General Assessment Flashcards
Key Components of the General Survey
Physical Appearance
Mental Status
Mobility
Patient Behavior
Additionally:
VS
Pain Scale
General Survey - Physical Appearance
Age - are they the stated age, do they appear younger, older
Physical Condition - toxic, non-toxic, ill-appearing, fit, de-conditioned, cachectic(wasting), respiratory distress, Lethargic
Dress - Disheveled, composed, appropriate for the weather
Hygiene - Odor (alcohol, urine, feces), unkempt, dirty, clean, well-groomed
Skin color - pale, diaphoretic, cyanotic, red, burned.
- some of these can be pert pos or neg for psych Pt’s
General Survey - Physical Appearance: Toxic vs non-toxic
Generic term
refers to the appearance of sepsis, or an infectious process
indicates an unstable Pt, or impending instability
Toxic = ED, Emergent, at risk, closely monitored
Unstable - hypoperfusion, hypoventilation
Non toxic is good to document
What for the clinical S/S - altered mental status etc etc
General Survey - Physical Appearance: Lethargic
Unresponsiveness, or slowed response or inactivity
Pts may describe the Sx of lethargy
Clinicians use lethargy to describe general appearance of patients
This is not on a continuum with fatigue and or sleepiness as a clinical sign
*Could be a sign of stroke or blood toxicity
*care with using this as a descriptor esp. in pediatrics
General Survey - Mental Status
General Appearance
Emotions
Thoughts
cognition
Judgement and insight
*Considered the psych equivalent of the PE
General Survey - Mental Status: Key Factors
Culture, social, economic, and religious background
Culture, social, economic, and religious back ground shape mental health
Health literacy
language barriers
Not every pt needs MS exam, but they all deserve adequate observation of mental status during an encounter
*Bare in mind culture vs MH vs psychosis
General Survey - Mental Status: Key words/descriptors
Emo/affect - stability, intensity, mood, cooperative, agreeable, calm, angry, combative, withdrawn, argumentative, defensive, impulsivity, distractibility
Thoughts - SI/HI, obsessions, phobias, paranoia, delusions, tangential, flight of ideas, hallucinations, preservation
Cognition -orientation, memory, alertness, attention (A+Ox4)
Judgements and insights - awareness, accuracy, appropriateness
General Survey - Mobility
Ambulation- steady, unstable, req assistance, shaky, antalgic, slow, shuffling, independent
Movement - Moving all extremities, symmetric, paralysis, spastic, weakness, rigid, ina stretcher, req transfer assistance
General Survey - Pt Behavior
Essentially the Same as mental status portion; uses the same descriptors.
orientation, memory, alertness, attention (A+Ox4)
General Survey - VS
In a healthy adult
BP 120/80
HR 60-100
RR 12-16
O2 95-100%
Temp - 97.8-99 (36.5 - 37.2)
Make sure to repeat any vitals that don’t fit your observations
These factors all affect one another
Pt conditions, pos and neg, affect these (COPD my have lower base lines, runner may have lower Hr)
VS are documented in the OBJECTIVE portion of the note; but you can report subjective things the Pt tells you in the subjective section of note HPI
General Survey - VS Pearls
Take your own vitals, especially if the ones doc don’t fit the clinical picture
Consider body habitus when checking BP
Sometimes manual BP is more accurate
one set is never enough
do not d/c a Pt with abn VS unless you can clearly explain in doc
A “hyperfocus” on BP can lead to elevated readings
White coat syndrome
Calibration of home BP cuffs
Give Pt time to relax if able
Explain VS to your Pts
Multiple site to take temp. Some are more accurate, but may be embarassing to the Pt
