The

general survey is the first step in a headto-toe assessment. The information gathered during the general survey provides clues about the overall health of the client. The general survey includes: a. Overall impression of the client this impression requires objective observation skills to assess the clients appearance, mobility, and body build. b. Mental Status Exam this exam helps to determine the clients emotional and cognitive functional status.

 Vital

Signs pulse, respiration, blood pressure, temperature, and pain are the bodys indicators of health. - Pain is considered to be the 5th vital sign. It is inexpensive to assess and does not involve the use of fancy instruments yet it can be an early predictor of impending disability.

 Forming

an overall impression consists of systematic examination and recording these general characteristics and impression of the client. Assess overall wellness or health of the client. Observe any significant abnormalities in the clients skin color, dress, hygiene, posture, gait, and body build, level of consciousness, level of comfort, behavior, body movements, affect, facial expression, speech and mental acuities.

 It

includes determining the clients level of consciousness, noting posture, and movements; and evaluating dress, grooming and hygiene, facial expression, speech, mood, feelings, and expressions, thought process and perceptions, and cognitive abilities. Mini-Mental State Examination this tool is quick, easy to use, and can be repeated to monitor the clients improving or deteriorating progress. - it is important to note that it assesses only the clients cognitive functions and does not assess the clients thought processes or moods.

 Non-invasive

physical assessment procedure that most clients are accustomed to. It provides data that reflect the status of several body systems including but not limited to the cardiovascular, neurological, peripheral vascular, and respiratory systems. Includes: temperature, pulse, respirations, blood pressure and pain.

 For

the body to function on cellular level, a core body temperature between 36.5C and 37.7C Several factors may cause normal variations in the core temperature like strenuous activities, stress and hormones (ovulation). Body temperature is lowest early in the morning (4-6am) and highest late in the evening (8pm-midnight).

shockwave is produced when the heart contracts and forcefully pumps blood out of the ventricles into the aorta. Then it travels along the fibers of the arteries and is commonly called arterial or peripheral pulse. Several characteristic should be assessed when measuring the pulse rate, rhythm, amplitude and contour, and elasticity. Amplitude can be quantified as: 1+ Thready or weak (easy to obliterate) 2+ Normal (obliterate to moderate pressure) 3+ Bounding (unable to obliterate or requires very firm pressure)

 Respiration

can easily observed without alerting the client by watching the chest movement. Notable characteristics of respiration are rate, rhythm, and depth.

 It

reflects the pressure exerted on the walls of the arteries. This pressure varies with the cardiac cycle, reaching a high point with systolic and a low point with diastole. It is expressed as the ratio of the systolic pressure over the diastolic pressure. Blood pressure is affected by: a. Cardiac output b. Distensibility of the arteries c. Blood volume d. Blood velocity e. Blood viscosity

 Pulse

Pressure difference between systolic and diastolic pressure. it reflects the stroke volume, the volume of blood ejected with each heartbeat.

 Pain

screening is very important in developing a comprehensive. It is important to identify the location, intensity, quality, duration and any alleviating or aggravating factors. Pain intensity measurement tools such as a 1-10 Likert scale may be used. Pain quality may be described as dull, sharp, radiating or throbbing.

 Character: Describe the signs or symptoms.

Onset: When did it begin? Location: Where is it? Does it radiate? Duration: How long it last? Does it recur? Severity: How bad is it? Pattern: What makes it better? Worse? Associated Factors: what other symptoms occur with it?

Assessment Procedure
GENERAL APPEARANCE Observe physical and sexual development.

Normal Findings

Abnormal Findings

Sexual development is appropriate for gender and age.

Include delayed puberty, male client with female characteristics, and female client with male characteristics. Client appears older that actual chronologic age.

Compare clients stated Client appears to be her age with her apparent stated chronologic age. age and developmental stage. Observe skin condition and color.
Color is even without obvious lesions: loght to dark beige-pink in lightskinned client: light tandark brown or olive in darkskinned clients.

Extreme pallor, flushed, or yellow in light-skinned client; loss of red tones and ashen gray cynosis in darkskinned client.

Observe dress.

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 clients developmental level, age, socioeconomic level, culture or subculture.

Uncoordinated clothing, extremely light clothing or 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 intolerance. Extremely loose clothing held up by pins or a belt 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. Poor hygiene may be seen in dementia or other conditions that indicate a self-deficit. If the client is cared for by others, poor hygiene may reflect neglect by caregiver.

Observe hygiene.

The client is clean and groomed appropriately for occasion. Stains on hands and dirty nails may reflect certain occupations such as mechanic or gardener.

Observe posture and gait.

Posture is erect and comfortable for age. Gait is rhythmic and coordinated with arm swinging at side.

Curvature of spine indicates a musculoskeletal disorder. Stiff, rigid movements are common in arthritis or Parkinsons disease. Slumped shoulders may signify depression. Client with chronic pulmonary obstructive disease tend to lean forward, brace themselves with arms.

Observe body build as well as muscle mass and fat distribution

A wide variety of A lack of subcutaneous fat with prominent body types fall within bones is seen in malnourished. Abundant a normal range: from fatty tissue is noted in obesity. small amounts of both fat and muscle to large amount of muscle/and or/fat. In general, the normal body is proportional.

MENTAL STATUS Observe the clients level of consciousness. Ask the client his/her name, address, and phone number. Observe behavior, body movements, and affect.

Client is alert and oriented to what is happening at the time of the interview and physical assessment. Client responds to your questions and interacts appropriately. Client is cooperative and 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. Facial features are symmetric with movement. Client establishes good eye contact when conversing with others. Smiles and frowns appropriately.

If the client does not respond appropriately. Lethargy, obtundation, stupor, and coma are seen in various conditions such as neurologic disorders and cerebrovascular disease. Uncooperative, bizarre behavior may be seen in the angry, mentally ill or violent client. Apathy or crying may be seen with depression. Incongruent behavior may be seen in clients who are in denial of problems or illness.

Observe facial expression.

Poor eye contact is seen in depressed clients. An expressionless, masklike face is common in Parkinsons disease. Staring, watchfulness appears in metabolic disorders and anxiety, inappropriate

Facial expressions. May indicate mental illness. Drooping or gross asymmetry occurs with neurologic disorder or injury.

Listen to speech. Note style and pattern. Observe mood, feeling, and expression. Ask client, how are you today?

Speech is clear, moderately paced, and culturally appropriate.

Disorganized speech, consistent speech, or long periods of silence may indicate mental illness or a neurologic disorder.

The 18 items below refer to how you have felt and behaved during the past week. For each item, indicate the extent to which it is true, by checking the appropriate box next to the item. 1. I do things slowly. Not at all Just a little Somewhat Moderately Quite a lot Very much 2. My future seems hopeless. Not at all Just a little Somewhat Moderately Quite a lot Very much 3. It is hard for me to concentrate on reading. Not at all Just a little Somewhat Moderately Quite a lot Very much 4. The pleasure and joy has gone out of my life. Not at all Just a little Somewhat Moderately Quite a lot Very much

5. I have difficulty making decisions. Not at all Just a little Somewhat Moderately Quite a lot Very much 6. I have lost interest in aspects of life that used to be important to me. Not at all Just a little Somewhat Moderately Quite a lot Very much

7. I feel sad, blue, and unhappy. Not at all Just a little Somewhat Moderately Quite a lot

8. I am agitated and keep moving around. Not at all Just a little Somewhat Moderately Quite a lot Very much 9. I feel fatigued. Not at all Just a little Somewhat Moderately Quite a lot Very much 10. It takes great effort for me to do simple things. Not at all Just a little Somewhat Moderately Quite a lot Very much

11. I feel that I am a guilty person who deserves to be punished. Not at all Just a little Somewhat Moderately Quite a lot Very much

12. I feel like a failure. Not at all Just a little Somewhat Moderately Quite a lot Very much 13. I feel lifeless -- more dead than alive. Not at all Just a little Somewhat Moderately Quite a lot Very much 14. My sleep has been disturbed -- too little, too much, or broken sleep. Not at all Just a little Somewhat Moderately Quite a lot Very much

15. I spend time thinking about HOW I might kill myself. Not at all Just a little Somewhat Moderately Quite a lot Very much

16. I feel trapped or caught. Not at all Just a little Somewhat Moderately Quite a lot Very much 17. I feel depressed even when good things happen to me. Not at all Just a little Somewhat Moderately Quite a lot Very much 18. Without trying to diet, I have lost, or gained, weight. Not at all Just a little Somewhat Moderately Quite a lot Very much

54 and up 36 - 53 22 - 35 18 - 21 10 - 17

Severely Depressed Moderate - Severe Mild - Moderate Borderline depression Possibly Mildly Depressed

0-9

No Depression Likely