2.4: Expected Versus Unexpected Findings
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.
| 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 |