Lippincott Nursing Pocket Card - June 2024
General Assessment
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Introduction
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Focused general assessment begins with taking a detailed health history regarding constitutional symptoms. This examination involves a general survey of the patient, measurement of vital signs, and pain assessment.
Optimal Patient Positioning
- Examine the patient in a position of their choosing to promote patient comfort.
- This may be performed with the patient fully dressed.
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Exam methods
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- Observational assessment
- Note patient’s level of consciousness, mood, and behavior, as well as any signs of distress.
- Note patient’s gait and any movement abnormalities, such as limping.
- Include general appearance, grooming, dress, facial expressions, eye contact, odors, and posture.
- Document the patient’s description of their current state of health.
- Describe the patient’s distinguishing characteristics, such as tattoos, scars, amputations, or other unique features.
- Observe for signs of distress, noting type and response.
- Vital signs
- Measure height and weight to determine body mass index (BMI).
- Measure blood pressure in both upper extremities, ensuring properly sized cuff.
- Isolated hypertension may be situational, such as “white coat syndrome.”
- Home BP monitoring may reveal better control.
- Measure orthostatic blood pressure if indicated.
- Examine pulse rate and rhythm by palpating the radial pulse.
- Normal rate falls between 60-90 beat per minute, although it may be altered due to medications or medical conditions.
- Pulse should be counted for a full minute, particularly if irregular.
- Rhythm should be regular. Abnormalities include irregularly irregular and regularly irregular.
- Examine the quality of peripheral pulses.
- Radial pulse is most commonly assessed due to accessibility.
- Pulses should be strong, but not bounding.
- Observe respiratory rate and quality of breathing.
- Normal respiratory rate is 12-20 breaths per minute in an adult.
- Breathing should be regular, although an occasional sigh is normal.
- Observe for equal chest expansion on inspiration.
- Measure and note temperature.
- Temperature may be measured in several ways.
- Oral and rectal temperatures remain the most common, with oral temperatures usually slightly lower than the core temperature and rectal being more accurate to the core temperature.
- Temporal and tympanic temperatures can be variable, and dependent on the user.
- Axillary temperatures are the least accurate and take at least 5-10 minutes to register.
- Pain assessment
- Onset/timing
- Note circumstances and timing of pain.
- Note causes of pain.
- Location
- Note where the pain is located.
- Note if the pain radiates to other areas.
- Duration
- Chronicity
- Acute pain defined as a predicted response to noxious stimulus.
- Chronic pain defined as lasting longer than 1 month beyond illness/injury recovery, lasting longer than 3-6 months due to chronic illness.
- Aggravating/alleviating factors
- Note if the patient experiences relief or aggravation with movement, rest, cold/heat, etc.
- Note if the pain has been relieved with any medications.
- Type of pain
- Somatic – emanates from muscles and soft tissues
- Neuropathic – emanates from nerves
- Visceral – emanates from deep structures/organs
- Document the pain as the patient describes it.
- Severity
- Utilize rating scales to assist in obtaining baseline.
- Utilize same scale to evaluate the effectiveness of interventions.
- Note patient’s baseline level of pain in those with chronic pain.
PEARLS
- Provide privacy for the patient; interview the patient alone to allow for personal questions they might be reluctant to discuss with others present.
- Orthostatic blood pressures may be indicated in patients presenting with syncope or near-syncope, dizziness, tachycardia, or palpitations.
- Ensure the use of a properly sized cuff, as erroneous values can be obtained with a cuff that is either too small or too large.
- In documenting the general assessment, be as descriptive as possible to create a visual depiction of the patient.
- Elicit from the patient what expectations they have for pain relief.
Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.