HEALTH ASSESSM

ENT
IN NURSING
Prepared by:
Mark Joseph V. Liwanag,RN,MSN
Assessing General Status
GENERAL SURVEY
 GENERAL SURVEY
 first part of the physical exam that begins the moment the
nurse meets the client.
 It requires the nurse to use all of her observational skills
while interviewing and interacting with the client.
 Outcome: provides the nurse with an overall impression of
the client’s whole being.
GENERAL
SURVEY
It is a study of the whole
person,
covering the general health
state and any obvious physical
characteristics.
It should give an overall
impression, “a gestalt”, of the
person
 PURPOSES

01 Conduct general survey of the client’s

health by gathering subjective and
objective data.
02 Use collected data to help assess client’s
general health.

03 Differentiate expected versus unexpected

findings in the physical assessment.
 PREPARATIONS

 Knowledge of norms or
expected findings is essential in
determining the meaning of the
data as one proceeds.
 Identify client and introduce self.
 Provide the client for privacy.
 Perform hand hygiene and
adhere to standard precautions.
MAJOR INDICATORS FOR GENERAL SURVEY
Physical Personal
Appearance Hygiene

Body
Behavior
Structure

Mobility Dress
 PHYSICAL APPEARANCE

The person appears Appears older than stated years

AGE
his/her stated age (Chronic alcoholism, chronic Illness)
 PHYSICAL APPEARANCE
SEX
sexual development is
M (9- Delayed or precocious
appropriate for gender and
14) puberty
age
F (8-13)
 PHYSICAL APPEARANCE
the person is alert and
oriented, attends to
LOC questions and responds
Confused, drowsy, lethargic

appropriately
 PHYSICAL APPEARANCE
SKIN Color tone is even, skin is intact Pallor, cyanosis, jaundice,
COLOR with no obvious lesions erythema, any lesions
 PHYSICAL APPEARANCE

FACIAL FEATURES Symmetric Asymmetric, drooping, masklike

 PHYSICAL APPEARANCE
No signs of Distress DOB, Pain, Facial Grimace
 BODY STRUCTURE
STATUR The ht. appears within the Excessively short or tall,
E normal range for age dwarfism, gigantism
 BODY STRUCTURE
NUTRITI Wt. appears within normal Underweight, overweight,
ON range for ht. obesity
 BODY STRUCTURE
SYMMET  Asymmetric body
 Body parts look equal
part,
RY bilaterally and are relatively
unilateral atrophy
& proportion to each other
 Shoulders slumped,
POSTUR  stand comfortably erect at
rigid spine and neck
E appropriate for age
 BODY STRUCTURE
Person sits comfortably in a chair
Tripod, curled up in fetal
POSITION or on the bed examination table,
position
arms relax at sides
 BODY STRUCTURE
Body build, Missing extremities or digits,
Body parts are proportion
Contour not proportion extremities
 MOBILITY
foot placement is accurate, walk Shuffling, dragging,
GAIT smooth, even and we-balanced non-functional leg
 MOBILITY
RANGE note full mobility for each joint,
Limited joint range of motion,
and that movement is deliberate,
OF accurate, smooth, and
paralysis(absent of
movement)uncoordinated
MOTION coordinated
 BEHAVIOR
Facial Expression - expressions are appropriate
Flat, depresses, angry, sad, anxious
to the situation

Mood and affect - comfortable and cooperative

Distrustful, suspicious, crying
with the examiner and interacts pleasantly

Speech - articulation is clear and Dysphagia, speech defect, garbled speech,

understandable, conveys ideas clearly extremes of few words or of constant talking
 DRESS
Consistent wear of certain clothing
Clothing is appropriate to the climate,
may provide clues; long sleeves may
looks clean, and fits the body, and is
conceal needle marks of drug abuse.
appropriate to the person’s culture and
Wearing fitted dress may some how
age group.
indicate hiding pregnancy.
 PERSONAL HYGIENE
Person appears clean and groomed Lack of grooming may
appropriately for his/her age, occupation
and socioeconomic growth. However, become sources of
culture consideration must be valued. diseases.
Deviations Related to Physical Development, Body Bui
ld, and Fat Distribution

Your Picture Here

occurs when there is short

supply of GH in childhood.

DWARFISM
Deviations Related to Physical Development, Body Bui
ld, and Fat Distribution

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GIGANTIS
M
Deviations Related to Physical Development, Body Bui
ld, and Fat Distribution

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ACROMEGAL
Y
Deviations Related to Physical Development, Body Bui
ld, and Fat Distribution

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Cushing’s
syndrome
Thank You!
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