1.1 General Survey Introduction
Open Resources for Nursing (Open RN)
Learning Objectives
- Perform a general survey assessment, including vital signs, ability to communicate, appropriateness of behaviors and responses, general mobility, and basic nutritional and fluid status
- Modify assessment techniques to reflect variations across the life span, cultural values and beliefs, and gender expression
- Document actions and observations
- Recognize and report significant deviations from norms
“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.”[1]
This quote provides a good description of learning how to perform a general survey assessment. A general survey assessment is a component of a patient assessment that observes the entire patient as a whole. General surveys begin with the initial patient contact and continue throughout the helping relationship. In this instance, observation includes using all five senses to gather cues. Nurses begin assessing patients from the moment they meet them, noting their appearance, posture, gait, verbal communication, nonverbal communication, and behaviors. Cues obtained during a general survey assessment are used to guide additional focused assessments in areas of concern.
Introduction to the Nursing Process
Before discussing the components of a general survey, it is important to understand how assessment fits under the standards for professional nursing practice established by the American Nurses Association (ANA). These standards are the foundation of the nursing profession and include duties that all registered nurses, regardless of role or specialty, are expected to perform competently.[2] There are six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. See Figure 1.1[3] for an illustration of the nursing process. The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. This textbook contains several chapters pertaining to techniques used during the assessment phase of the nursing process. Read more about the “Nursing Process” in the Open RN Nursing Fundamentals textbook.
Assessment
According to the ANA, assessment includes collecting “pertinent data, including but not limited to, demographics, social determinants of health, health disparities, and physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic, ongoing process with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”[4]
Patient data is considered either subjective or objective, and it can be collected from multiple sources.
Subjective Assessment Data
Subjective data is information obtained from the patient and/