General Survey

General Survey

Myung-Hee Pak, RN, MSN, CNS

General Survey
Physical
Appearance

Age
Sex
LOC
Skin color
Facial features
No signs of acute

Body Structure
Stature
Nutrition:WDWN, or malnourished
Symmetry:
Posture: erect, slumped over,
Aging person who may be
stooped with kyphosis
Position
Body build, contour
Obvious physical deformities:
note congenital or acquired
defects

General Survey

Study of the whole individual

Overall impression
Begins at the first encounter with a
person
Introduction to the physical
assessment
Composed of 4 parts: physical
appearance, body structure, mobility
& behavior

General Survey
Behavior

Mobility
Gait:coordinated,
arms swinging
freely
Range of Motion
(PROM or AROM)
No involuntary
movement

Facial expression
Mood and affect:
appropriate to
situation, flat, hostile,
cooperative
Speech:garbled,
unclear
Dress/
Hygiene:appropriate,
cultural, for weather,
body odor

Factors Controlling Blood

Pressure

Includes Height & Weight

Vital signs: Temperature, Pulse,
Respiration & Blood Pressure
Recognize transcultural
considerations
Note S/S (signs/symptoms) of
distress/pain
Illustration Pat Thomas, 2006

Assessing Distress/Pain
Assessment includes:
S- Severity
L- Location
I- Influencing factors
D- Duration
A- Associated Symptoms

Assessing Distress/Pain
Pain assessment = 5th vital sign
Utilize pain scale
Understand chronic vs acute pain
Recognize gender, transcultural and
developmental factors effecting pain

O
OnsetExactly when did it start? When did you first notice it?
P
Provocative or palliative
What brings it on? What where you doing when you
first noticed it? What makes it better? Worse?
Q
Quality and quantity
How does it look, feel, or sound? How intense/severe is
it?
R
Region or radiation
Where is it? Does it spread anywhere?
S
Severity scale
How bad is it (on a scale of 1 to 10)? Is it getting better,
worse, staying the same?
T
Timing
Is it constant or does it come or go?
Duration- How long did it last?
Frequency- How often does it occur?
U
Understanding patients perception of the problem
What do you think it means?

Sample Documentation:
General Survey

This is a 34 yo black female office manager, WD

appropriate for age, WN, grooming appropriate for age,
appears stated age, sexual development appropriate.
A&Ox3, responds to questions appropriately articulation
clear. Maintains eye contact, calm, cooperative, with
appropriate expressions. Skin color dark olive, tone
even, intact, hyperpigmented macules on bilateral
cheeks and lower arms. Facial features symmetrical.
Bilateral body parts are symmetrical and proportionate,
posture erect, sitting comfortably in chair facing
examiner. No obvious physical deformities. Ambulatory
with steady gait, full, smooth ROM without involuntary
movements. VS:HT 54, WT 165 lb, both appropriate
for age and body build and proportionate. BP(Rt
arm:sitting) 125/85, NAD, P 78 RRR, RR 16 even,
unlabored, T 98F oral.

Structure and Function

Assessing Skin, Hair & Nails
Myung-Hee Pak, RN, MSN, CNS

Think of skin as bodys largest organ

system
Covers 20 square feet of surface area in
adults
Skin is sentry that guards body
Environmental stresses, e.g., trauma,
pathogens, dirt
Adapts it to other environmental influences,
e.g., heat, cold

Structure and Function

Skinthree layers
1. Epidermis:avascular
basal cell layer:keratin
& melanin
horny cell
layer:desquamated
every 4 wks
Derivation of skin color

2. Dermis
Connective tissue or
collagen
Elastic tissue

3. Subcutaneous layer

Structure of Skin

Epidermal appendages
1. Hair: terminal &
vellus hair
2. Sebaceous glands
3. Sweat glands
Eccrine glands:sweat to
control temp
Apocrine glands:thick
milky secretion to hair
follicle, bacteria, body
odor

4. Nails: hard plates of

keratin

Skin Cancer

Structure of Nails

http://www.nlm.nih.gov/medlineplus/ency/
anatomyvideos/000125.htm

Assessing the Skin

Rationale for Assessment:reflect
underlying disease and hydration status, if
any breaks- can predispose for infection
Integumentary System= skin, hair, nails.
Skin- Epidermis, Dermis, Subcutaneous
tissue
Incorporates subjective and objective
assessments
Includes inspection and palpation
techniques

Subjective Assessment: Skin

Past history of skin disorders?
(allergies, hives, psoriasis, or eczema)
Changes in pigmentation(size or color)?
Changes in a mole?(color, shape & size)
Excessive dryness, or moisture?
Pruritus?
Any lesions that do not heal
Trauma to skin (stiches, burns)
Use of tanning salons, sun lamps
How much time does person spend outside

Objective Assessment- Skin

The Physical Exam

Subjective Assessment: Skin

Excessive bruising?
Hair loss
Change in nails
Rash or lesion?
Meds
Environmental hazards- work, sun,
insects, plants
Self care- cosmetics, soaps, etc.

Equipment:Strong, direct lighting, small

centimeter ruler, penlight, gloves
Begins with INSPECTION
Assess hands, nails = nonthreatening
Assess for color changes:pallor,
erythema, cyanosis, jaundice
Pigmentations: Freckles, Nevus (mole),
Birthmarks

Objective Assessment- Skin

The Physical Exam

Proceed to PALPATION
Temperature: use back of hands
Texture:use finger tips-smooth, rough
Moisture:diaphoresis or dehydration
Edema:use scale +1~+4
Turgor:elasticity.. Tenting=dehydration
Vascularity or Bruising:ecchymosis
Mobility:elasticity
Thickness

Abnormal Findings (cont.)

Primary skin lesions

Macules
Papules
Patches
Plaques
Nodules
Wheals

Tumors
Urticaria (hives)
Vesicles
Cysts
Bullas
Pustules

Slide 12-22

Macule

Slide 12-23

Papule

Slide 12-24

Nodule

Slide 12-25

Wheal

Slide 12-26

Vesicle/Bulla

Slide 12-27

Cyst

Slide 12-28

Pustule

Abnormal Findings (cont.)

Secondary skin lesions
Debris on skin surface
Crusts
Scales

Slide 12-29

Break in continuity of skin

surface

Fissures
Erosions
Ulcers
Excoriations
Scars
Atrophic scars
Lichenifications
Keloids
Slide 12-30

Crust

Slide 12-31

Scale

Slide 12-32

Fissure

Slide 12-33

Erosion

Slide 12-34

Ulcer

Slide 12-35

Excoriation

Slide 12-36

Scar

Atrophic Scar

Slide 12-37

Slide 12-38

Lichenification

Keloid

Slide 12-39

Slide 12-40

Psoriasis of scalp

Abnormal Findings (cont.)

Psoriasis Involving the Scalp

Vascular Lesions
Hemangiomas
Port-wine stain (nevus
flammeus)
Strawberry mark (immature
hemangioma)
Cavernous hemangioma
(mature)

Telangiectases
Spider or star angioma
Venous lake

Purpuric lesions
Petechiae
Purpura

Lesions caused by
trauma or abuse
Pattern injury
Hematoma
Contusion (bruise)

Slide 12-41

Scar
Scar of Arm Following Open Reduction of
a Fracture

Cherry angiomas common in adults over 30

Excoriations from branches

Excoriations from Multiple Tree Branch
Scratches

Tinea pedis + athletes foot

Scaling and Fissures of Tinea Pedis

Ecchymosis

Ecchymosis

Ecchymosis Caused by Injury from Falling

on a Hard Object

Venus star

Cellulitis

Venous Star on Overweight Female

Gangrene

Cyanosis
Cyanotic Phase of Raynauds Disease

Raynauds
Pallor Caused by Vasoconstriction
(Raynauds Phenomenon)

Telangiectasia dilation of capillaries

Telangiectasia in Female with Progressive
Systemic Sclerosis

Assessment of Lesions
The Physical Exam
Color
Pattern or Shape
Size in cm
Elevation (flat or raised)
Location and distribution on body
Exudate (color, odor)

SOAP NOTES
1.Impaired skin
integrity r/t
2. Risk for
impaired skin
integrity r/t
3. Disturbed
body image r/t.
4. Enhansed
Health seeking
behaviors r/t

Ulcer on the Great Toe of 37-Year-Old

Insulin-Dependent Diabetic Male

Stage 4 decubitus

Decubitus stage 2 & 3

Assessmet

Diabetic, ulcer

Assessing Hair

Plan
1. Teaching
Hygiene
Cancer prevention

Inspection and palpation

Color
Texture
Distribution
Lesions of scalp

10

SOAP NOTES
Assessmet
1.Potential for
infection r/t
2.Body image
disturbance r/
t.

Plan
1. Hygiene
shampoo and
combing

Figure 1-63.
Alopecia

Assessment of Nails
Shape and contour: convex, slightly
curved or flat and smooth, 160 degrees.
Consistency- surface smooth and
regular, not brittle or splitting, uniform
thickness.
Capillary Refill- depress nailbed color
blanches , color should return <1-2
seconds

Figure 1-62.
Balding

Pediculosis
Pediculosis Pubis

Figure 1-66.
Anatomy of the Nails

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Clubbing & amputation

Cyanosis

SOAP NOTES
Assessmet
1.Potential for
infection r/t
2.Body image
disturbance r/
t.

Health Promotion
Teach all adults to examine skin once
a month & a yearly exam by
dermatologist.
Teach diabetics the importance of
skin care to feet

Plan
1. Hygiene

Health Promotion
Danger signs of pigmented lesions
(moles):
A - Asymmetrical Shape
B - Border Irregularity
C - Color
D - Diameter greater than 6mm
E - Elevation (flat or raised).

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Malignant melanoma
Nodular Malignant Melanoma

Lesions caused by trauma or

abuse: Pattern injury

Basal cell carcinoma

Basal Cell Carcinoma

Summary
General survey overall appearance of an
individualbeginning of the physical
health assessment
Physical health assessment begins with
the skin including the hair and nails
Includes inspection & palpation
Health promotion through teaching is
incorporated

A flat macular hemorrhage is

called a(n):
A. Purpura
B. Ecchymosis
C.Petechiae
D.Hemangioma

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