Enumerate/list down per 3 elements or components all possible observations and provide

rationale or underlying bakit yan oobserbahan, ex it suggest, it may reflect any underlying
conditions such as_____ as many as you have list down. With the discuss element of the 3
survey provide all possible observations. And provide recent rationale.

Next meeting we have series of quizzes

10 items per each lesson f2f

Elements/Components of General Survey

1. General Assessment/Overall impressions of Clients and clients emotional and cognitive
functional status through mental status examination
2. Examination (Head to toe assessment)
3. Taking of Vital Signs

General Survey pa lang, Wala pa sa pe

Quiz
Mental status examination
Initial general assessment
- general survey elements, which are overall impression of the patient, examination of data,
taking of vital signs.
- list down 3 examples ng oobserbahan per element then put rationale
Example - it indicates na balbabla

With the discussed 3 elements of the General Survey, provide all possible observations and
provide rationale each.

⅔ isang noble prize

Instrument and Gamit sa lab next recit

General Assessment

Essential Information

Identify: Full name, Note Gender, Ask age, ask about their college

Appearance

Age: Does the patient appear to be his stated age, or does he look older or younger?

Physical condition: Does he look healthy? Is his weight appropriate for his height, or is he
underweight or overweight? Note any obvious limitations, such as an amputation.

Dress: Is he dressed appropriately for the season? Note whether his clothing is clean and well
kept, or soiled or torn.

Personal hygiene: Is he clean and well groomed, or unshaven and unkempt, with dirty skin,
hair or nails? Does he have a strong body odor or unusual breath odor? Can you smell alcohol,
urine, or feces?

Skin: Look for obvious scars or rashes. Document any abnormalities, such as an unusually pale
or ruddy complexion, cyanosis, or jaundice.

Communication

Speech: Document whether he speaks clearly in English or another language and note
anything unusual for example, provides only one word responses, doesn't respond when
spoken to, speech is slurred, hoarse, loud, soft, incoher ent, hesitant, slow, fast, or nonsensical.
Indicate if he has trouble completing sentences because of shortness of breath or pain.

Hearing: Make sure he hears well enough to respond to questions. If he's hearing impaired,
note whether he hears better through one ear or the other and whether he wears a hearing aid.
If he's deaf, assess whether he reads lips or uses sign language.

Vision: Can he see well enough to read instructions in English or an- other language?
Document whether he needs glasses or contact lenses to see or read, if he's blind, or if he can't
read because he's illiterate.

Cognitive functions
Awareness: Is he oriented and aware of his surroundings, or dis- oriented and unaware of time,
place, and person?

Mood: Does he respond to ques tions appropriately? Is he talkative, or does he offer

information only in response to questions? Does he seem. hesitant, avoid eye contact, or look to
a family member before answer- ing? Does he seem angry?

Thought processes: Note whether he can maintain a conversation. Does he make relevant
statements and follow commands appropri ately, or does his mind wander?

By knowing what to look for, you can more thoroughly document important patient
characteristics quickly and accurately.

Motor Ability
Observations ( GENERAL Rationale
ASSESSMENT/Examination)

Appearance

Age: ● Age: This can be helpful to determine

● Infants and Toddlers the potential underlying health
● Young adults conditions that are common in certain
● Middle-aged adults age groups.
● Body condition: It can provide insights
Physical condition: into their nutritional status and
Body Condition (Healthy or Not) potential health risks.
Weight ● Dress: It indicates their social
Height circumstances, mental state, and
Underweight ability to care for themselves.
Overweight ● Personal hygiene: It reflects on their
Cachexia self-care practices and overall health.
Anorexia ● Skin: The skin is the largest organ of
Amputation the body and can reveal signs of
● Above-knee amputation infection, malnutrition, and other
● Below-knee amputation medical conditions.
● Arm amputation

Dress: Is he dressed appropriately for the

season?
● Clean
● Soiled
● Torn

Personal hygiene:
● Clean/Groomed
● Unshaven
● Unkempt
● Dirty Skin (Hair or Nails)
● Strongly Body Odor
● Unusual Breath Odor
● Can you smell alcohol, urine, or feces?

Skin:
● Scars
● Rashes
● Pale
● Ruddy Complexion
● Cyanosis
● Jaundice
● Tattoos
Communication ● Gather accurate information: Clear
speech allows patients to express
Speech: Note anything unusual speech for their symptoms, concerns, and
example: medical history accurately.
● Slurred ● Provide clear instructions and
● Hoarse information: Understanding a patient's
● Loud hearing, vision, and language
● Soft proficiency helps healthcare providers
● Incoherent and instructions to ensure
● Hesitant comprehension.
● Slow ● Build trust and rapport: Effective
● Fast communication fosters a sense of
● Nonsensical trust and allows patients to feel heard
and understood, which can lead to
Indicate if he has trouble completing better cooperation with treatment
sentences because of shortness of breath or plans.
pain. ● Identify potential cognitive issues:
Difficulties with speech, hearing, or
Hearing: vision can sometimes indicate
Hears well/better underlying cognitive problems.
Hearing Aid
Deaf (Uses signs language) By understanding a patient's communication
abilities, healthcare providers can adapt their
Vision: communication style and utilize appropriate
Check: tools (like assistive devices or interpreters) to
● Need Glasses ensure a successful patient interaction and
● Blind achieve the best possible health outcomes.
● Illiterate

Cognitive functions ● Identifies cognitive impairment: Early

detection of cognitive decline or
Awareness: Is he oriented and aware of his impairment allows for prompt
surroundings, or disoriented and unaware of intervention and management of
time, place, and person? underlying conditions.
● Peripheral awareness ● Ensures patient safety: A patient's
● Sensory awareness awareness and orientation impact
● Self-awareness. their ability to make informed
decisions about their care and
Mood: Does he respond to questions participate safely in treatment
appropriately? Is he talkative, or does he offer procedures.
information only in response to questions? ● Provides insight into mental health: A
Does he seem to? hesitant, avoid eye contact, patient's mood, thought processes,
or look to a family member before answering? and behavior can offer clues about
● Depressed potential mental health conditions like
● Despairing depression or anxiety.
● Irritable ● Optimizes communication:
● Anxious Understanding a patient's cognitive
● Angry abilities helps healthcare providers
● Expansive tailor communication strategies to
 ● Euphoric ensure comprehension and obtain
● Empty accurate information.
● Guilty
● Hopeless
● Futile
● Self-contemptuous
● Frightened
● Perplexed

Consider Cultural
● Differences Faith and Religious Beliefs
● Social and Economic Sensitivity
● Social and Economic Sensitivity

Determine gait/balance. ● Body Alignment: This refers to the

● Body Alignment body's posture in standing, sitting,
● Gait and walking. Proper alignment
● Appearance and Movement of Joints ensures efficient movement and
● Capabilities and Limitations for reduces stress on joints.
Movement ● Gait: This is the pattern of walking,
● Muscle Mass and Strength including stride length, foot
● Physical Energy for Activities placement, and overall smoothness of
● Echopraxia movement. Abnormalities in gait can
● Copropraxia indicate underlying issues.
● Tripod Position ● Appearance and Movement of Joints:
● Orthopneic Position The range of motion, stability, and
● Sitting presence of pain or swelling in joints
● Supine are assessed.
● Semi Fowler's ● Capabilities and Limitations for
● Sims Movement: This involves observing
● Dorsal recumbent the individual's ability to perform
movements like bending, reaching,
and turning.
● Muscle Mass and Strength: Adequate
muscle mass and strength are
essential for maintaining balance and
stability.
● Physical Energy for Activities: This
assesses an individual's endurance
for daily tasks and their ability to
maintain activity levels.
● Echopraxia: This is the involuntary
imitation of movements observed in
others.
● Copropraxia: This is the involuntary
imitation of complex actions or
gestures.
● Tripod Position: This refers to a

Observations
Thought content
The examiner assesses what the patient is
saying for indications of hallucinations,
delusions, obsessions, symptoms of
dissociation, or thoughts of suicide or harm to
others.
Hallucinations
Auditory: (Hearing things)
Visual: (seeing things)
Gustatory: (tasting things)
Tactile: (feeling sensations)
Olfactory: (smelling things). Command
hallucinations are auditory and instruct the
patient to take some action, often harmful to
self or others.
Delusions
● Grandiose (delusions of grandeur)
● Persecution (belief that someone wants
to cause them harm)
● Erotomanic (belief that someone
famous is in love with them)
kneeling position with the buttocks
resting on the heels and hands placed
forward for support. It's used to
assess balance and lower body
strength in children.
● Orthopneic Position: This is an upright
posture with forward-leaning support
often adopted by people with
respiratory problems to ease
breathing.
Rationale
● Hallucinations and delusions are
characteristic symptoms of
psychosis, a severe mental state
where individuals lose touch with
reality. Early detection and
intervention are crucial for managing
psychosis effectively.
● Suicidal or homicidal thoughts
require immediate attention. By
evaluating thought content,
examiners can determine the level of
risk posed to the patient or others
and take appropriate steps to ensure
safety.
● The content of a patient's thoughts
can provide clues about underlying
mental health conditions such as
anxiety, depression, or obsessive-
compulsive disorder (OCD). This
information guides the diagnostic
process and helps in developing
targeted treatment plans.
 ● Jealousy
● Thought insertion (belief that someone
is putting ideas or thoughts into their
mind)
Thought Process
Thought process refers to the logical
connections between thoughts and their
relevance to the main thread of conversation.
● Looseness of association (irrelevance)
● Flight of ideas (change topics)
● Racing (rapid thoughts)
● Tangential (departure from topic with no
return)
Judgment
The examiner asks the individual what he or
she would do in the event of a common-sense
problem, such as running out of prescription
medication.
Insight
Insight is a person's capacity to perceive an
issue and understand its nature and severity.
Observe the Body Posture
Observe the motor movements
● Balance
● Evaluating thought processes is
essential for understanding an
individual's mental clarity and ability
to communicate effectively. By
analyzing the flow and structure of
thoughts, healthcare professionals
can identify potential signs of
disorders like schizophrenia or
mania, where thought patterns
become disorganized or illogical.
● Assessing judgment helps gauge an
individual's ability to make sound
decisions and respond appropriately
to real-world situations. By posing
hypothetical scenarios, healthcare
professionals can evaluate a
person's capacity to weigh risks and
consequences, plan effectively, and
exercise sound decision-making
skills.
● The importance of evaluating insight
in mental health assessment is also
not limited. Firstly, it enables one to
understand a person’s knowledge of
the disease and its influence on life.
Lack of awareness implies treatment
unwillingness and, therefore, lack of
possibilities for recovery. A person
diagnosed with depression, who
does not have insight into this state,
will likely not take pills or attend
therapy..
● This can be helpful in various
settings, including physical therapy,
 ● Gait occupational therapy, developmental
● Gross motor function assessments, and neurological
● Fine motor function evaluations..
● Coordination
● Sensory functioning
● Temperature sensory functioning
● Kinesthetic sensations
● Tactile sensory motor functioning
● Cranial Nerve
● Tremors

Observe body type ● This can be helpful in fitness

settings, guiding someone toward
● Ectomorph exercise programs or nutritional
● Endomorph habits that best suit their goals.
● Mesomorph

Observations (VITAL SIGNS) Rationale

Body Temperature ● A normal temperature indicates

general well-being, while a high
Core Temperature temperature may indicates
● Is the Temperature of the deep tissues of infection or inflammation,
the body, such as the cranium, thorax, necessitating further
abdominal cavity, and pelvic cavity investigation. Furthermore, a
Surface Temperature: normal heart rate means that
● The temperature of the skin, the your heart is beating effectively
subcutaneous tissue and fat. enough to maintain oxygen-rich
Pyrexia: Above the normal ranges blood flow to your organs. A
Hyperpyrexia: Very high fever heart that beats too fast or too
A client who has fever is referred as febrile; the one slowly may indicate an
who has not is underlying illness.
afebrile.
● Normothermia: Normal values of body
temperature.
 ● Pyrexia: An elevated body temperature due
to an increase in the body temperature’s set
point.
● Hyperthermia: An elevated body
temperature due to failed thermoregulation.
● Heat stroke: A presentation of severe
hyperthermia.
● Low temperature: A lowered body
temperature, where the body loses heat
faster than it can produce heat.
● Hypothermia: An abnormally low body
temperature, where the body temperature
drops below a safe level.
Normal Range: (36.6-37.7 C)

Pulse or Heart Rate ● A normal heart rate suggests

● Peripheral Pulse: is a pulse located in the your heart is functioning
periphery of the body e.g. in the foot, and or effectively to deliver oxygen-rich
neck blood to your organs.
● Apical Pulse (central pulse): it is located at Abnormally fast or slow heart
the apex of the heart the PR is expressed in rates can signal underlying
beats/ minute (BPM) health concerns.
● Pulse Deficit- It is a difference that exists
between the apical and radial pulse
● Arrhythmia — Irregular heartbeat.
● Atrioventricular node — Pick up electrical
signals and pass them to the lower
chambers of the heart.
● Atrium/Atria — One of the two upper
chambers of the heart.
● Bradycardia — Abnormally slow heartbeat..
● Flutter — Fast and uncoordinated
contractions. Not as disordered as
fibrillation.
● Palpitation — The feeling caused by
irregular heartbeats.
● Syncope — Loss of consciousness caused
by lack of blood flow to the brain. Often
caused by arrhythmia.
● Tachycardia — Abnormally fast heartbeat.
● Transesophageal echocardiography — A
test that bounces sound waves off the heart
by means of a tube inserted down the throat.
● Ventricle — One of the two lower chambers
of the heart.
● Wolff-Parkinson-White syndrome — A
disease caused by an extra electrical
pathway connecting the upper and lower
chambers of the heart.
Normal Range: 60-100 bpm
 Respiratory Rate
● Bradypnea: Abnormally slow.
● Tachypnea: Shallow
● Dyspnea: Shortness of breath
● Hyperpnea: Abnormally deep and appears
laboured.
● Apnea: “No breath” (Absence of breathing)
Normal Range: 12-20 bpm
● A normal respiratory rate (12-20
breaths per minute) indicates
your lungs are functioning
efficiently. Deviations from this
range, such as bradypnea (slow
breathing), tachypnea (rapid
breathing), hyperpnea (deep,
labored breathing), or apnea
(absence of breathing), can
signal respiratory problems or
underlying health conditions.

Blood Pressure ● Regular monitoring allows early

Angina: Chest pain detection and management of
potential cardiovascular issues.
Normal: 120/80 mmHg
Hypotension: <90 or < 60 mmHg
Prehypertension: 120/80 to 130/89 mmHg
Stage 1 Hypertension: 140/90/ 159/99 mmHg
Stage 2 Hypertension: >160 or > 100 mmHg

Blood oxygen saturation (SpO2) ● Blood oxygen saturation (SpO2)

Normal: (Sp02:95-100%) is a crucial indicator of how
Low: (Sp02:90-94%) effectively your red blood cells
Critical: (Sp02:<90%) are carrying oxygen throughout
Danger for patient: (Sp02:<70%) your body.

Blood Glucose Level ● Blood oxygen saturation (SpO2)

is a crucial indicator of how
Normal Range: 70 and 100 mg/dL (3.9 and 5.6 effectively your red blood cells
mmol/L) are carrying oxygen throughout
your body.

References:

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Temperature_management/

https://www.okheart.com/about-us/ohh-news/glossary-of-common-heart-rhythm-terms

https://www.physio-pedia.com/Respiratory_Rate#:~:text=Tachypnea%20is%20the%20medical
%20term,or%20a%20decreased%20respiratory%20rate.