GENERAL SURVEY
A complete physical assessment is initiated by performing general observations of the
patient, obtaining the patient’s vital signs, and assessing a patient for pain. These initial
observations can provide data about the patient’s respirations, pulse, temperature, and blood
pressure. These measurements provide information about the patient’s basic physiological
status. The presence of pain can affect a patient’s physical, emotional and mental health.
The general survey provides information about the characteristics of an illness, a client’s
hygiene and body image, emotional state, recent changes in weight that may reveal of
disease, and the client’s developmental status. This is the first step in a head-to-toe
assessment. The information gathered during the general survey provides clues about the
overall health of the client. The general survey includes:
 Overall impression of the client or general observations.
 Mental Status Exam or Assessment.
 Height and Weight Measurement
 Vital Signs (Fever Assessment)
 Pain Assessment
EQUIPMENTS TO BE USED:
 Standing platform scale with height measuring attachment
 Stretcher scale (for hospitalized clients)
 Thermometer
 Sphygmomanometer and cuff
 Stethoscope
 Watch with second hand
CLIENT PREPARATION:
 Conduct the general survey with the client sitting or standing. An experienced nurse
can do this almost automatically before beginning the physical assessment
 Ask the client to remove shoes and any heavy outer clothing before you measure
height and weight.
 When weighing a hospitalized client, always weigh at the same time of the day, with
the same scale, and with the client wearing the same clothing
ASSESSMENT TECHNIQUES
GENERAL OBSERVATION
ASSESSMENT
NORMAL FINDINGS
ABNORMAL FINDINGS
PROCEDURE
Observe physical & sexual Sexual
development
is Abnormal findings include
development
appropriate for gender and delayed puberty, male client
age
with female characteristics,
and vice versa
Compare client’s stated Client appears to be her Client appears older than
age with her apparent age stated chronologic age
actual chronologic age
and development stage
(ex. hard life, manual labor,
chronic illness, alcoholism,
smoking)
Observe skin condition Color is even without obvious Abnormal findings include
and color
lesions: light to dark beige- extreme pallor, flushed, or
pink in light skinned client; yellow
in
light-skinned
Clinical tip: Keep in mind light tan to dark brown or clients; loss of red tones and
that underlying red tones olive in dark-skinned clients
ashen gray cyanosis in
from good circulation give a
dark-skinned client
liveliness or healthy glow to
all shades of skin color
Observe dress
Clinical tip: Be careful not to
make premature judgments
regarding the client’s dress.
Styles and clothing fads (ex.
torn
jeans
or
pants,
oversized clothing, or baggy
pants), developmental level,
socio-economic level, and
culture all influence a
person’s dress (ex. Indian
women wear saris; Hasidic
Jewish men wear black suits
and black skull caps)
Observe hygiene
Determine what the normal
level of hygiene is for the
client’s developmental and
socioeconomic level and
cultural background
Dress is appropriate for
occasion and weather. Dress
varies considerably from
person to person, depending
on individual preference.
There may be several normal
dress variations depending
on the client’s developmental
level, age, socioeconomic
level,
and
culture
or
subculture.
***Some older adults may
wear
excess
clothing
because
of
slowed
metabolism and loss of
subcutaneous fat, resulting in
cold intolerance
The client is clean and
groomed appropriately for
occasion. Stains on hands
and dirty nails may reflect
certain occupations such as
mechanic or gardener
***Asians
and
Native
Americans have fewer sweat
glands and, therefore, less
obvious body odor than most
Caucasians
and
black
Africans who have more
sweat glands. Additionally,
some cultures do not use
deodorant cultures
Observe posture and gait
Posture
is
erect
and
comfortable for age. Gait is
rhythmic and coordinated
with arms swinging at side
Uncoordinated
clothing,
extremely light clothing, or
extremely warm clothing for
the weather conditions may
be seen on mentally ill,
grieving, depressed, or poor
clients. This may also be
noted in clients with heat or
cold intolerances. Extremely
loose clothing held up by
pins or a belt may suggest
recent weight loss. Clients
wearing long sleeves in
warm weather may be
protecting themselves from
the sun or covering up
needle marks secondary to
drug abuse. Soiled clothing
may indicate homelessness,
elderly, vision deficits, or
mental illness.
A dirty, unshaven, unkempt
appearance with a foul body
odor may reflect depression,
drug abuse, or low socioeconomic level (ex. a
homeless
client).
Poor
hygiene may be seen in
dementia or other conditions
that indicate a self-care
deficit. If others care for the
client, poor hygiene may
reflect neglect by caregiver
or caregiver role strain.
Breath odors from smoking
or from drinking alcoholic
beverages may be noted as
diet-related odors such as
garlic or soy products
Curvatures of the spine (ex.
lordosis, scoliosis, kyphosis)
may indicate a disorder in
the musculoskeletal system.
Stiff, rigid movements are
common in arthritis or for
those
with
Parkinson’s
disease. Slumped shoulders
may signify depression. In
addition, clients who suffer
from chronic pulmonary
obstructive disease tend to
lean forward, and brace
themselves with their arms.
Tense or anxious clients
may
elevate
shoulders
toward their ears and hold
the entire body stiffly.
Observe body build as A wide variety of body types
well as muscle mass and fall within a normal range:
fat distribution
from small amounts of both
fat and muscle to large
amounts of muscle and/or fat.
In general, the normal body is
proportional.
***For the older adults,
osteoporotic thinning and
collapse of the vertebrae
secondary to bone loss may
results to kyphosis. In older
men, gait may be wider
based with arms held
outward. Older women tend
to have a narrow base and
may waddle to compensate
for a decreased sense of
balance. Steps shorten with
decreased speed and arm
swing. Mobility may be
decreased, and gait may be
rigid
A lack of subcutaneous fat
with prominent bones is
seen in the under nourished.
Abundant fatty tissue is
noted in obesity.
MENTAL STATUS ASSESSMENT
This exam helps the nurse to determine the client’s emotional or cognitive functional
statuses. Although this exam assesses the functioning of the neurological system, it can still
be included in this part of the exam if the nurse detects any abnormalities related to it. The
mental status exam provides information about the cerebral cortex function. Cerebral
abnormalities disturb the client’s intellectual ability, communication ability, or emotional
behaviors. This exam also provides clues regarding the validity of the subjective information
provided by the client. For example, if the nurse finds that the client’s thought processes are
distorted and memory is impaired, another means of obtaining subjective data should be
identified because the client may not be capable of being a reliable historian of his health
history. Therefore, the nurse can then take measures to adjust the rest of the assessment
and refer to other health team members as necessary. For example, a client may have a
short-term memory loss. Therefore, asking this client what she ate an hour ago may result in
collection of invalid data. If the client has extreme impaired mental health such as
schizophrenia, the data offered by the client may also be incorrect.
Assessment of a client’s mental status includes determining the client’s level of
consciousness, noting posture and body posture and body movements; and evaluating dress,
grooming and hygiene, facial expression, speech, mood, feelings, and expressions, thought
processes and perceptions, and cognitive abilities. Normally, the entire mental status exam is
performed only in certain situations. These situations include but are not limited to history of
mental illness, behavioral changes, memory loss, or brain lesions or injuries. Sometimes it
may be appropriate to perform the Mini-Mental State Examination (done later in the
neurological assessment). The aforementioned tool is quick, easy to use, and can be
repeated to monitor the client’s improving or deteriorating progress; however, it is important
to note that it assesses only the client’s cognitive functions and does not assess the client’s
thought processes or moods.
ASSESSMENT TECHNIQUES
ASSESSMENT
NORMAL FINDINGS
PROCEDURE
Observe the client’s level Client is alert and oriented to
of consciousness.
what is happening at the time
of the interview and physical
Ask the client his / her assessment. Client responds
name, address, and phone to your questions and
number.
interacts appropriately.
Observe behavior, body Client is cooperative and
movements, and affect
purposeful in his or her
interactions with others. Mild
to moderate anxiety may be
normal in a client who is
having a health assessment
performed.
Affect
is
appropriate for the client’s
situation.
Observe facial expression
Facial features are symmetric
with
movement.
Client
establishes good eye contact
when conversing with others.
Smiles
and
frowns
appropriately
Listen to speech. Note Speech is clear, moderately
style and pattern.
paced,
and
culturally
appropriate
***Normally, in older adults,
responses may be slowed
but speech should be clear
and moderately paced
Observe mood, feeling,
and
expressions.
Ask
client, “How are you feeling
today?”
ABNORMAL FINDINGS
Lethargy,
obtundation,
stupor, and coma are seen
in various conditions such
as neurologic disorders and
cerebrovascular disorders
Uncooperative,
bizarre
behavior may be seen in the
angry, mentally ill, or violent
client. Anxious clients are
often fidgety and restless.
Some degree of anxiety is
often seen in ill clients.
Apathy or crying may be
seen
with
depression.
Incongruent behavior may
be seen in clients who are in
denial of problems.
***In the older adults,
purposeless
movements,
wandering, aggressiveness,
or withdrawal may indicate
neurological deficits
Poor eye contact is seen in
depressed
clients.
An
expressionless,
masklike
face is common among
those who have Parkinson’s
disease. On the other hand,
staring, and watchfulness
appear in some metabolic
disorders and anxiety. In
addition, inappropriate facial
expressions (ex. smiling
when
expressing
sad
thoughts)
may
indicate
mental illness. Drooping or
gross asymmetry occurs
with neurologic disorder or
injury (ex. Bell’s palsy or
stroke)
A disorganized speech, a
consistent (nonstop) speech
or long periods of silence
may indicate mental illness
or a neurologic disorder
(ex. dysarthria, dysphasia,
speech
defect,
garbled
speech)
MEASUREMENT OF HEIGHT AND WEIGHT
The general level of a person’s health can be reflected in the ratio of height and weight. It is
normal for a client’s weight to vary each day because of fluid loss or retention.
 If the client has experienced a change in weight:
o Determine the amount
o Assess the period of time over which the weight change occurred
o Determine possible causes for weight loss such as change in diet habits,
appetite, or physical symptoms (ex. nausea)
 Weigh clients capable of bearing weight on a standing scale. Use a stretcher scale for
clients who are unable to bear weight.
o Calibrate the scale by setting the weight at zero and noting whether the balance
beam registers in the middle of the mark. Scales with a digital display should
read zero before use.
o Have client stand on scale platform and remain still
o Adjust scale weight on the balance beam until the tip of the beam registers in
the middle of the mark. Weight is measured in pounds or kilograms (2.2lb =
1kg). Digital scales display results in seconds.
 With the client standing erect on a scale, raise the metal rod attached to the scale up
and over the client’s head. The rod should be placed level horizontally at a 90-degree
angle to the measuring stick. Height is measured in inches or centimeters.
MEASUREMENT OF THE CLIENT’S VITAL SIGNS
Pulse, respiration, blood pressure, temperature are the body’s indicators of health. Usually,
when a vital sign (or signs) is abnormal, something is wrong in at least one of the body
systems.
The nurse usually begins the “hands-on” physical examination by taking vital signs. This is a
common, non-invasive physical assessment procedure that most clients are accustomed to.
Vital signs provide data that reflect the status of several body systems including but not
limited to the cardiovascular, neurological, peripheral vascular, and respiratory systems.
Measure the client’s temperature first, followed by the pulse, respirations, and blood
pressure. Measuring the temperature puts the client at ease and causes him or her to remain
still for several minutes. This is important because pulse, respirations, and blood pressure are
influenced by anxiety and activity. By easing the client’s anxiety and keeping him or her still,
the nurse helps to increase the accuracy of the data.
TEMPERATURE
*** Normal Values ***
Site
Oral
Rectal
Axillary
Tympanic
Fahrenheit
97.6 – 99.6
98.6 – 100.6
96.6 – 98.6
98.6 – 100.6
Celsius
36.5 – 37.4
37.0 – 38.1
36.0 – 37.0
37.0 – 38.1
PULSE RATE
•
•
•
•
•
•
Normal Rate = 60 – 100 bpm
Mean / Average = 80 bpm
May be as low as 50 bpm in healthy athletes
Regular in rhythm
Equal bilaterally in strength / amplitude
The amplitude of the pulse rate can be quantified as follows:
 1+ thready or weak (easy to obliterate)
 2+ normal (obliterate with moderate pressure)
 3+ bounding ( unable to obliterate or requires very firm pressure)
• Deviations from normal pulse rate:
 > 100 bpm = TACHYCARDIA
o Anxiety, fear, nervousness
 < 60 bpm = BRADYCARDIA
o Prolonged sitting or standing
 PULSE DEFICIT
o Difference between the apical and the radial pulse
RESPIRATORY RATE
• Normal Rate = 12 – 20 cpm
• Regular and spontaneous rhythm
• Equal bilateral chest expansion of 1 – 2 inches
TYPES OF RESPIRATION
TYPE
NORMAL / EUPNEA
APNEA
BRADYPNEA
TACHYPNEA
HYPERVENTILATION
HYPOVENTILATION
CHEYNE – STOKES
KUSSMAUL
DESCRIPTION
12 – 20 cpm and regular
Absence of respiration
Slow, shallow respiration
More than 20 cpm and regular
Increased rate and depth
Decreased rate and depth
Periods of apnea and hyperventilation
Very deep with normal breathing
BLOOD PRESSURE
CLASSIFICATION OF BLOOD PRESSURE
CLASSICATION
SBP in mmHg
DBP in mmHg
OPTIMAL
< 120
< 80
NORMAL
< 130
< 85
HIGH NORMAL
130 – 139
85 - 89
STAGE 1 Hypertension
140 – 159
90 – 99
STAGE 2 Hypertension
160 – 179
100 – 109
STAGE 2 Hypertension
> 180
> 110
Factors Affecting Blood Pressure:
1. Cardiac output
• Blood pressure increases with increased cardiac output and decreases
with decreased cardiac output
2. Distensibility of the arteries
• Blood pressure increases when more effort is required to push blood
through stiffened arteries
3. Blood volume
• Blood pressure increases with increased volume and decreases with
decreased volume
4. Blood velocity
• Blood pressure increases when blood flow is slowed due to resistance
and decreases when blood flow meets no resistance
5. Blood viscosity (thickness)
• Blood pressure increase when the blood is thickened and decreases with
thinning of the blood
A client’s blood pressure will normally vary throughout the day due to external
influences. These include the time of day, caffeine or nicotine intake, exercise,
emotions, pain, and temperature. The difference between systolic and diastolic
pressure is called the pulse pressure. The pulse pressure should be determined after
the blood pressure is measured because it reflects the stroke volume – the volume of
blood ejected with each heartbeat.
Blood pressure may also vary depending on the positions of the body and of the arm.
Blood pressure in a normal person who is standing is usually slightly higher to
compensate for the effects of gravity. Blood pressure in a normal reclining person is
slightly lower because of decreased resistance.
PAIN ASSESSMENT
Pain is considered as the 5th vital sign and its screening is very important in developing a
comprehensive plan of care for the client. Therefore, it is essential to assess for pain at the
initial assessment. When pain is present, it is important to identify the location, intensity,
quality, duration, and any alleviating or aggravating factors to the client.
ASSESSMENT TECHNIQUES
ASSESSMENT
PROCEDURE
Observe comfort level
NORMAL FINDINGS
ABNORMAL FINDINGS
Client assumes a relatively Facial expression indicates
relaxed
posture
without discomfort (ex. grimacing,
excessive position shifting. frowning). Client may brace
Facial expression is alert and or holds body part that is
pleasant
painful. Breathing pattern
indicates distress (shortness
of breath, shallow, rapid
breathing)
Ask the client if he or she No subjective report of pain
Subjective report of pain,
has any pain
assess further for location,
intensity,
quality,
and
duration
DOCUMENTATION OF FINDINGS
Sample Objective Data:
 Posture is erect and gait is smooth.
 Neatly dressed on lightweight clothes appropriate for summer season.
 Clean nails, well groomed.
 Well-developed body built for age with even distribution of fat and firm muscle.
 Client is alert, friendly, cooperative, and answers questions with good eye contact.
 Smiles and laughs appropriately.
 Speech is fluent, clear, and moderately paced.
 Thoughts are free flowing.
 Able to recall recent events earlier in day (ex. What she had for breakfast) without
difficulty
 With height of 5’4” and weight of 60 kilos
 With vital signs of:
o T = 37.2˚C
o PR = 84 bpm, regular, bilateral, equally strong and resilient
o RR = 16 cpm, regular, equal bilateral chest expansion
o BP = 120/80 mmHg, bilateral arms
APPROPRIATE NURSING DIAGNOSES
Wellness Diagnosis
 Health-Seeking behaviors related to desire and request to learn more about health
promotion
Risk Diagnoses
 Risk for activity intolerance related to deconditioned status
 Risk for self-directed violence related to depression, suicidal tendencies,
developmental crisis, lack of support systems, loss of significant others, poor
coping mechanisms and behaviors
Actual Diagnoses
 Impaired verbal communication related to hearing loss
 Impaired verbal communication related to inability to clearly express self or
understand others (aphasia)
 Impaired verbal communication related to aphasia, psychological impairment, or
organic brain disorder
 Acute or chronic confusion related to dementia, head injury, stroke, alcohol or drug
abuse
 Impaired memory related to dementia, stroke, head injury, alcohol or drug abuse
 Dressing/grooming self-care deficit related to impaired upper-extremity mobility
and lack of resources
 Bathing/hygiene self-care deficit related to inability to wash body parts or inability
to obtain water
 Disturbed thought processes related to alcohol or drug abuse, psychotic disorder,
or organic brain dysfunction
 Pain related to stimulation of the nerve endings.