General Survey

Nursing Notes: General Survey, Mental Status & Physical Assessment Techniques

Learning Objectives

By the end of this material, you should be able to:

Define components of the general survey.
Explain the process of conducting a general survey.
Explain the process of conducting a Mini Mental Status Exam (MMSE).
Recognize expected findings in the general survey.
Identify physical assessment techniques and explain how they are performed.

1. General Survey

What is a General Survey?

The general survey is the nurse's overall observation of the patient.

It begins the moment you meet the patient and involves observing the patient's:

Appearance
Behavior
Body structure
Gait
Mental status
Mobility
Vital signs and measurements

The general survey provides an overall impression of the patient's physical and mental condition.

Components of the General Survey

The lecture identifies four main components:

1. Appearance

2. Behavior

3. Body Structure

4. Gait

2. Appearance

When assessing appearance, observe the patient as a whole.

Look at:

Gender
Race
Ethnicity
Apparent age
Level of consciousness (LOC)
Signs of distress
Body odor
Hygiene
Grooming
Dress

Age

Ask yourself:

Does the patient appear their stated age?
Do they appear younger or older than their stated age?

Age can provide clues about the patient's overall health and condition.

Ethnicity

Ethnicity refers to a person's cultural or social group.

The nurse should observe and document appropriately while avoiding assumptions or bias.

Body Odor

Body odor can provide clues about abnormalities.

During inspection, unusual odors may be noticed.

Level of Consciousness (LOC)

Level of consciousness (LOC) describes how awake, alert, and responsive a patient is.

The lecture identifies five levels:

Alert

An alert patient:

Is awake
Is easily aroused
Is fully aware of stimuli
Responds appropriately

Expected finding: Patient is awake, aware, and appropriately responsive.

Lethargic

A lethargic patient:

Drifts off to sleep unless stimulated
Wakes to vocal stimuli
Responds appropriately
Responses may be delayed or "fuzzy"

Key idea: The patient can be awakened by talking to them but responds slowly.

Obtunded

An obtunded patient:

Sleeps almost all the time
Is difficult to arouse
Requires a shake or loud shout to awaken
May be confused when awakened
Speech may be mumbled

Key idea: More difficult to arouse than a lethargic patient.

Stupor

A patient in stupor:

Is spontaneously unconscious
Responds only to vigorous shaking or painful stimuli
May withdraw from the source of pain
May groan or mumble
May move restlessly
Retains reflex activity

Coma

A patient in a coma:

Is completely unconscious
Does not respond to internal stimuli
Does not respond to external stimuli
Does not respond to pain

LOC Progression

Think of the levels as decreasing responsiveness:

Alert → Lethargic → Obtunded → Stupor → Coma

Signs of Distress

During the general survey, look for signs that the patient is experiencing distress.

Pain

Possible signs of pain include:

Facial grimacing
Guarding a painful area
Diaphoresis

Guarding

The patient protects or holds a painful area.

Diaphoresis

Excessive sweating.

Difficulty Breathing

Look for:

Sternal retractions
Labored breathing
Accessory muscle use
Anxiety

Sternal Retractions

Visible pulling inward of tissues around the sternum during breathing.

Labored Breathing

Breathing that appears difficult or requires increased effort.

Accessory Muscle Use

Use of additional muscles of the neck/chest to help with breathing.

3. Behavior

The general survey includes observing the patient's behavior.

Assess:

Affect
Mood
Speech
Hygiene and grooming
Dress
Signs of patient abuse
Signs of substance abuse

Affect

Affect is the patient's observable emotional expression.

Observe whether the patient's facial expressions and behavior appear appropriate to the situation.

Mood

Mood is the patient's reported or apparent emotional state.

Examples:

Happy
Sad
Anxious
Irritable

Speech

Observe:

Clarity
Rate
Volume
Ability to communicate

Changes in speech may provide information about the patient's condition.

Hygiene & Grooming

Observe whether the patient appears appropriately:

Clean
Groomed
Maintained

Changes in hygiene can provide clues about physical or mental health.

Dress

Observe whether the patient's clothing is:

Appropriate for the environment
Appropriate for the weather
Appropriate for the situation
Clean and maintained

Signs of Patient Abuse

During the general survey, remain alert for possible signs of abuse or neglect.

The nurse should observe without making assumptions.

Signs of Substance Abuse

Observe for findings that may indicate substance use or intoxication.

The nurse should remain objective and avoid bias.

CAGE Questionnaire

The lecture includes the CAGE questionnaire as a screening tool related to alcohol use.

CAGE stands for:

C — Cut down
A — Annoyed
G — Guilty
E — Eye-opener

It is used to screen for possible problematic alcohol use.

4. Body Structure

Body structure refers to the patient's overall physical build and appearance.

Assess:

Stature
Nutrition
Posture
Symmetry
Mobility
Body movement
Body Mass Index (BMI)

Stature

Stature refers to the patient's height and overall physical build.

Observe whether the patient's body size and development appear appropriate.

Nutrition

Observe the patient's overall nutritional appearance.

Consider:

Body build
Weight
Muscle mass
General appearance

Measurements such as height and weight can provide additional information.

Posture

Posture refers to how the patient holds their body.

Observe whether the patient:

Stands upright
Sits upright
Appears comfortable
Has unusual positioning

Symmetry

Symmetry means that corresponding sides of the body appear similar.

During inspection, compare one side of the body with the other.

Examples:

Shoulders
Arms
Legs
Facial features

Look for differences from side to side.

Mobility

Assess how the patient moves.

The lecture identifies:

Ambulatory

The patient is able to walk or move around.

Immobile

The patient is unable to move independently or has significantly limited mobility.

Mobility Aids

Devices used to assist movement, such as:

Cane
Walker
Crutches
Wheelchair

Body Movement

Observe how the patient moves their body.

Look for:

Smooth vs. abnormal movement
Coordination
Difficulty moving
Involuntary movements

Myoclonus

Myoclonus refers to sudden, brief, involuntary muscle jerking.

During observation of body movement, note any abnormal involuntary movements.

5. Gait

Gait is the way a person walks.

Assess:

Balance
Stability
Coordination
Speed
Ability to walk
Use of mobility aids

Ask yourself:

"Does the patient walk normally and safely?"

Abnormal gait may indicate a problem with strength, balance, coordination, or the nervous system.

6. Mental Status

Mental status refers to the patient's overall:

Appearance
Behavior
Cognition
Thought process

Mental status is evaluated through observation and interaction with the patient.

Cognition

Cognition refers to mental processes such as:

Orientation
Memory
Attention
Understanding
Thinking

The Mini Mental Status Exam (MMSE) can be used to assess cognitive function.

Mini Mental Status Exam (MMSE)

The Mini Mental Status Exam (MMSE) is a structured screening tool used to assess aspects of cognition and mental status.

It helps evaluate areas such as:

Orientation
Attention
Memory
Recall
Language
Ability to follow commands

Important distinction:

The general survey provides an overall observation of the patient's mental status.

The MMSE provides a more structured assessment of cognitive function.

General Process of Conducting an MMSE

The MMSE generally assesses several cognitive areas.

1. Orientation

Determine whether the patient knows:

Who they are
Where they are
When it is
What is happening

Examples of questions:

"What is your name?"
"Where are you right now?"
"What month is it?"
"What year is it?"

2. Registration

Assess the patient's ability to hear and remember new information.

The examiner may give the patient several words and ask them to repeat them.

3. Attention and Calculation

Assess the patient's ability to concentrate and perform a mental task.

Examples may include:

Counting
Spelling a word backward
Performing simple calculations

4. Recall

Ask the patient to remember information presented earlier.

Example:

"Can you tell me the three words I asked you to remember?"

5. Language

Assess the patient's ability to:

Name objects
Repeat information
Follow commands
Read
Write
Communicate appropriately

6. Following Commands

Give the patient a simple command and observe whether they understand and follow it.

Important Nursing Point

The MMSE is a screening assessment, not a diagnosis by itself.

Document the patient's responses accurately.

7. Measurements in the General Survey

Measurements can provide objective information about the patient's condition.

Vital Signs

Assess:

Temperature
Pulse
Respirations
Blood pressure
Oxygen saturation
Pain

These are important components of the patient's overall assessment.

Waist Circumference

The lecture identifies the iliac crest as the landmark used when measuring waist circumference.

Use:

Measuring tape
Iliac crest as the anatomical landmark

The lecture identifies these risk values:

35 inches or greater in women = at risk
40 inches or greater in men = at risk

Height

When measuring height:

Remove shoes.
Position appropriately for accurate measurement.
For a supine, non-weight-bearing measurement, use a firm surface.

Weight

Weight can be measured using:

Different scales
Electronic bed scales

Important changes noted in the lecture:

More than 5% weight loss in 6 months–1 year
2–3 lb. or more gained in one day

These changes may require further assessment.

Body Mass Index (BMI)

Body Mass Index (BMI) is a measurement based on a person's height and weight.

It is used as a general measure related to body weight.

BMI is one component of the overall assessment and should be considered along with the patient's complete clinical picture.

8. Physical Assessment Techniques

There are four major physical assessment techniques:

Inspection
Palpation
Percussion
Auscultation

A common order is:

Inspection → Palpation → Percussion → Auscultation

Important exception:

For an abdominal assessment, the usual order is:

Inspection → Auscultation → Percussion → Palpation

This prevents manipulation of the abdomen from changing bowel sounds before they are assessed.

Inspection

Inspection is visual observation of the patient.

Key points:

It is the first technique of assessment.
It begins the minute you meet the patient.
Observe the patient systematically.
Compare symmetry from side to side.
Observe body odor for possible abnormalities.

What can you inspect?

Appearance
Skin color
Body structure
Posture
Gait
Movement
Hygiene
Distress
Symmetry
Behavior

How to perform inspection

Look carefully at the patient.
Observe systematically.
Compare corresponding sides.
Note abnormal findings.
Document objective findings.

Palpation

Palpation uses the sense of touch to assess the patient.

It can provide information about:

Texture
Temperature
Moisture
Tenderness
Pain

How to perform palpation

Explain the procedure to the patient.
Use your hands/fingers to assess the appropriate area.
Begin gently when appropriate.
Assess tissue characteristics.
Note tenderness or pain.
Compare sides when appropriate.
Document findings.

Example

The nurse may palpate an area to determine whether it is:

Warm or cool
Dry or moist
Soft or firm
Tender or non-tender

Percussion

Percussion involves tapping on the body to produce vibrations.

It helps the nurse assess the:

Density of underlying tissue
Characteristics of structures beneath the surface

How to perform percussion

Position the patient appropriately.
Place the finger appropriately on the body surface.
Tap to produce a vibration.
Listen to and interpret the resulting sound.
Compare areas when appropriate.

The sound produced can provide information about the underlying tissue.

Auscultation

Auscultation means listening to sounds made by the body.

A stethoscope is commonly used.

Examples of sounds that may be assessed include:

Heart sounds
Lung sounds
Bowel sounds
Blood flow sounds

How to perform auscultation

Position the patient appropriately.
Use the appropriate part of the stethoscope.
Place the stethoscope on the correct anatomical location.
Listen carefully.
Compare sounds when appropriate.
Document findings.

9. Subjective vs. Objective Data

Physical assessment combines subjective and objective data.

Subjective Data

Subjective data is what the patient tells you.

Examples:

"My leg hurts."
"I feel dizzy."
"I am having trouble breathing."

Subjective information often comes from:

Chief complaint
History of present illness (HPI)
Review of systems (ROS)

Objective Data

Objective data is what the nurse can observe, measure, or verify.

Examples:

Temperature: 101°F
Blood pressure: 150/90
Patient is diaphoretic
Patient has an abnormal gait
Patient is lethargic

10. Related Vocabulary From Your Previous Lecture

These terms may appear together with the general survey and physical assessment.

Chief Complaint

The chief complaint is the patient's main reason for seeking care.

It should be:

Brief
In the patient's own words

History of Present Illness (HPI)

The history of present illness (HPI) describes the patient's current problem from its onset to the present.

Review of Systems (ROS)

The review of systems (ROS) is a systematic review of symptoms involving different body systems.

Referred Pain

Referred pain is pain that is felt in a location different from where the actual problem originates.

HIGH-YIELD EXAM REVIEW

Objective 1: Define Components of the General Survey

Four major components:

A — Appearance

Age
Gender/race
Ethnicity
LOC
Distress
Body odor

B — Behavior

Affect
Mood
Speech
Hygiene/grooming
Dress
Abuse/substance-abuse indicators

C — Body Structure

Stature
Nutrition
Posture
Symmetry
Mobility
Body movement

D — Gait

How the patient walks
Balance
Coordination
Stability
Mobility aids

Also assess:

Mental status
Measurements
Vital signs

Objective 2: Explain the Process of Conducting a General Survey

Think: "Look before you touch."

Begin inspection the moment you meet the patient.
Observe appearance.
Determine level of consciousness (LOC).
Look for signs of distress.
Assess behavior.
Observe body structure.
Assess posture and symmetry.
Observe mobility and gait.
Observe body movement.
Obtain appropriate measurements and vital signs.
Document objective findings.

Objective 3: Explain the Process of Conducting an MMSE

Assess:

Orientation
↓
Registration
↓
Attention/calculation
↓
Recall
↓
Language
↓
Following commands

The MMSE assesses cognition and contributes to evaluation of mental status.

Objective 4: Recognize Expected Findings in the General Survey

Expected/normal general survey findings may include:

Appearance

Appropriate hygiene and grooming
Appropriate dress
No obvious signs of distress
Body odor without unusual concerning odors
Appearance generally consistent with stated age

Behavior

Appropriate affect
Appropriate mood
Clear/appropriate speech
Cooperative behavior

LOC

Alert
Awake
Fully aware
Responds appropriately

Body Structure

Appropriate stature
Appropriate nutritional appearance
Upright/appropriate posture
Symmetry from side to side
Appropriate body movement

Mobility/Gait

Ambulatory when appropriate
Stable gait
Coordinated movement
No unexpected mobility problems

Respiratory appearance

No obvious labored breathing
No sternal retractions
No inappropriate accessory muscle use

Objective 5: Identify Physical Assessment Techniques

Remember:

I-P-P-A

I = Inspection

Look

P = Palpation

Touch

P = Percussion

A = Auscultation

Listen

What each technique does:

Technique	What you do	What you assess
Inspection	Look	Appearance, symmetry, movement, abnormalities
Palpation	Touch	Texture, temperature, moisture, tenderness, pain
Percussion	Tap	Density of underlying tissue
Auscultation	Listen	Sounds made by the body

Exception for the abdomen:

Inspection → Auscultation → Percussion → Palpation

MUST-KNOW VOCABULARY

Affect — Observable emotional expression.

Body Mass Index (BMI) — Measurement based on height and weight used as a general indicator of body weight.

Body structure — Overall physical build and organization of the body.

Chief complaint — Patient's main reason for seeking care.

Cognition — Mental processes involving thinking, memory, attention, and orientation.

Ethnicity — A person's cultural or social group.

Gait — The manner or pattern in which a person walks.

History of present illness (HPI) — Story of the current health problem from onset to present.

Inspection — Visual observation; the first physical assessment technique.

Auscultation — Listening to sounds made by the body.

Percussion — Tapping the body to produce vibrations that help assess underlying tissue density.

Palpation — Using touch to assess characteristics such as texture, temperature, moisture, tenderness, and pain.

Lethargic — Drowsy; drifts to sleep unless stimulated but wakes to vocal stimuli and responds slowly.

Obtunded — Difficult to arouse; requires shaking or loud shouting and may be confused when awakened.

Level of consciousness (LOC) — Degree of alertness and responsiveness.

Mental status — Assessment of appearance, behavior, cognition, and thought process.

Mini Mental Status Exam (MMSE) — Structured screening examination used to assess cognitive function.

Myoclonus — Sudden, brief, involuntary muscle jerking.

Posture — Position in which a person holds their body.

Hygiene — Practices related to cleanliness and personal care.

Symmetry — Similarity between corresponding sides of the body.

Subjective data — Information reported by the patient.

Objective data — Information observed, measured, or verified by the healthcare professional.

Referred pain — Pain perceived in a location different from the actual source.

Review of systems (ROS) — Systematic review of symptoms involving different body systems.

Stupor — State of unconsciousness in which the patient responds only to vigorous shaking or pain.

Coma — Complete unconsciousness with no response to internal or external stimuli or pain.

Appearance — Overall visual presentation of the patient.

Behavior — Observable actions and responses, including affect, mood, speech, hygiene, grooming, and dress.

Gait — Pattern of walking and movement.

Stature — Height and physical build.

Mobility — Ability to move independently.

Ambulatory — Able to walk or move around.

Immobile — Unable to move independently or significantly restricted in movement.

Mobility aids — Devices used to assist a patient's movement.

Body movement — How the patient moves their body, including coordination and involuntary movements.

Signs of distress — Observable indications of pain or difficulty breathing, such as grimacing, guarding, diaphoresis, retractions, labored breathing, accessory muscle use, and anxiety.

FINAL MEMORY SHEET

GENERAL SURVEY

Appearance + Behavior + Body Structure + Gait

APPEARANCE

Age + Ethnicity + LOC + Distress + Odor

BEHAVIOR

Affect + Mood + Speech + Hygiene/Grooming + Dress

BODY STRUCTURE

Stature + Nutrition + Posture + Symmetry + Mobility

LOC

Alert → Lethargic → Obtunded → Stupor → Coma

PHYSICAL ASSESSMENT

I-P-P-A

Inspection = LOOK

Palpation = TOUCH

Percussion = TAP

Auscultation = LISTEN

ABDOMEN

I-A-P-P

Inspection → Auscultation → Percussion → Palpation

MMSE

Orientation → Registration → Attention/Calculation → Recall → Language → Commands

SUBJECTIVE VS. OBJECTIVE

Subjective = Patient says it

Objective = Nurse sees/measures it