GENERAL SURVEY

STEPS IN PERFORMING GENERAL

SURVEY
1. Consider the following:
a. adequate lighting
b. comfortable room temperature
2. Introduce self and verify clients
identity. Explain the procedure,
purpose, and how the client can
cooperate

3. Provide privacy and ask if they

prefer to have a family member with
them during the procedure.
4. Perform Hand Hygiene

5. Observe patient for built, height,

and weight in relation to the clients
age, lifestyle, and health

6. Observe the patients posture and

gait, standing, sitting, and walking.

7. Observe the clients overall

grooming and hygiene.
8. Note body and breath odor

9. Observe for signs of distress in

posture or facial expressions

10. Note Obvious signs of health or

illness

11. Assess Clients Attitude

12. Note Clients responses
13. Listen to quantity, quality, and
organization of speech
14. Listen to relevance and
organization of thoughts
15. Document Findings

ASSESSMENT OF THE
HEAD AND NECK

STEPS IN PERFORMING GENERAL

SURVEY
1. Consider the following:
a. adequate lighting
b. comfortable room temperature
2. Introduce self and verify clients
identity. Explain the procedure,
purpose, and how the client can
cooperate

3. Provide privacy and ask if they

prefer to have a family member with
them during the procedure.
4. Perform Hand Hygiene

5. Inspect the skull for size, shape, and

symmetry

Hydrocephalus

 Different shapes for head

6. Observe Hair, including quantity,

distribution and texture

8. Inspect the face including

symmetry, facial expression, facial
expression, and features.

9. Observe skin including color,

texture, hair distribution, and lesions
10. Palpate the head for nodules or
masses and depressions

11. Inspect the neck position,

symmetry, lumps or masses

12. Inspect movement of the neck

structures, thyroid cartilage, thyroid
gland

Thyroid assessment

13. Inspect Range of Motion

14. Assess Muscle strength

15. Palpate entire neck for enlarged

lymph nodes

 Enlarged Lymph Nodes

16. Observe the thyroid Gland

17. Palpate the thyroid gland for
enlargement, masses, or nodules. If
enlarged, auscultate over the thyroid
area for bruit.

18. Document

ASSESSMENT OF THE
HAIR, SKIN, AND NAILS

1. Assemble the equipment

2. Consider the following:
a. adequate lighting
b. comfortable room temperature
3. Introduce self and verify clients identity.
Explain the procedure, purpose, and how
the client can cooperate
4. Provide Privacy and ask if they prefer to
have a family member with them during
the procedure

6. Have the client remove all clothing

and put on examination gown or drape
7.Ask the
client to sit
in an
upright position
with arms
relaxed at
the sides.

8. Inspect skin for color

9. Inspect and palpate any skin lesions
and characterize

10. Observe and assess the following:

skin temperature, moisture, and
texture.
11. Press skin over tibia and ankle

12. Assess skin for mobility and turgor

13. Inspect hair for color, amount, and

distribution

14. Assess for presence of Parasites

15. Inspect for presence of scalp

lesions

16. Inspect texture, color, and shape of

nails

17. Inspect the condition of the nail beds

18. Document Findings

ASSESSMENT OF THE
EYES, EARS, NOSE, AND
THROAT

1. Assemble Equipment
2. Consider the following:
a. adequate lighting
b. comfortable room temperature
3. Introduce self and verify clients identity.
Explain the procedure, purpose, and how
the client can cooperate
4. Provide Privacy and ask if they prefer to
have a family member with them during
the procedure

5. Perform Hand Hygiene don gloves

and observe other appropriate
infection control procedures

6. Let the client sit in an upright

position
7. Inspect the upper and the lower
eyelids

8. Inspect sclera and conjunctiva and

note for exudates, lesions, and foreign
bodies

9. Inspect pupil size, shape, and

reaction

10. Inspect the cornea and the anterior

chamber with the use of the penlight

11. Assess ocular muscle movements

by asking the client to follow an object
with his eyes through the 6 fields of
gaze

12. Inspect the lacrimal apparatus for

any swelling and discharge

13. Inspect the retinal structures by

the use of an opthalmoscope
14. Check for visual acuity
a. Position the client in sitting or
standing position 20 feet from the
snellens chart
b. instruct to remove glasses if any
and to cover the left eye with the
occluder

c. Instruct to read as many lines on the

chart as possible and record the visual
acuity of the last line where more than
half of the letters were read correctly.
d. Move the client closer to the chart if
the client is unable to read and note
the distance where the client is able to
read to the top line
e. Repeat the test on the right eye

15. Palpate the lacrimal sac for

obstruction by pressing the index
finger near the inner canthus and note
for any discharges.

16. Inspect the external ear and note

the position, color, size, and shape

17. Note any deformities, nodules

inflammations, and lesions
18. Note color, amount, and
consistency of serumen

19. Palpate the auricle between the

thumb and index finger, noting any
tenderness, lesions, and presence of
pain

20. Palpate the mastoid tips using the

index and middle finger and note for
any tenderness

21. Auditory Screening Test: Voice

whisper test
a. Instruct client to occlude ear with
one finger
b. examiner stands 2 feet behind the
client and whisper a 2 syllable word
c. repeat with the other ear

22.Auditory screening test: WEBER

TEST
a. hold handle of a tuning fork and
strike the line on the ulnar border of
your palm to activate it.
b. place the stem of the
tuning fork against the
middle of the
clients forehead at the
midline or the front
of the teeth.

c. ask the client if the sound is heard

centrally or towards one side.

23. Auditory Screening test: RINNE

TEST
a. stand behind or to one side of the
client and strike the tuning fork

b. place the stem of the tuning fork

against the clients right mastoid
process to test bone conduction
c. instruct the client
to indicate if the
sound is heard.
d. ask the client to
tell when the sound stops.

e. Move the tuning fork forward

infront of the right auditory meatus
when the sound has stopped, with
tines facing forward.

f. ask the client if the sound is still

heard and note the length of time he
hears the sound

24. Otoscopic Assessment

a. ask the client to tip away from the
ear being assessed
b. Select the speculum that will
comfortably fit the patient
c. slowly insert the speculum into
the canal assessing the canal for
inflammation, exudates, lesions, and
foreign bodies

d. Continue to insert the speculum until

the tympanic membrane is visualized,
and identify the color, the light reflex, and
note for the presence of perforations
bulging or retractions, bubbles or fluids.
e. ask the client to close the mouth
pinch the nose close, and blow gently
while observing the movement of the
tympanic membrane.
f. gently withdraw the speculum and
repeat the process with the other ear.

25. Inspect the nose, noting any

trauma, bleeding, lesions, masses,
swelling, and asymmetry,

26. Note for patency of the nostrils by

occluding one nostril with a finger and
asking the patient to breathe in and
out
27. Inspect the internal aspect of the
nose with the use of an otoscope with
nasal speculum, assessing each nostril
separately

28. Inspect the mucus membranes for

color and discharges

29. Inspect the middle and inferior

turbinates and the middle meatus for
color, swelling, drainage, and polyps

30. Observe the nasal septum for deviation,

perforation, lesions, and bleeding

31. Observe the clients face for any

swelling around the nose and the eyes.

32. Palpate the nasal sinuses by gently

pressing the thumbs under the bony
ridge of the upper orbits and observe
the presence of pain

33. Palpate the maxillary sinuses by

applying gentle pressure in the area under
the intraorbital ridge using the thumb or
middle finger and observe for the presence
of pain.

34. Percuss the frontal sinuses using

the middle or index finger using the
dominant hand and note for the sound

35. Percuss the maxillary sinuses using

the dominant middle or index finger
and note for the sound

36. Inspect the mouth by standing

infront of the client and smell the
breath
37. Observe the lips for color,
moisture, swelling, lesions, and
inflammation
38. Instruct the client to open the
mouth and use a tongue blade to
inspect the membranes that connect
the upper and lower lips, and the gums
for color, inflammation, lesions, and

39. With the clients tongue back in the

mouth, ask the client to press it
against the cheek, and provide
resistance with your finger pads held
on the outside of the cheeks and note
for strength and compare bilaterally.
40. Ask the client to open the mouth
as wide as possible and using a tongue
blade and a penlight, assess the inner
cheeks and Stensens ducts and
observe for color, inflammation,
hydration, and lesions.

41. Observe the dentures and

orthodontics for fit

42. Count the upper and the lower

teeth and note for discoloration, loose
and missing teeth, and malformation.

43. Ask the client to tilt the head back

and alce the tongue blade on the
middle thid of the tongue and shine a
light at the back of the clients throat
and ask the client to say AAAH

44. Observe the position, size, color,

and general appearance of the tonsils
and uvula, and note for gag reflex and
presence of swelling and exudates

45. Document findings in the clients

records