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Adult Health Nursing (NURS 372) Assessment LAB Guidelines

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University of Delaware

Adult Health Nursing (NURS 372)

Assessment LAB Guidelines

Delaware Technical Community College
Jack F. Owens Campus
Nursing Department
ASSESSMENT LAB GUIDELINES
Complete assessment involves a nursing history, a behavioral and physical examination.
1. PREPARATION FOR THE EXAMINATION:
 Gather appropriate equipment (pen light, stethoscope, and watch), perform standard
of care: wash your hands, identify yourself, identify your client using 2 identifiers,
explain to your client you are going to perform an assessment, provide privacy, and
raise the bed to a working level if necessary.
2. GENERAL SURVEY:
 This is a critical decision point. Findings may change the direction of the examination. Any
client in acute distress will require an immediate assessment of the body systems(s) affected.
Note if client is in any acute distress: difficulty breathing, pain, anxiety, etc. If such signs are
present, defer general survey until later.
 Survey includes:
 Survey environment for safety concerns
 Review baseline readings & subsequent pattern of vital signs, height/weight, I & O,
FSBS recordings, pulse oximetry readings, and determine date of last stool.
 Determine client’s primary language and culture, including gender and race.
 Reconfirm with client (after reviewing medical/surgical history, medications, and
allergies) the primary reason for which he/she sought health care.
 Determine need for preventative screening based on age
 Observe general appearance and behavior
1. Body type
2. Posture, gait, and body movements
3. Hygiene, grooming, dress, and body odor
4. Nutritional status
5. Affect and mood
6. Speech
7. Client abuse
8. Substance abuse
9. Sleep
 Measure vital signs and Ht/Wt if applicable.
 Evaluate all devices attached to client for correct functioning: IV site, IV fluid and rate,
oxygen devices, dressings, drains, TED stockings, sequential compression devices
(SCD’s), and any others.

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Adult Health Nursing (NURS 372) Assessment LAB Guidelines

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