GENERAL SURVEY

State of awareness
 Before we start do you have any questions for
me?
 Can you state your name for me sir?
 When is your birthday?
 Do you know where we are now?
 Do you know the date and time today?
 Sir can you close your eyes for me, okay, open
them up.
 Can you smile for me? Puff your cheeks.
 Can you tell me what I am holding?
 Can you tell me what color this is?
 Can you count my fingers sir?
 Who is the president of the Philippines?
Obvious signs of distress, pain, anxiety.
 Do you feel any pain right now? Can you rate
it from 0 to 10, zero as no pain and 10 as worst
pain?
 Have you ever experienced fear on your
partner or family member?
 Do you feel threatened at home or at work?
 Do you feel any pressure when it comes to
work and school?
Speech
 Sir, I will be saying some words and what
you’re going to do is to repeat after me okay?
 Could you say readiness for me? Paragraph,
Delicious, below?
TEST FOR APHASIA
 Can you point your nose? Your mouth? Knee?
 Sir can you read this paragraph aloud?
 Sir, can you write a sentence for me?
Mood and Affect
 How do you generally feel most of the time?
 How would you say you feel generally?
Happy? Angry? Sad? Frightened?
 Are you enjoying anything lately?
 What can you say about life?

Gait
 Sir, can you walk from this area going towards
that wall and turn around and comeback?
 Sir can you walk again with heel to toe? (test
for ataxia)
 Sir can you walk on your heels? (test for deep
fibular nerve, if there’s neuropathy, lesion or
damage)

Posture
 Sir can you please stand straight?

Body movements
 Sir can you wave your hands for me sir?
 Can you flex your arms sir?
 Flexion, extension, abduction, adduction,
rotate hips,

Hygiene, grooming and odor

 Inspect client’s hygiene, grooming, and odor.
 How do you often brush your teeth?
 How many times do you take a bath every
day?
 Are you having problem when it comes to
control your body odor?
VITAL SIGNS:
Temperature
 Place patient in appropriate position
 Disinfect the probe of the thermometer
(bottom to top)
 Dry the probe of the thermometer
 Roll client’s sleeve.
 Dry the armpit.
 Place probe of the thermometer in axilla
 Degree sign flashes, when flashes stops, it will
beep and will display the result in LCD
 Turn off unit.
 Disinfect the probe and return to protective
cover.
 Document
Pulse
 Assess for factors affecting pulse or any
cardiovascular alterations
 Select site appropriate for assessment
 Use secondhand watch
 Have the patient in resting position, palpate
and count the pulse for a full minute
 Assess rhythm and volume
 Document
Respiration
 Position patient assumed for breathing
 Assess for factors affecting RR such as
medications, signs of cerebral anoxia, dyspnea
 Use watch with second hand
 Observe or palpate or count the RR (if patient
is aware, place hand against chest/ put the
patient’s arm across his chest assuming that
you are counting the pulse
 Count for full minute (1 inhalation and 1
exhalation = 1 respiration)
 Observe the depth, characteristics, and
regularity of respiration
 Document
Blood pressure
 Assess for signs and symptoms of
hypertension and hypotension
 Assess factors affecting the BP such as
medications or vigorous activities
 Prepare all the needed materials (Stethoscope,
sphygmomanometer, BP cuff, watch w/ 2nd
hand)
 Explain the procedure to the client
 Perform hand hygiene
 Provide privacy
 Position the client appropriately
 Sitting position unless specified
 Both feet flat on the floor
 Elbow slightly flexed
 Palms facing upward
 Forearms supported at heart level
 Expose upper arm
 Wrap the deflated cuff evenly to the upper
arm.
 Locate brachial artery. Apply the center of the
bladder over the artery. For adults place the
lower boarder of the cuff 2.5 cm or 1 inch over
the antecubital fossa.
 If this is an initial assessment, perform
preliminary palpatory determination of the
systolic blood pressure
 Locate the brachial artery
 Close valve by turning the knob
clockwise
 Pump the cuff until you no longer feel
the brachial pulse (blood cannot flow
in the artery)
 Note the pressure in which you no
longer feel the pressure.
 Release the pressure completely and
wait for 1-2 mins for further
determinations
 Position the stethoscope appropriately
 Cleanse the earpiece
 Ensure that stethoscope hangs freely
from ear to diaphragm
 Place the bell over the brachial pulse
and hold the diaphragm with thumb
and index finger.
 Place the client’s BP
 Pump the cuff until it reaches 30 mmHg
above the point in which the brachial pulse
disappeared.
 Release valve carefully so that pressure
release 2-3mmHg per second
 As pressure pulse, identify the manometer at
each of the 5 phases as possible.
 Deflate the cuff completely and rapidly
 Wait 1-2 mins before making further
determinations.
 If the assessment is initial, repeat the
procedure
 Disinfect the cuff and document.