COLLEGE OF NURSING
STUDENT: _________________________________________________ DATE: _______________________
BLOCK: ________________________________________________ SCORE: ______________________
CLINICAL INSTRUCTOR: __________________________________________________________________
CONDUCTING GENERAL SURVEY
General Appearance & Mental Status
PROCEDURE CHECKLIST
I. OBJECTIVES
1. To identify the general and the mental status of a client
2. To determine if there is an underlying medical condition using inspection assessment
technique.
3. To provide mental status assessment to know if client is coherent enough to pursue further
with the physical assessment.
II. MATERIALS/EQUIPMENTS
1. Physical Examination form
2. Pen/Notebook
III. PROCEDURE STEPS. CHECK THE DONE NOT SCORE
APPROPRIATE BOX. 1 DONE
The student is expected to perform the following: 0
PREINTRODUCTORY PHASE
1. Review client’s medical records.
2. Prepare all necessary materials or equipment needed.
INTRODUCTORY PHASE
3.Introduce yourself by giving your name, title, and role.
4.Wear proper ID, neat uniform and RLE hair.
5.Perform handwashing and if needed, wear PPE.
6.Verify the client’s identity using institution protocol.
7.Provide privacy by closing the doors and windows and
drawing the curtain.
8.Maintain comfortable room temperature.
9.Explain to the client what you are going to do, why is
necessary and how he/she can participate.
WORKING PHASE DONE NOT SCORE
A. Vital Signs 1 DONE
10.Assess vital signs of the client. (body temperature, 0
pulse, respiration, blood pressure, pain) and note for
any variations.
B. Signs of Distress and Pain.
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
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Health Assessment 2nd Semester January 2021 Rhoda Grace Estioco-Ruelos, MAN, RN Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Faculty Dean
COLLEGE OF NURSING
11.Observe for signs of distress in posture (slumped
posture) or facial grimace and sad expression.
12.Note for difficulty of breathing(cough), skin color
(cyanotic or pallor, lesions?)
C. Appearance in Relation to Age.
13.Compare client’s stated age with his/her apparent
age and developmental stage. (Does client appear
older or younger than actual chronological age?)
D. Body Structure.
14.Observe physical development, body build and fat
distribution. (A lack of subcutaneous fat with
prominent bones is a sign of malnutrition. Abundant
fatty tissue is a sign of obesity)
15.Observe body proportions. Ask client to spread the
arms out to the side and make a comparison of the
arm span to the height of the client. (Note for
symmetry of body parts, general proportions of the
body and the length of the limbs.)
E. Height and Weight
16. Measure height and weight and observe variations. (Is
the height and weight appropriate to body structure?)
F. Posture and Gait
17. Ask the client to walk few steps away from you.
and towards you. (Note for manner of walking such as
speed, balance, coordination and symmetry of
movements. Is it stiff or rigid? Is the client using
physical mobility devices?)
18.Ask the client to stand and note symmetry of body
parts, balance and physical deformities. (Observe for
any curvatures of spine such as lordosis, scoliosis or
kyphosis)
19.Assess for any physical deformities whether
caused by injury/accident, congenital or
developmental. (congenital malformations, birth
marks, amputations, webbed digits or extra digits.)
G. Hygiene and Grooming
20.Assess personal hygiene and grooming and clothes
the client is wearing. (Is it appropriate to the client’s
age group, weather, culture and occasion? Is it neat
and clean? Are there any signs of self-care deficit in
relation to personal hygiene and clothing?)
H. Body Odor and Breath
21.Note for body odor and breath odor such as foul
body odor (smell of urine or feces coming from
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
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Health Assessment 2nd Semester January 2021 Rhoda Grace Estioco-Ruelos, MAN, RN Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Faculty Dean
COLLEGE OF NURSING
the body and ammonia or acetone odor, & alcohol
breath).
I. Facial Features and Expression
22. Note for symmetrical movement of face and size of
facial features.
23. Observe facial expression during the general survey
process.
J. Affect and Mood
24. Ask client’s current feelings.
25.Observe for appropriateness of client’s responses.
Does the client cooperate and follow instructions?
26. Observe level of consciousness.
Note: The appropriateness of client’s verbal responses with
his/her nonverbal cues
K. Speech
27. Listen and observe for client’s quantity of speech,
pattern, sentence structure, clarity and strength of voice
(rapid or slow pace, clear or unclear tone, loud or
soft?) when answering questions.
POST IMPLEMENTATION PHASE
28. Validate the information gathered for accuracy,
reliability, and completeness.
29. Discard PPE used appropriately and perform
handwashing.
30.Report significant findings and needs that requires
immediate intervention to nurse supervisor or the
physician. Document and record data and findings
gathered in the client’s chart in a factual manner
using appropriate terminologies.
TOTAL SCORE
/30
PRECEPTOR’S NAME AND SIGNATURE
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
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Health Assessment 2nd Semester January 2021 Rhoda Grace Estioco-Ruelos, MAN, RN Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Faculty Dean
COLLEGE OF NURSING
REFERENCE:
Weber J. & Kelley, J. (2014). Health Assessment in Nursing Fifth Edition, p.123-133
Berman, A., Snyder, S., and Frandsen, G. (2016). Kozier and Erb’s Fundamentals of Nursing,
Concepts, Process, and Practice Tenth Edition, p.540-549
REVISED FOR SCHOOL YEAR 2020-2021
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
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Health Assessment 2nd Semester January 2021 Rhoda Grace Estioco-Ruelos, MAN, RN Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Faculty Dean
