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2.4: Expected Versus Unexpected Findings

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    47131
  • Table \(\PageIndex{1}\)a  compares expected and unexpected findings when performing a general survey assessment. These findings are included in documentation regarding the general survey assessment.

    Table \(\PageIndex{1}\)a: Expected Versus Unexpected Findings on General Survey Assessment
    Assessment Expected Findings Unexpected Findings (notify provider if a new finding*)
    Signs of distress No signs of distress Unresponsive, difficulty breathing, confused, moaning, or grimacing
    Mood and appearance Calm and cooperative

    Responds appropriately to questions

    Appears stated age

    Mood is depressed, anxious, or agitated

    Signs of suspected substance use disorder are present, such as the scent of alcohol

    Orientation Alert and oriented to person, place, and time Unable to provide name, location, or day
    Hygiene Well groomed. Clothing is appropriate for weather Unkempt appearance or inappropriate clothing according to the weather
    Family dynamics Family members demonstrate mutual respect, trust, and caring Family members communicate in an unfriendly, disrespectful, or hostile manner

    Signs of suspected abuse are present

    Speech and communication Speech is clear and understandable; patient follows instructions appropriately Speech is garbled or difficult to understand; unable to respond appropriately to questions or follow commands
    Range of motion Moves all extremities equally bilaterally with good posture New facial drooping or altered/unequal movement of extremities
    Mobility Gait is smooth and even and can maintain balance without assistance. If present, assistive devices are used appropriately and this is documented Gait is shuffling, staggering, or limping. Balance is impaired; assistive devices like a cane or walker are not used appropriately
    Nutrition BMI within normal range BMI out of range. Unexplained weight loss or gain has occurred
    Fluid status Moist mucous membranes Dry skin and dry mucous membranes; sunken eyes in adults; sunken fontanel in infants
    CRITICAL CONDITIONS to report immediately:   Newly unresponsive or altered mental status; difficulty breathing; vital signs out of range; skin is cool, clammy, or cyanotic
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