General Assessment

Question 0

Measurements

Answer 0

Weight
Height
BMI
Waist to Hip Ratio

Question 1

General Survey

Answer 1

Physical Appearance
Body Structure
Mobility
Behaviour

Question 2

Vital Signs and Expected Ranges

Answer 2

Temperature, taken orally 36- 38 degree C
Respiration 12- 20 breaths per minute
Pulse 60-100 beats per minute
Oxygen Saturation 92- 100 %
Blood Pressure 120-139/80-89 mmHg

Question 3

Taking temperature

Answer 3

Before taking ask: when did you last have a hot/cold beverage, chew gum or smoke?

Wait 2 min after smoking, 5 minutes after chewing gum and a half hour after liquids

Insert covered probe into one of the posterior sublingual pockets and hold it or have patient hold it for duration of reading

Normal range is 36-38

Question 4

Taking a Radial Pulse

Answer 4

Palpate radial pulse

If rhythm is regular, take for 30 seconds. If not, take for a full minute

Assess rate, rhythm and force

Briefly take pulse in both wrists to assess equality bilaterally.

Question 5

Taking Respiration Rate

Answer 5

Do at same time as pulse, but do not tell patient you are observing their breathing

Count for 30 seconds if regular, for a minute if irregular

Expect regular breathing that isn’t to shallow, deep or laboured without loud or laboured breathing sounds

Question 6

Taking Blood Pressure

Answer 6

First inquire if the patient has smoked, had coffee or been changed position recently

Ask if they have a mastectomy or have had surgery that would dictate which arm blood pressure be read from. If not, ask if they have a preference of side

Ensure patients feet are not crossed or dangling!!!

Size cuff, making sure end is 40% of arm diameter and width is 80% of arm

Palpate brachial pulse

Put on cuff in line with brachial artery

Palpate radial pulse while inflating cuff and inflate 30mmHg past where you last feel pulse

Auscultate brachial artery while letting out pressure at 2mmHG/s

Listen for the korotokoff’s sounds I,IV, and V to determine first systolic and then diastolic pressure

Question 7

Physical Appearance

Answer 7

Age
Sex
Level of Consciousness 
Facial Features
Colour

Question 8

Body Structure

Answer 8

Stature - height within normal range for age and genetic background

symmetry - body parts equal bilaterally and in proportion to each other

Posture - comfortably erect and appropriate for age

Position - sitting comfortably with arms at side and head turned to examiner

Nutrition - weight within normal range for body structure and height. Even distribution of body fat

Body structure/contour - arm span equal to height. Body length from crown to pubis approximately equal to length from pubis to sole. Note obvious deformity, congenital or acquired defects

Question 9

Mobility

Answer 9

Gait - accurate foot placement. Base width approximately equal to shoulder width. Smooth, even and well balanced walk. Presence of any associated movements, like symmetrical arm swing of associated

Range of Motion - full mobility in each joint with deliberate, accurate, smooth and coordinated movement

Question 10

Behaviour

Answer 10

Mood and affect
Facial expressions
Dress
Hygiene/self care

Question 11

BMI

Answer 11

Weight in kg/ (height in meters)squared

Question 12

What are korotokoff’s sounds

Answer 12

Phase 1 systolic is a clear tap
Phase 4 muffling of sounds
Phase 5 diastolic pressure, silence