PHYSICAL GENERAL SURVEY

Examination

Involves
OBSERVATION skills

Clues about the

Health status of the

ASSESSING
client

GENERAL HEALTH
Provides the nurse with
an overall impression of
PROF. JONAHLYN G. CORPUZ,MAN the client’s whole being

• PROF. JONAHLYN G. CORPUZ,MAN

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• PROF. JONAHLYN G. CORPUZ,MAN

GENERAL SURVEY GENERAL SURVEY

General
Components 1. General appearance (Body Build , Posture & Gait,
of health hx- Posture Grooming/Hygiene, Body odor & Breath odor, Signs of
appearance of body built Distress, Obvious Signs of Illness(es)

Measurement
Level of
comfort
of height and hygiene and Mental Status (Orientation:( time, person, place
weight ) and Level of Consciousness, Affect , Mood , Quantity &
Quality of Speech , Organization of thoughts:
Consideration: • Client’s age
Measurement
Mental status Mental status • Culture, • sex, and
of vital signs
• educational level, socio • Race
economic status, and “ are useful in interpreting
• Current circumstances findings.” for increase risk for
• PROF. JONAHLYN G. CORPUZ,MAN known conditions

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ASSESSING APPEARANCE AND MENTAL

1. Introduce self
STATUS
- Verify the client’s identity ASSESSING APPEARANCE AND MENTAL STATUS
- Explain to the client what you are
going to do, why it is necessary----- ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL
- and how he or she can cooperate.
• Discuss the result will be used
in planning further care and 1. Observe BODY BUILD Proportionate , Excessively thin or
treatments. • ECTOMORPH varies with lifestyle. obese.
• MESOMORPH
2. Perform hand hygiene and • ENDOMORPH
observe appropriate Consider :
infection control.
• Height, and weight, in
relation to the client’s :
3. Provide for client privacy • Age
• Lifestyle and
• Health.

• PROF. JONAHLYN G. CORPUZ,MAN • PROF. JONAHLYN G. CORPUZ,MAN

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 BODY BUILD BODY BUILD
PROF. JONAHLYN G. CORPUZ,RN,MAN

PROF. JONAHLYN G. CORPUZ,RN,MAN

• TYPICAL TRAITS OF • TYPICAL TRAITS ON A
AN MESOMORPH:
• ECTOMORPH: • naturally Athletic
• Small “delicate” frame physique
and bone structure • Generally hard body
• Classic “hard gainer” • responds the best to
• Flat chest weight training- Well
defined muscles
• Small shoulders
• Rectangular shaped
• Thin body
• Lean muscle mass
• Strong
• Finds it hard to gain • Gains muscle easily
weight
• Gains fat more easily
• Fast metabolism than ectomorphs

• PROF. JONAHLYN G. CORPUZ,MAN • PROF. JONAHLYN G. CORPUZ,MAN

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• TYPICAL TRAITS OF
AN
• ENDOMORPH:
• Soft and round body
• Gains muscle and fat
very easily
• Is generally short
• "Stocky" build
• Round physique
• Finds it hard to lose
fat
• Slow metabolism
BODY BUILD • Muscles not so well
defined

• PROF. JONAHLYN G. CORPUZ,MAN • PROF. JONAHLYN G. CORPUZ,MAN

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• PROF. JONAHLYN G. CORPUZ,MAN

WEIGHT
• Regular
HEIGHT • Measure in pounds or (lb) or kilograms (kg)
a. Remove shoes and stand erect. • Use the same scale (for accuracy)
• Same similar clothing everyday; no footwear
b. Back against the measuring stick.
• The client’s stand on a platform and read the
digital display panel
c. Eyes should be looking straight ahead.
Raise the stick until it rests on the client’s head • Clients who cannot stand are weighed on
and use a ruler or flat object to measure on the chair or bed scales
client’s head

• PROF. JONAHLYN G. CORPUZ,MAN

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 • PROF. JONAHLYN G. CORPUZ,MAN

ASSESSING APPEARANCE AND MENTAL STATUS

ABNORMAL -Excessively thin or obese
ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM
NORMAL

• Observe client’s Relaxed , erect - Tense,

posture and gait, posture; slouched ,
standing, sitting, coordinated bent posture ,
and walking movement uncoordinated
movement,
NORMAL Proportional tremors.

• PROF. JONAHLYN G. CORPUZ,MAN

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• PROF. JONAHLYN G. CORPUZ,MAN

Observe client’s POSTURE Observe client’s GAIT

- standing, sitting, and walking

• PROF. JONAHLYN G. CORPUZ,MAN

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• PROF. JONAHLYN G. CORPUZ,MAN • • PROF.

PROF.JONAHLYN
JONAHLYNG.
G.CORPUZ,MAN
CORPUZ,MAN

Observe client’s standing, sitting, and walking ASSESSMENT NORMAL FINDINGS

Relaxed , erect posture; coordinated movement

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 • PROF. JONAHLYN G. CORPUZ,MAN

ASSESSING APPEARANCE AND MENTAL STATUS

DEVIATIONS FROM NORMAL ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL
• Tense, slouched, bent posture, uncoordinated movement,
tremors. Observe overall hygiene and Well groomed, Dirty, unkempt
grooming. Relate these to Clean ,neat
client’s activities prior to
assessment.

• PROF. JONAHLYN G. CORPUZ,MAN

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• PROF. JONAHLYN G. CORPUZ,MAN • PROF. JONAHLYN G. CORPUZ,MAN

ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL

7.Note body and breath
odor in relation to activity
level
No body odor or minor Foul body odor, ammonia ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM
body odor relative to odor , acetone breath odor; NORMAL
work or exercise; foul breath
Observe for signs of No distress Bending over because
no breath odor.
distress in posture and of abdominal pain,
facial expression wincing,
frowning, and
labored breathing

Bad breath
• related to poor oral hygiene is most common and caused by release of
sulphur compounds by bacteria in the mouth.

Ammonia-like odor (also described as urine-like or "fishy") in people

with chronic kidney failure

Ketoacidosis can be smelled on aJONAHLYN

PROF. person's breath.
G. This is due to acetone PROF. JONAHLYN G.
CORPUZ,RN,MAN CORPUZ,RN,MAN
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• ASSESSMENT
PROF. JONAHLYN G. CORPUZ,MAN
NORMAL FINDINGS DEVIATIONS FROM NORMAL ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL

Note obvious Healthy Pallor , Assess the client’s Cooperative, Negative, hostile,
signs of health appearance weakness, attitude able to follow withdrawn
instructions,
or illness (e.g. lesions
Skin color or
breathing)

PROF. JONAHLYN G.
• PROF. JONAHLYN G. CORPUZ,MAN
CORPUZ,RN,MAN
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 ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL
• PROF. JONAHLYN G. CORPUZ,MAN

11. Note the client’s Appropriate to the Inappropriate to the

affect/mood; assess situation situation.
the appropriateness of
the client’s responses.
• Affect

Affect
• is described by such terms as constricted, normal range, appropriate
to context, flat, and shallow.

Mood
• refers to the feeling tone and is described by such terms as anxious,
depressed, dysphoric, euphoric, angry, and irritable. ...

• Lack of affect, in which emotional subjects are described in a detached

manner.
• PROF. JONAHLYN G. CORPUZ,MAN Appropriateness of the client’s responses

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• PROF. JONAHLYN G. CORPUZ,MAN

Appropriateness of the client’s responses ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL

Listen for: Understandable, Rapid or slow pace; overly

• MOOD quantity of speech (amount moderate pace; loud or soft; uses
and pace) clear tone and generalizations; lacks
quality (loudness, clarity, inflection; association.
inflection) and exhibits thought
organization (coherence of association
ANXIOUS thought, over generalization,
vagueness).
Over generalize
ANGRY Vagueness • draw a conclusion or make a
• lack of certainty or
statement about (something) that is
distinctness.
more general than is justified by the
• lack of preciseness in thought
available evidence.
or communication.

dyspONIC EUPHORIC
depression
PROF. JONAHLYN G.
CORPUZ,RN,MAN
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ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL ASSESSMENT NORMAL DEVIATIONS

FINDINGS FROM NORMAL
Listen for Logical Illogical sequence;
relevance and sequence; makes flight of ideas;
organization of sense; has sense confusion; vague 14.Document findings in
thoughts. of reality the client record using
handwritten or electronic
forms and checklists
Minimal or unusual connection
between ideas;
supplemented by narrative
notes went appropriate.
lack of understanding;
uncertainty.

PROF. JONAHLYN G. CORPUZ,RN,MAN

• PROF. JONAHLYN G. CORPUZ,MAN

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 • PROF. JONAHLYN G. CORPUZ,MAN
ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL

2. Measurement of Vital
Evaluation: Signs (BP,RR,PR,T) and
• Perform a detailed follow up examination of other
individual systems based on findings that
Anthropometric
deviated from expected or normal for the client for Measurement (Height and Weight)
the client.
• Relate findings to previous assessment data if
available.
Vital signs:
A. To establish baseline data which to compare future
• Report significant deviations from normal to the measurements
primary care provider
B. to detect actual and potential problem

• PROF. JONAHLYN G. CORPUZ,MAN

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ASSIGNMENT

MODULE- GENERAL SURVEY

SKILL:
• ASSESSING GENERAL APPEARANCE &
MENTAL STATUS

PROF. JONAHLYN G.
CORPUZ,RN,MAN
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• Description:
Assessment of the Mental status includes determining the
client’s level of consciousness; noting posture and body
movements; and evaluating dress; grooming and hygiene,
facial expression, speech, mood, feelings, and
expressions, thought processes and perceptions, and
cognitive abilities.

• Entire mental status examination is performed only in

certain situations include but not limited to history of
mental illness, behavioral changes, memory loss , or
brain lesions or injury.

• Assessment of the client’s mental status will provide an

information regarding the client’s level of cognitive
functioning and emotional stability. These data will be
useful to determine the reliability of the client’s
response throughout the any rest of the physical
examination.

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