Components of Mr. Ahmed’s General Survey

Case Considerations

The head-to-toe physical assessment is used for ongoing assessments, to obtain baseline information, for continuity of care, and for when the nurse is assigned multiple patients to care for on a given shift. The assessment should follow an organized sequence, address all major body systems, and have a specific focus on the patient's primary problems. Documentation Questions Subjective & Objective Data 1. A. What questions would you ask to collect subjective data? Include priority subjective data based on Mr. Ahmed’s medical history

Describe the components of Mr. Ahmed’s general survey. (2 points) B. Identify the components of a focused head-to-toe physical assessment for Mr. Ahmed (4 points) Consider assessments you would perform; use a health systems approach. For example, include: □ Head or Neuro [alertness – LOC, eyes, ears, nose, mouth] □ Cardiovascular & peripheral vascular [heart] □ Respiratory [lungs] □ Gastrointestinal [abdomen] □ Integument [skin] 2. A. What assessment for Mr. Ahmed would you perform to evaluate his fluid balance. What did the assessment findings indicate? (2 points) B. Document how patient education needs were addressed regarding the need for fluid replacement therapy. (2 points) Assessment 3. A. Document your assessment findings related to the focused assessment of all relevant health systems including fluid balance, potassium replacement, and antibiotic therapy. (6 points) B. What do you think is Mr. Ahmed’s primary problem(s) or issues? (2 points) Plan of Care 4. Document any other patient teaching and nursing care you provided to Mr. Ahmed, provide rationale. (2 points) Total 20 points

Subjective & Objective Data 

Question #1 A. What questions would you ask to collect subjective data? Include priority subjective data based on Mr. Ahmed’s medical history.Describe the components of Mr. Ahmed’s general survey 
B. Identify the components of a focused head-to-toe physical assessment for Mr. Ahmed 
AssessmentQuestion #2A. What assessment for Mr. Ahmed would you perform to evaluate his fluid balance? What did the assessment findings indicate?
B. Document how patient education needs were addressed regarding the need for fluid replacement therapy. 
Question #3A. Document your assessment findings related to the focused assessment of all relevant health systems including fluid balance, electrolytes/potassium replacement, and antibiotic therapy. 
B. What do you think is Mr. Ahmed’s primary problem(s) or issues?
Plan of CareQuestion #4Document any other patient teaching and nursing care you provided to Mr. Ahmed, provide rationale.