02.01 General Assessment (Physical assessment)

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Included In This Lesson

Study Tools

Outline

Overview

  1. The general assessment includes things you can observe on initial encounter with the patient
  2. It requires some interview, but very little hands-on assessment

Nursing Points

General

  1. Information to be gathered
    1. Alertness
    2. Patient identifiers
    3. Hygiene
    4. Signs of distress
    5. Emotions
    6. Affect
    7. Posture
    8. Skin appearance
    9. Sensory deficits (generally)
      1. Hearing
      2. Speech
      3. Vision
    10. Pain/general feeling
    11. Full set of vital signs

Assessment

    1. Recommended order of actions + what will be assessed with those actions
      1. Walk in the room
        1. Is the patient awake/alert?
        2. If not – call name, then gently shake, then increasingly noxious stimuli to wake
      2. Introduce yourself to the patient
        1. Can they hear/see you?
        2. How do they respond?
      3. Obtain 2 patient identifiers
        1. How is their speech quality?
        2. Do they seem confused?
        3. Are there any barriers to communication?
      4. Ask the patient how they are feeling
        1. How is their mood?
        2. Is their affect appropriate?
        3. Are they in pain?
      5. Assess general appearance
        1. How is their hygiene? Do they appear unkempt?
        2. Do they appear to be in distress?
          1. Rapid breathing
          2. Grimacing
          3. Restlessness
        3. How is their skin color, on first glance? Jaundiced? Cyanotic? Pale? Flushed?
        4. Are they sitting upright with good posture?
      6. Take a full set of vital signs
    2. Abnormal findings
      1. Inappropriate affect
        1. If the patient reports one emotion/mood, but their facial expressions show another
      2. Unconscious – see neuro assessment
      3. Signs of distress
        1. Rapid abnormal breathing
        2. Grimacing
        3. Restlessness
        4. Crying
      4. Abnormal skin colors
        1. Jaundice – liver
        2. Cyanosis – oxygen
        3. Pallor – perfusion
        4. Flushed – pain, inflammation, fever, etc.

Nursing Concepts

  1. If you note any signs of distress, stop your assessment and intervene before continuing
  2. If you note any extremely abnormal vital signs, investigate and report your findings before continuing
  3. If you note any communication barriers, implement alternative options before continuing
    1. Translator
    2. Writing pad
    3. Picture board
    4. Etc.
  4. Make note of any abnormal findings so that you can document them with your assessment later

Patient Education

  1. At this stage, inform the patient that you will be doing a full head to toe assessment, what that entails, and why

Transcript

In this video we’re going to talk about the general portion of your head to toe assessment. This is the first 2 minutes of interaction with your patient and it can tell you a LOT of information before you even lift a finger to assess them!
The first thing you’ll do is walk in the room and introduce yourself to your patient.

You’ll already be noticing their level of alertness, general appearance, posture, etc. Then you’re gonna ask for your 2 patient identifiers. If they give you correct answers, you know they’re likely not confused, they can hear you, and you can assess their speech quality as well.

Then, ask them how they’re feeling or if they’re in any pain. This is a huge part of the assessment. If the patient says “I feel great”, but they’re tearful and look upset – we know something’s off. So we can assess their emotions and whether or not their affect is appropriate based on what they’re telling us.

We also can observe if they’re in any distress – how’s their breathing? Are they grimacing? Do they visibly look uncomfortable. We can see the patient here looks nice and calm, isn’t breathing heavy, and doesn’t look like she’s in any distress.

While you’re talking to them, make sure you’re looking at their general posture, are they sitting upright? How’s their hygiene? Do they appear to be unkempt? And, of course, we can see their basic skin color – looking for jaundice, cyanosis, paleness, or if they seem flushed. This patient looks tan with a normal skin tone for her ethnicity, so that’s a normal finding. Once you’ve completed your observations, take a full set of vital signs.

Big points to note here – if you note any distress, stop your assessment and intervene. If you have any abnormal vital signs, stop your assessment and address them. If there are any communication barriers to overcome, make sure you do that before you continue. And, of course, make note of any abnormal findings so that you can document them later.
So that’s your general health assessment, make sure you watch the other health assessment videos and you’ll be an expert at a full head to toe assessment in no time. Now, go out and be your best self today. And, as always, happy nursing!