General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care.

Guidelines for General Observations

Appearance

Age Appears to be stated age
Appears older or younger than stated age
Physical condition Physically fit, strong, appropriate weight for height
Deconditioned, weak, underweight or overweight for height
Limitation due to amputation or paralysis
Dress Dressed appropriately or inappropriately for the weather
Clean and well-kept clothing
Soiled or torn clothing; smell of alcohol, urine, or feces
Hygiene Clean and well-groomed
Unkempt; unshaven, dirty skin, dirty hair, dirty nails
Body odor or unusual breath odor
Skin color Appropriate for race.
Pale, ruddy, cyanotic, jaundiced, or tanned

Mobility

Ambulation Walks independently; steady gait
Uses a cane, crutches, wheel chair, or walker
Unsteady, slow, hesitant, or shuffling gait; leans to  one side; unable to support own weight
Transfers from chair to bed independently
Needs (from one, two, or three person) assistance to transfer from chair to bed.
Movement Moves all extremities
Has right or left sided weakness; paralysis
Cannot turn in bed independently; cannot shift weight in bed independently
Has jerky or spastic movements of (specific) body parts.

 

Top 5 Malpractice Claims Made Against Nursing Professionals

 
Chances are at some point in your career, you will either:

  • Have a claim made against your professional services.
  • You will be named in a group lawsuit – whether as part of a larger group of health care professionals and/or included with your health care facility.
  • Witness a negligent act by another health care professional during the course of a normal work day.
  • Be deposed to testify on behalf of yourself, your employer or colleague.

 
No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy. It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

  1. Failure to follow standards of care
  2. Failure to use equipment responsibly
  3. Failure to document
  4. Failure to assess and monitor the patient
  5. Failure to communicate.

 

I will discuss these five common allegations in the coming blog posts, so stay in touch!

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