apply gloves 8. Inspection & palpation of hair (head and body) and scalp - student RN should observe/ inspect first noting distribution of hair, color, texture, i.e. pt. hair appears smooth/ dull/ bright/ fine/ thin/ coarse etc., brown/ blonde/ gray etc. and is evenly distributed/ sparse/ pt appears balding (state location of hair loss). - student RN should now palpate scalp (can do at same time as stating description of hair) i.e. pt scalp is smooth upon palpation with slight mobility of skin, no lesions/ hematomas/ flaking/ lice or erythema noted. - student RN should now describe body hair (if visible)i.e. pt. body hair present on face, arms, legs etc. (for female note abnormal findings by stating body hair located on chin- stating POSSIBLE hirsutism), light colored and dispersed evenly around (state areas noted or state areas not noted- lack of hair could identify possible circulatory problems). 9. Inspect and palpate the nails - student RN will now note nails for shape, contour, consistency, color, thickness and cleanliness i.e. pt. fingernails (and/or toe nails) round/ smooth/ yellow/ brown/ ecchymotic/ gangrenous/ thick/ thin/ rough/ sharp etc. with no edema, drainage, erythema present at nail bed. Nail angle at approximately 160 degrees with no clubbing/ depressions/ pitting noted. *For items 2 & 6, students must say the following statement to receive full points during their head-to-toe assessment: “At this time, I will obtain, record and document vital signs and obtain and document a complete health history”
