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
|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|
|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:
- Failure to follow standards of care
- Failure to use equipment responsibly
- Failure to document
- Failure to assess and monitor the patient
- Failure to communicate.