General Survey

General Survey & Physical Appearance Assessment

• General survey and physical appearance assessment involves collecting both objective and subjective data to make clinical judgments, plan goals, and determine appropriate nursing interventions.

• Objective Data: Data obtained through direct physical assessment of a client, utilizing inspection, percussion, palpation, and auscultation.

• Subjective Data: Information communicated directly by the client in response to assessment questions.

Facial Features and Expressions

• Expected Findings: Facial features and movements are symmetrical across both sides of the face.

• Unexpected Findings:

  • Expressionless or masklike face.

  • Asymmetrical facial features, including a drooping eyelid or drooping on one side of the mouth.

  • Involuntary facial movements, such as muscle twitching or excessive blinking.

  • Swelling (e.g., swelling around the eyes).

  • Facial lesions.

Emotional State Assessment

• Assessment Method: Determined by performing a survey of the client's behaviors and verbal statements.

• Expected Findings: A relaxed posture, smiling, and active responsiveness to communication indicate that the client is calm.

• Unexpected Findings:

  • Restlessness, grimacing, or uncharacteristic quietness, which may indicate pain, anxiety, or emotional distress.

  • Expressions or displays of anger, distrust, depression, and sadness.

  • Behaviors such as being uncooperative, withdrawn, or tearful.

Eye Contact Dynamics

• Expected Findings: Making direct eye contact is expected; however, the level of eye contact is heavily influenced by cultural background and shyness, requiring cultural consideration during interpretation.

• Unexpected Findings:

  • Avoidance of eye contact: May indicate confusion, anxiety, or defensiveness.

  • Penetrating stare: Can communicate negative feelings.

  • Squinting or staring without blinking: May manifest an underlying eye dysfunction.

Level of Consciousness (LOC)

• Assessment Criteria: Evaluated by asking direct questions during greeting to determine if the client is awake, easily aroused, alert, and oriented to person, place, time, and situation.

• Unexpected Findings & Classifications:

  • Delirium: Acute, sudden-onset confusion that fluctuates in severity.

  • Dementia: Chronic, progressive confusion over time.

  • Lethargy: The client is not fully awake and quickly drifts off to sleep when lack of interaction occurs, but is easily awakened when their name is called.

  • Obtundation: The client is asleep and arouses only with loud auditory or physical stimulation. When awake, the client is confused, speaks in one-word sentences, and returns to sleep without constant stimulation.

  • Stupor: The client is unconscious but will respond to physical or painful stimuli with movement or incoherent vocalizations.

  • Coma: The client is completely unconscious and displays no response to physical or painful stimuli.

Skin Assessment

• Expected Findings: Skin is intact, warm to the touch, and exhibits even color tones consistent with genetic background.

• Unexpected Findings:

  • Temperature and Moisture Alterations: Cool, hot, diaphoretic (sweaty), or clammy skin.

  • Tone Variations:

  • Pallor: Skin tone lighter than surrounding areas.

  • Cyanosis: Bluish skin tone.

  • Jaundice: Yellowish skin tone.

  • Erythema: Red to purple skin tone.

  • Lesions: Presence of obvious skin lesions or breakdown.

Behavioral Assessment & Speech Patterns

• Behavioral assessment occurs during initial survey and evaluates speech, mood, and affect.

• Speech Observation Parameters: Fluency, pace, and articulation.

• Unexpected Speech Findings:

  • Laryngeal Disease: Manifests as a hoarse voice or ability to speak only in a whisper.

  • Dysarthria: Speech sounds are unclear, though word choice remains appropriate.

  • Aphasia: The client struggles to find words or express an idea.

  • Echolalia / Thought Process Alterations: Unusual word choices or repetitive vocalizations.

  • Tone & Pace Variations:

  • Sarcastic, unbelieving, or hostile tone.

  • Fast pace and loud volume: Indicates anxiety.

  • Quiet voice: Indicates fear or shyness.

  • Extended pauses before answering straightforward questions: Indicates hearing impairment, confusion, or formulation of an untruthful response.

  • Slow, quiet, monotone speech: Commonly associated with depression.

Mood and Affect

• Mood Assessment: Mood is a sustained emotional state evaluated by observing verbal and nonverbal expressions or asking directly, "How are you feeling?". Observe whether the stated mood aligns with verbal responses and nonverbal actions.

• Affect Assessment: Affect is the physical, external expression of mood as perceived by others.

• Expected Findings: Pleasant, cooperative behavior, with situationally appropriate emotional responses (e.g., nervousness during medical evaluations).

• Unexpected Findings:

  • Inappropriate Affect: Demonstrating inappropriate emotional responses, such as smiling or laughing when discussing a difficult situation.

  • Flat Affect: An expressionless face regardless of topic, potentially indicating depression.

Personal Hygiene, Grooming, and Odor Assessment

• Overview: Hygiene practices vary across cultures, socioeconomic statuses, and occupations. Assessment includes clothing, hair, nails, body/breath odor, and dental hygiene.

• Grooming Assessment:

  • Expected Findings: Clean, well-fitting clothing appropriate for the weather; well-maintained hair and facial hair; trimmed, clean nails.

  • Unexpected Findings:

  • Mismatched or improperly buttoned clothing, dirty or uncombed hair: May indicate depression, cognitive impairment, or dependent adult abuse.

  • Extremely loose or tight clothing: Suggests recent significant weight loss or gain.

  • Long sleeves on hot days: May indicate metabolic abnormalities or attempts to conceal physical injuries or needle marks.

• Odor Assessment:

  • Expected Findings: Neutral or pleasant body and breath odors.

  • Unexpected Findings:

  • Halitosis: Bad breath stemming from poor oral hygiene.

  • Alcohol Odor: Presence of alcohol on breath.

  • Fruity Breath: Associated with diabetic ketoacidosis, malnutrition, or dehydration.

  • Ammonia Odor: Associated with kidney disease.

  • Musty Body/Breath Odor: Associated with liver disease.

  • Fetid Odor: Heavy, offensive smell associated with respiratory or dental infections.

  • Fecal Breath Odor: Associated with severe bowel obstruction and secondary vomiting.

Dental Hygiene Assessment

• Lips:

  • Expected: Smooth, moist, darker tone than surrounding skin (pink to brown).

  • Unexpected: Dry, cracked lips (dehydration or lip licking); lesions, scabs, or cold sores (infection/disease).

• Gums (Gingiva):

  • Expected: Intact, moist, firmly attached to teeth in a scalloped boundary. Color ranges from pale/coral pink in lighter skin tones to brown in darker skin tones (which may feature a dark line along the gum margin).

  • Unexpected: Bleeding, swollen, overgrown, spongy, retracted, or discolored gums.

• Teeth:

  • Expected: Intact, aligned, smooth; white, pale yellow, or grey in appearance.

  • Unexpected: Missing, misaligned, or broken teeth. Brown or dark yellow discoloration resulting from medication side effects, tobacco use, poor dental hygiene, excessive water fluoridation, or dental caries.

Body Structure, Posture, and Overall Build

• Posture Assessment:

  • Expected Findings: Upright sitting or standing posture with arms relaxed at sides. When standing, a vertical plumb line aligns through the outer ear, shoulder, hip, patella, and ankle.

  • Unexpected Findings:

  • Slumped or rigid posture; fidgeting.

  • Stiff neck and spine moving as a single rigid unit: Indicates pain or immobility (e.g., arthritis).

  • Tripod Position: Leaning forward with arms supported on knees to assist breathing in respiratory distress.

  • Fetal Position / Guarding: Lying curled up or crossing arms over abdomen due to abdominal pain.

• Overall Build Assessment:

  • Expected Findings: Height within expected reference ranges; bilateral limb symmetry and proportion to overall body size; weight evenly distributed.

  • Unexpected Findings: Height outside reference ranges; limb length asymmetry; disproportionate body parts; uneven weight distribution in the face, neck, and trunk (indicates endocrine disorders).

Mobility, Gait, and Range of Motion

• Gait Assessment:

  • Expected Findings: Smooth, steady gait with feet spaced approximately shoulder-width apart. Arms swing freely and symmetrically. Ability to sit down and rise from a chair without using hands for assistance.

  • Expected Variations: Use of assistive devices (canes, walkers) during ambulation.

  • Unexpected Findings: Wide stance, staggering, stumbling, shuffling, dragging, limping, leg immobility, guarding, difficulty coming to a complete stop, or relying on armrests to rise from or lower into a seated position.

• Range of Motion (ROM):

  • Expected Findings: Joint movements are conscious, smooth, coordinated, and bilaterally symmetrical.

  • Unexpected Findings: Limited ROM, pain during movement, paralysis, jerky or uncoordinated motion, movement hesitancy, bilateral asymmetry, or crepitus (cracking sound/sensation generated by bone surfaces rubbing together).

• Involuntary Movements:

  • Spasticity: Hypertonicity of muscles, manifesting as increased resistance during passive joint extension.

  • Rigidity: Constant muscle resistance to any passive joint manipulation.

  • Fasciculation: Continuous, rapid twitching of a resting muscle.

  • Myoclonus: Sudden, involuntary muscle jerking (e.g., hiccups, seizure activity, myoclonic jerks when falling asleep).

  • Tic: Involuntary, repetitive muscle group movements driven by neurological or psychogenic causes (e.g., facial grimaces, winks, shoulder shrugs).

  • Tremors: Involuntary rhythmic movement of opposing muscle groups affecting one or more joints, occurring either at rest or during voluntary movement.

Anthropometric Measurements & BMI

• Height Measurement Protocol:

  • Stadiometer (balance scale measuring pole or wall-mounted device): Instruct client to remove shoes, stand upright with posterior body touching the pole/wall, and look straight ahead.

  • Supine Measurement: For non-ambulatory clients, place flat on a firm surface, remove shoes, and measure from top of head to bottom of heel using a tape measure.

• Weight Measurement Protocol:

  • Equipment: Balance scale (large weight in $22.7\,kg$ [$50\,lb$] increments, small weight in $0.1\,kg$ [$0.25\,lb$] increments) or electronic scale calibrated to zero.

  • Serial Weighing Standards: Weigh at the same time each day, using the same scale, wearing the same type of clothing, with shoes and outerwear removed.

  • Non-Weight-Bearing Clients: Utilize specialized bed or chair scales.

• Unintentional Weight Change Thresholds:

  • Weight Gain: Unintentional gain of $5\,lb$ ($2.27\,kg$) in a single day indicates acute fluid retention (e.g., heart failure).

  • Weight Loss: Unintentional loss of $5\%$ of body weight in $1\,month$ or $10\%$ in $6\,months$ indicates pathology (fever, infection, malignancy, endocrine disorders).

• Body Mass Index (BMI) Formulas & Classifications:

  • Imperial Formula:     $BMI = \frac{\text{weight (lb)}}{(\text{height (in)})^2} \times 703$

  • Metric Formula:     $BMI = \frac{\text{weight (kg)}}{(\text{height (m)})^2}$

  • Classifications:

  • Underweight: $< 18.5\,kg/m^2$

  • Healthy Weight: $18.5\text{ to }24.9\,kg/m^2$

  • Overweight: $25\text{ to }29.9\,kg/m^2$

  • Obesity: $\ge 30\,kg/m^2$ (Correlated with heightened risk for hypertension, diabetes mellitus, cardiovascular disease, and specific cancers).

• Case Study 1 Assessment:

  • Profile: 54-year-old client displaying loss of muscle mass and weakness. Weight: $45.5\,kg$, Height: $175.3\,cm$.

  • Calculation: BMI is $14\,kg/m^2$ (Severe Underweight).

  • Risk Factors: Increased susceptibility to infection and delayed wound healing.

  • Comprehensive Nutritional Inquiry Questions:

  • Is the weight loss recent?

  • Is the client intentionally attempting to lose weight?

  • Is the client following a special diet, or experiencing food allergies or intolerances?

  • What is the status of the client's appetite?

  • Are GI symptoms present (nausea, vomiting, diarrhea, stomach pain, heartburn) related to eating?

  • Does the client regularly skip meals?

  • Does the client consume nutritional supplements?

  • Is financial assistance needed to acquire food?

  • Has a recent stressful life event occurred?

Vital Signs Overview

• Definition & Utility: Baseline objective measurements assessing the functional integrity of the circulatory, neurological, endocrine, and respiratory systems. Includes temperature, pulse, respirations, blood pressure, pulse oximetry, and subjective pain rating.

• Measurement Frequency: Dependent on clinical stability and facility policy. Unstable clients require increased frequency. Monitoring increases prior to/after risky procedures.

• Delegation: May be delegated to assistive personnel only if the client is clinically stable and baseline readings are established.

• External Interference Factors: Room temperature, physical exertion, recent oral intake of hot/cold items, and ambient noise levels.

Body Temperature Assessment

• Physiology: Core body temperature is maintained between $36^\circ\text{C}\text{ to }38^\circ\text{C}$ ($96.8^\circ\text{F}\text{ to }100.4^\circ\text{F}$) via thermoregulation. Core temperature (rectal, arterial/urinary catheter probes) remains steady and is approximately $0.5^\circ\text{C}$ higher than skin surface temperature.

• Diurnal Variation: Temperature is lowest in early morning between $1\text{ and }4\text{ a.m.}$ and peaks in late afternoon around $4\text{ p.m.}$

• Temperature Scale Conversion Formulas:

  • Fahrenheit to Celsius:     $C = (F - 32) \times \frac{5}{9}$

  • Celsius to Fahrenheit:     $F = \left(\frac{9}{5} \times C\right) + 32$

• Measurement Routes & Temperature Values:

  • Oral:

  • Expected Range: $36^\circ\text{C}\text{ to }38^\circ\text{C}$ ($96.8^\circ\text{F}\text{ to }100.4^\circ\text{F}$).

  • Average Adult: $37^\circ\text{C}$ ($98.6^\circ\text{F}$).

  • Older Adult Average: $35^\circ\text{C}\text{ to }36.1^\circ\text{C}$ ($95^\circ\text{F}\text{ to }97^\circ\text{F}$) due to reduced subcutaneous fat.

  • Protocol: If the client has eaten, drunk, or smoked, wait at least $10\,minutes$ before measuring.

  • Rectal: Most accurate core temperature reading. Typically $0.5^\circ\text{C}$ ($0.9^\circ\text{F}$) higher than oral. Contraindicated in clients with rectal bleeding, diarrhea, rectal disorders, or recent rectal surgery.

  • Temporal Artery: Uses a probe slid across the forehead and behind the ear. Yields readings nearly $0.5^\circ\text{C}$ ($1^\circ\text{F}$) higher than oral.

  • Infrared Non-Contact: Measures thermal radiation from the frontal bone or temporal artery. Consistent with temporal readings.

  • Axillary: Less accurate; requires longer measurement duration. Typically $0.5^\circ\text{C}$ ($0.9^\circ\text{F}$) lower than oral.

  • Tympanic: Quick core reflection. Consistent with oral readings. Inaccuracies occur due to cerumen impaction, side-lying posture on the scanned ear, local infection, or ear canal pathology.

• Hyperthermia (Fever): Elevated body temperature resulting from infection, tissue breakdown, or neurological dysfunction. Manifestations include erythematous, warm, or dry skin; diaphoresis; dry mucous membranes; altered mental status; and potential seizures.

• Hypothermia: Low body temperature resulting from cold environment exposure or failure of thermoregulation (e.g., shock, cardiac arrest). Manifestations include pale or cyanotic cool skin, sluggish capillary refill, shivering, and altered mental status.

Peripheral Pulse Assessment

• Assessment Parameters: Palpable arterial pulsations evaluating heart rate, rhythm, amplitude (strength), and bilateral equality.

• Anatomical Sites:

  • Radial Pulse: Located on thumb side of inner wrist; primary site for routine screening.

  • Apical & Carotid Pulses: Preferred sites if the client is unstable or has poor cardiac output.

  • Doppler Ultrasound (DUS): Handheld transducer amplifying arterial blood flow sounds when pulses are faint or difficult to palpate.

• Palpation Technique: Use finger pads of index and middle fingers. Press firmly without occluding blood flow. If regular, count for $30\,seconds$ and multiply by $2$. If irregular, count for a full $60\,seconds$. Never palpate bilateral carotid arteries simultaneously to avoid cerebral ischemia.

• Pulse Qualities & Clinical Findings:

  • Expected Resting Rate: $60\text{ to }100/\text{min}$ for adults.

  • Bradycardia: Resting pulse $< 60/\text{min}$. Expected in highly trained athletes. Unexpected cases stem from hypothyroidism, hypothermia, or medication adverse effects.

  • Tachycardia: Resting pulse $> 100/\text{min}$. Occurs secondary to pain, fever/infection, exercise, anxiety, or medication effects.

  • Dysrhythmia / Arrhythmia: Irregular rhythm. Documented as "regularly irregular" (e.g., skipping every 4th beat) or "irregularly irregular" (disorganized pattern).

  • Pulse Strength Scale:

  • $0$: Absent, impalpable pulse.

  • $+1$: Weak, thready, diminished pulse.

  • $+2$: Normal, brisk pulse (expected finding).

  • $+3$: Increased, strong pulse.

  • $+4$: Bounding, full volume pulse.

  • Equality: Assessed via simultaneous bilateral palpation (except carotids). Asymmetry indicates local arterial occlusion, thrombus, or anatomical displacement.

Pulse Oximetry Assessment

• Physiology: Measures pulse oxygen saturation ($SpO_2$) via light wavelengths to estimate arterial hemoglobin oxygen saturation ($SaO_2$).

• Sensor Locations: Finger, nose, forehead, earlobe, or foot. Earlobe and forehead probes offer rapid, reliable readings during low peripheral perfusion.

• Accuracy Threshold: Pulse oximeters are unreliable at saturation levels $< 70\%$.

• Interfering Factors: Carbon monoxide poisoning, jaundice, dark skin pigmentation, painted or thickened nails, intravenous circulatory dyes, client motion, external ambient light, and impaired peripheral circulation (peripheral vascular disease, hypothermia, severe vasoconstriction, hypotension, peripheral edema).

• Hypoxia Indicators: $SpO_2 < 90\%$ is an emergency requiring evaluation. Clinical manifestations include cyanosis of skin, lips, and nail beds; altered respiratory rate, depth, or adventitious sounds; and behavioral shifts like irritability, restlessness, or confusion.

Respiratory Assessment

• Physiology: Ventilation, diffusion, and perfusion driving carbon dioxide and oxygen exchange, involuntarily controlled by the brainstem.

• Assessment Technique: Count respiratory rate discreetly without alerting the client to prevent conscious alteration of breathing.

• Rate Parameters:

  • Expected Adult Range: $12\text{ to }20\,\text{breaths/min}$.

  • Bradypnea: Respiratory rate $< 12\,\text{breaths/min}$.

  • Tachypnea: Respiratory rate $> 20\,\text{breaths/min}$.

  • Apnea: Complete absence of respirations.

• Depth & Rhythm:

  • Depth: Evaluated as shallow (minimal chest expansion) or deep/labored (full chest expansion).

  • Rhythm: Regular (even interval and depth) or irregular (fluctuating rate/depth; requires counting for a full $60\,seconds$).

• Factors Influencing Respirations:

  • Physical Exertion: Increases rate and depth to excrete $CO_2$ and absorb $O_2$.

  • Pain: Acute chest/abdominal pain leads to shallow breathing to limit movement; opioid analgesics depress rate and depth.

  • Anxiety: Sympathetic nervous stimulation increases respiratory rate.

  • Smoking: Causes airway alteration leading to increased respiratory rate.

  • Posture: Upright position optimizes chest expansion; slumped or supine posture restricts expansion.

  • Medications: Narcotics/opioids depress CNS and decrease respiratory rate; stimulants/amphetamines increase rate and depth.

  • Neurological Injury: Direct brainstem injury disrupts respiratory rate and rhythm.

  • Hemoglobin Alterations: Reduced hemoglobin or sickled erythrocytes impair oxygen delivery, causing compensatory increases in respiratory rate and depth.

Blood Pressure Assessment

• Physiology: Measure of force exerted by blood against arterial walls, recorded in $mm\,Hg$. Peak arterial pressure during ventricular contraction is Systolic Pressure; minimal pressure during ventricular relaxation is Diastolic Pressure.

• Equipment Sizing Standard:

  • Bladder length must encircle at least $80\%$ of the targeted limb circumference.

  • Bladder width must equal approximately $40\%$ of the targeted limb circumference.

• Electronic BP Device Contraindications: Severe hypertension, hypotension ($systolic < 90\,mm\,Hg$), dysrhythmias, seizures, or physical trauma.

• Alternative Measurement Sites: Forearm (radial artery) or Thigh (popliteal artery, cuff placed $2.5\,cm$ [$1\,in$] above popliteal fossa with client prone or knee flexed). Thigh systolic pressure measures $10\text{ to }40\,mm\,Hg$ higher than brachial artery pressure.

• Blood Pressure Classifications (Adults):

  • Expected Reference Range: Systolic $< 120\,mm\,Hg$ AND Diastolic $< 80\,mm\,Hg$.

  • Hypotension: Systolic $< 90\,mm\,Hg$ OR Diastolic $< 60\,mm\,Hg$.

  • Elevated Blood Pressure: Systolic $120\text{ to }129\,mm\,Hg$ AND Diastolic $< 80\,mm\,Hg$.

  • Stage 1 Hypertension: Systolic $130\text{ to }139\,mm\,Hg$ OR Diastolic $80\text{ to }89\,mm\,Hg$.

  • Stage 2 Hypertension: Systolic $\ge 140\,mm\,Hg$ OR Diastolic $\ge 90\,mm\,Hg$.

• Determinants & Variables of Blood Pressure:

  • Smoking: Induces acute vasoconstriction, elevating blood pressure.

  • Gender: Post-pubertal males show higher pressures than females; post-menopausal females display higher readings than age-matched peers.

  • Ethnicity: African American populations display the highest global incidence of severe, early-onset hypertension, elevating risk for stroke, myocardial infarction, and death. White Americans display lower incidence rates.

  • Diurnal Rhythm: Pressure rises gradually throughout the day, peaking in late afternoon, and declining overnight.

  • Pharmacotherapy: Antihypertensives, cardiac drugs, and opioids lower BP; vasoconstrictors and amphetamines elevate BP.

  • Obesity: Positively correlated with elevated systemic blood pressure.

• Orthostatic Blood Pressure Measurement Protocol:

  1. Place client in supine position for $3\,minutes$, then measure BP.

  2. Position client upright sitting; wait $1\text{ to }3\,minutes$, then measure BP.

  3. Position client standing; wait $1\text{ to }3\,minutes$, then measure BP.

  • Diagnostic Criterion for Orthostatic Hypotension: A drop in systolic pressure $\ge 20\,mm\,Hg$ OR a drop in diastolic pressure $\ge 10\,mm\,Hg$ between positional changes.

Pain Assessment

• Nature of Pain: Highly subjective metric evaluating physical or emotional distress, rated and characterized primarily by the client.

• Sources of Pain:

  • Visceral Pain: Originates in major internal organs (e.g., appendicitis, cholecystitis, colitis). Characterized as deep, cramping, squeezing, or dull. Transmitted via autonomic nervous system (ANS); often triggers diaphoresis, nausea, and vomiting.

  • Somatic Pain: Originates in musculoskeletal structures (muscles, bones, tendons, ligaments, blood vessels). Characterized as deep achy or throbbing pain (e.g., bone fractures, muscle trauma). Triggers ANS responses including sweating, nausea, and tachycardia.

  • Referred Pain: Pain perceived in a body location remote from its origin site (e.g., cardiac ischemia causing left arm or neck pain).

• Classifications of Pain:

  • Acute (Transient) Pain: Short duration ($\le 6\,months$), clear onset related to injury/illness, predictable healing trajectory, and resolves upon underlying tissue healing.

  • Chronic (Persistent) Pain: Duration $> 6\,months$ (up to 20+ years), continuous or recurrent, potentially unidentifiable origin.

  • Malignant Pain: Associated with advanced cancer (tumor organ distention, tissue necrosis).

  • Nonmalignant Pain: Stemming from chronic musculoskeletal conditions (arthritis, low-back pain) or neuropathic conditions (fibromyalgia, peripheral neuropathy).

• PQRST Assessment Framework:

  • Provocation / Palliation: What activity initiated the pain? What exacerbates it? What relieves it?

  • Quality: Descriptive terms (e.g., sharp, dull, stabbing, throbbing, cramping).

  • Region / Radiation: Exact location and whether pain radiates to other areas.

  • Severity: Intensity rating measured on a $0\text{ to }10$ numeric scale ($0 = \text{no pain}$, $10 = \text{worst imaginable pain}$). Evaluates current level, baseline managed level, and functional tolerance threshold.

  • Timing: Onset time, duration, frequency, and diurnal patterns.

• Objective Pain Cues: Tachycardia, elevated blood pressure, local swelling, bruising, inflammation, facial grimacing, body guarding, clenching teeth, frowning, restlessness, or immobility. Chronic pain sufferers display subtle cues, including light massaging of affected areas, frequent sighing, and reduced physical activity.

Documentation Requirements and Case Applications

• Narrative Charting Guidelines: Documentation must be objective, complete, accurate, organized, and timely.

• Survey Documentation Content: Speech rate/rhythm/articulation, clothing cleanliness and appropriateness, skin characteristics, dental status, behavior, mood, mobility, gait, assistive devices, height, weight, and BMI.

• Vital Signs Documentation Standards:

  • Temperature: Degree, unit ($^\circ\text{C}$ or $^\circ\text{F}$), and anatomical route.

  • Pulse: Rate, strength ($0\text{ to }+4$), rhythm, and palpation site.

  • Pulse Oximetry: Percentage ($SpO_2\%$) and supplemental oxygen flow rate (in $\text{L/min}$) / delivery mode.

  • Respirations: Rate, rhythm, depth, and effort.

  • Blood Pressure: Systolic and diastolic values ($mm\,Hg$) and cuff application location.

  • Pain: Rating ($0\text{ to }10$), location, duration, characteristics, exacerbating factors, and interventions (or explicit denial of pain).

• Case Study 2 - Assessment & Charting Application:

  • Client Profile: Mr. Joe Dobbs presented for abdominal pain. Ambulates with a grimace, guarding his abdomen. Dressed appropriately for weather, well-nourished, unshaven face, possible halitosis, slightly round belly with no visible scars or blemishes. Appears anxious and fidgety. Oriented to name, DOB, and situation.

  • Anthropometric Data:

  • Height: $5'\,8''$

  • Weight: $226\,lb$

  • BMI: $34.4\,kg/m^2$ (Classified as Obese)

  • Vital Signs Data:

  • Blood Pressure: $165/85\,mm\,Hg$ (Seated in chair; Stage 2 Hypertension)

  • Pulse: $95/\text{min}$

  • Respirations: $22/\text{min}$, shallow (Tachypneic)

  • Temperature: $99.8^\circ\text{F}$

  • Pulse Oximetry: $98\%$ on room air

  • Subjective Pain Assessment Data:

  • Denies dyspnea/shortness of breath.

  • Current Pain Severity: $7/10$ on numeric scale (decreased from earlier severity).

  • Onset: Started previous evening.

  • Location: Middle of stomach (epigastric/umbilical).

  • Pain Quality: Cramping, deep, dull ache.

  • Self-Treatment History: Took ibuprofen and a laxative yesterday without relief; no medications taken today.