NSG 302: Health Promotion and Assessment - General Survey and Vital Signs
General Survey Overview and Objectives
General Survey Definition: The general survey is an initial appraisal of a client’s overall presentation and behaviors. It provides a general health state and physical characteristics to form an overall impression.
Four Primary Areas of General Survey:
Physical Appearance: Age, sex, level of consciousness, skin color, and facial features.
Body Structure: Stature, nutrition, symmetry, posture, position, and body build/contour.
Mobility: Gait and range of motion.
Behavior: Facial expression, mood/affect, speech, and personal hygiene.
Objectives:
List information for the four general survey areas.
Discuss measurement of weight and height (including BMI).
Discuss relevant developmental care for infants, children, and aging adults.
Identify steps to perform the survey (Appearance, Behavior, Indicators of abuse/neglect, Body structure, Mobility, Measurements, Vital signs, Pain).
Describe expected and unexpected findings.
Discuss documentation of findings.
Data Types and Foundational Skills
Objective Data: Information that can be measured or observed through physical examination or diagnostic testing.
Subjective Data: Information based on the patient's perceptions, feelings, and concerns.
Foundational Actions:
Hand Hygiene: Must be performed prior to the assessment.
Environment: Create a suitable environment for assessment.
Introduction and Identification: Introduce oneself and identify the patient using two identifiers (e.g., name and date of birth).
Trust and Rapport: Establish a professional relationship.
Communication: Use both verbal and nonverbal communication; identify potential miscommunication.
Physical Appearance: Findings and Assessment
Age: Note if the patient appears their stated age.
Sex: Note development and presentation relative to stated sex.
Level of Consciousness (LOC):
Expected: Alert and oriented.
Unexpected: Confusion, Lethargy, Stupor, Obtundation, or Comatose.
Skin Color:
Expected: Tone is even and appropriate for ethnicity; skin is warm and intact.
Unexpected: Cool or hot temperature, diaphoresis (excessive sweating), clamminess, or tone variations.
Facial Features:
Expected: Symmetric features.
Unexpected: Expressionless, asymmetry, involuntary movements, swelling, or lesions.
Emotional State:
Expected: Relaxed, smiling, and responsive.
Unexpected: Restless, grimacing, or quiet emotions.
Eye Contact:
Expected: Direct eye contact.
Unexpected: Avoidance (unless culturally inappropriate), squinting, or staring.
Behavior and Hygiene
Speech:
Expected: Normal fluency, pace, and articulation.
Unexpected: Whispering, disarticulation, absence of speech, or abnormal tone/pace.
Mood and Affect:
Expected: Pleasant and cooperative.
Unexpected: Inappropriate responses, flat affect, or expressionless demeanor.
Personal Hygiene Indicators: Check grooming, clothing, hair, nails, odor, and dental hygiene.
Indicators of Potential Abuse or Neglect: Assess for indicators of abuse, neglect or human trafficking during the general survey:
Physical injuries inconsistent with the provided explanation.
Difficulty walking or sitting due to perineal or rectal pain.
Being accompanied by an overly attentive companion who answers for the client.
Unkempt appearance, malnourishment, or dehydration.
Body Structure and Mobility
Posture:
Expected: Relaxed, straight vertical line (plumb line).
Unexpected: Slumped, rigid, or fidgeting.
Body Build:
Expected: Normal height, symmetry, and adequate nourishment.
Unexpected: Height out of range, asymmetry, or uneven weight distribution.
Mobility / Gait:
Expected: Smooth gait and normal range of motion.
Unexpected: Wide stance, staggering, stumbling, dragging, limping, immobility, guarding, or inability to rise/sit without using hands.
Involuntary Movements (Unexpected): Spasticity, rigidity, fasciculation, myoclonus, tic, and tremors.
Range of Motion (ROM):
Expected: Conscious, smooth, and coordinated movements.
Unexpected: Limitations, pain, immobility, uncoordinated movements, joint asymmetry, or crepitus.
Measurements: Height, Weight, and BMI
Weight: Use a standardized scale. Clients should remove shoes and heavy outer clothing.
Serial Weights: Weigh at the same time of day, using the same scale, with the same type of clothing.
Unexpected Findings: Unintentional gain of 5 lbs in a day may indicate fluid retention; loss of 5% in a month or 10% in six months may indicate disease.
Height: Use a wall-mounted device or a measuring pole. The client should be shoeless, looking straight ahead, with feet and shoulders against the hard surface.
Body Mass Index (BMI): A marker of optimal weight for height and an indicator of obesity or malnutrition.
Classification BMI Range (kg/m²)
Underweight: < 18.5
Healthy Weight: 18.5 – 24.9
Overweight: 25 – 29.9
Obesity: 30 and above
Waist Circumference: Measured at the smallest circumference below the rib cage and above the iliac crest. Risk for disease increases if >35 inches for women and >40 inches for men.
Vital Signs
Vital signs provide objective data regarding the circulatory, neurological, endocrine, and respiratory systems.
Temperature: Body temperature is regulated by the hypothalamus. The core temperature is typically 0.5° C higher than surface temperature.
Normal Oral Range: 35.8° C to 37.3° C (96.4° F to 99.1° F).
Diurnal Cycle: Lowest in the early morning (1–4 a.m.); peaks in the late afternoon (4–6 p.m.).
Routes:
Oral: Convenient; rich blood supply from carotid arteries. Wait 15 minutes after hot/cold liquids and 2 minutes after smoking.
Rectal: Most accurate core temperature. Use only when other routes are impractical (e.g., coma). Insert lubricated probe 2–3 cm (1 inch) into the adult rectum toward the umbilicus.
Axillary: Safer but less accurate; used frequently in infants.
Tympanic: Quick and reflects core temperature via the ear canal.
Pulse: Assessment includes rate, rhythm, and force (amplitude).
Normal Adult Rate: 60 to 100 beats per minute (bpm).
Bradycardia: < 60 bpm (normal in well-trained athletes).
Tachycardia: > 100 bpm (occurs with anxiety, exercise, or fever).
Pulse Force Scale:
3+: Full, bounding (anxiety, exercise).
2+: Normal (expected finding).
1+: Weak, thready (hemorrhagic shock).
0: Absent.
Respirations: Normal breathing is relaxed, regular, automatic, and silent. Adult Rate: 12 to 20 breaths per minute.
Assessment Tip: Do not mention you are counting respirations to avoid the client altering their pattern. Count for 30 seconds (or 60 if irregular).
Factors: Narcotics slow the rate; stimulants and anxiety increase it.
Blood Pressure (BP): The force of blood against vessel walls.
Systolic: Maximum pressure during left ventricular contraction.
Diastolic: Resting pressure between contractions.
Cuff Sizing: Bladder width = 40% of arm circumference; bladder length = 80% of arm circumference. A cuff that is too small leads to a falsely high reading; one that is too large leads to a falsely low reading.
Orthostatic (Postural) BP: Taken in supine, sitting, and standing positions. A drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic indicates orthostatic hypotension.
Pulse Oximetry (SpO₂): Expected Range: 95% to 100%. Hypoxia: < 90% (emergency). Factors Affecting Accuracy: Dark skin tone, nail polish, jaundice, and impaired circulation (hypothermia, hypotension).
Developmental Considerations
Infants: Reverse the order of vitals (respirations, then pulse, then temperature). Watch the abdomen for respirations.
Children: BP is not normally checked in those under 3 years. Use the radial site for pulses in children older than 2.
Aging Adults: Temperature is often lower than in younger groups. Body weight may decrease, and fat distribution often shifts to the abdomen and hips. If posture is poor, arm span can be used to estimate height.
Clinical Implications and Lifestyle
Hypotension Factors: Acute Myocardial Infarction (AMI), shock, vasodilation.
Hypertension Risk Factors: Smoking, dyslipidemia, diabetes mellitus, age, gender, and family history.
Hypertension Lifestyle Modifications:
Weight loss.
Limit alcohol.
Increase aerobic exercise.
Reduce sodium intake ().
Maintain adequate dietary Potassium (), Calcium (), and Magnesium ().
Smoking cessation.
Reduce saturated fats and cholesterol.
Glossary of Terms
Aphasia: Difficulty finding words or expressing ideas.
Auscultatory Gap: A period when Korotkoff sounds disappear during BP auscultation.
Bradycardia: A resting heart rate of less than 60 beats per minute.
Diaphoresis: Excessive sweating.
Diurnal Variation: Biological rhythms that occur daily, such as the rise and fall of body temperature.
Dysarthria: Distorted speech sounds; word choice may be correct, but the sound is unclear.
Lethargic: Not fully awake; drifts off to sleep easily but is easily aroused.
Obtunded: Sleeps most of the time; requires loud shouting or vigorous shaking to arouse.
Orthostatic Hypotension: A significant drop in blood pressure when moving from a lying to a sitting or standing position.
Stupor: Spontaneously unconscious; responds only to persistent and vigorous shake or pain.
Study Quiz
What is the correct order for taking vital signs in an infant who is resting quietly in a parent's arms? Respirations, then Pulse, then Temperature. (You count respirations and pulse while the infant is quiet before disturbing them to take a temperature).
A blood pressure cuff that is too narrow for a client's arm will result in what type of reading? Falsely high blood pressure reading.
Which type of pain is characterized by a duration of more than 6 months and may not have an identifiable cause? Chronic pain. (Note: This specific time definition is from standard nursing knowledge, as it was not explicitly defined in the provided text).
Define "Orthostatic Hypotension" based on specific numerical drops in systolic and diastolic pressure. A drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic when moving from supine to sitting or standing.
What are two examples of acute physical pain mentioned in clinical contexts? While specific examples aren't listed, the text implies acute pain arises from injury or surgery. Standard examples include post-operative pain or pain from a fracture. Usually ankle related.
At what time of day is a client's body temperature typically at its lowest? In the early morning (1–4 a.m.).
A pulse force of +1 is described as what? Weak, thready (e.g., associated with hemorrhagic shock).
Which pain source originates from large internal organs and often presents with nausea and sweating? Visceral pain.
When calculating BMI, a result of 27.5 kg/m² falls into which category? Overweight (Range is 25 – 29.9 kg/m²).
How long should a nurse wait to take an oral temperature if a client has just smoked a cigarette? Wait two minutes, but I’ve also heard thirty minutes, after smoking.