ASSESSING GENERAL STATUS

• General survey


  1. Is the first part of the physical examination that begins the moment the nurse meets the client

  2. Provides the nurse with an overall impression of the client’s whole being
• Components of general survey

  • Physical development and body build
  • Gender and sexual development
  • Apparent age as compared to reported age
  • Skin condition and color
  • Dress and hygiene
  • Posture and gait
  • Level of consciousness
  • Behaviors, body movements and affect
  • Facial Expression
  • Speech
  • Vital signs
• Indicators of health


  • Temperature
  • Pulse
  • Respirations Vital Signs
  • Blood pressure
  • Pain
• Temperature


  • The normal core body temperature is 36.5°C to 37.7°C (96°F and 99.9°F orally)
  • Body temperature is lowest early in the morning (4:00 to 6:00 AM)
  • Body temperature is at its highest late in the evening (8:0 PM to midnight)
  • Hypothermia (lower than 36.5°C or 96.0°F) causes include prolonged exposure to cold, hyperglycemia, hypothyroidism, starvation
  • Hyperthermia (higher than 38.0°C or 100.0°F) causes include viral and bacterial infections, malignancies, trauma, various blood, endocrine, and immune disorders
• Pulse


  • Rate is 60-100 beats per minute
  • Rhythm can be regular or irregular
  • Amplitude and contour
  • Elasticity indicates the ease of measurement
• Respiration


  Common terms include Tachypnea, Apnea, Dyspnea, Eupnea
• Blood pressure


  • Reflects the pressure exerted on the walls of the arteries
  • Expressed as the ratio of systolic pressure over diastolic pressure
  • Factors affecting blood pressure include cardiac output, elasticity of arteries, blood volume, blood velocity, peripheral vascular resistance, blood viscosity
  • Common terminologies include Hypertension, Hypotension, Normotension
• Pain


  • COLDSPA assessment method: Character, Onset, Location, Duration, Severity, Pattern, Associated Factors
  • FLACC SCALE for pain measurement
• Mental status


  • Refers to the client’s level of cognitive and emotional functioning
  • State of well-being where an individual realizes abilities, copes with stresses, works productively, and contributes to the community
  • Factors affecting mental health include economic and social factors, unhealthy lifestyle choices, exposure to violence, personality factors, spiritual factors, cultural factors, neurologic system changes, psychosocial development level and social issues
• Factors affecting mental health

  • Spiritual factors
  • Cultural factors
  • Changes or impairments in the structure and functions of the neurologic system
  • Psychosocial development level and social issues
• Mental Status Assessment Tool
• Mental Status Examination (MSE) is a medical examination; an extension of the physical exam
• Elements of MSE include:
• Quick Inventory of Depressive Symptomatology is a measure of depressive signs and symptoms
• Interpretation of QIDS scores:
• World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) is a screening tool sensitive to early detection of risky and high-risk drinking
• Interpretation of AUDIT scores:
• Developmental Stages, Tasks, and Life Events
• Developmental Theories: