Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

• Bathing/hygiene ADL deficit
• Impaired comfort
• Coping impairment

The expected outcome to achieve in performing a general survey is that 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 health care professionals, as needed, for further evaluation. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

The expected outcomes have been met when the assessment has been completed without the patient experiencing anxiety or discomfort; an overall impression of the patient has been formulated; the findings have been documented; and the appropriate referrals have been made to other health care professionals, as needed, for further evaluation.

Document findings related to assessment of the patient's physical appearance, body structure, mobility, and behavior. Document the patient's height, weight, BMI, and waist circumference. Document the presence or absence of pain as well as an initial pain assessment if present. Record the patient's temperature (T), pulse (P), respiration (R), and blood pressure (BP) measurements as well as the oxygen saturation measurement. Note any referrals.

Practice documenting assessment techniques and findings in Lippincott DocuCare.

• Patient is unable to tolerate standing for height or weight measurement: Obtain a chair scale or bed scale to measure weight (refer to Skill 3-2). Obtain a measuring stick to measure height. Alternatively, use tape to mark the patient's length in the bed with the patient supine, the head in the midline position, and the legs extended flat on the bed. Measure the resulting length.