– It begins upon contact with the patient and conducted while the nurse prepares the patient for the physical exam.
– It must be assessed in relationship to culture, educational level, socioeconomic status and current circumstances
– It involves observation of the patient’s general appearance and mental status, measurement of vital signs, height and weight.
– Vital signs are measured to establish baseline data against which to compare future measurements and to detect actual and potential health problems. Pain assessment is included in the taking of vital signs.
- Gender, Age, Civil Status
- General appearance – e.g. disheveled/kempt/unkempt
- Facial expression
- Body Built, Height and Weight in relationship to patient’s age, lifestyle and health
- Posture and Gait
- Hygiene, Grooming and Body and Breath Odor
- Signs of Distress in posture or facial expression
- Obvious Signs of illness
- Level of consciousness
- Mood and Affect
- IV set-up
- Cardio-pulmonary set-up
- Special devices attached to the patient – e.g. cast, foley catheter, etc.
- Special devices attached to bed – e.g. bed frames, pulleys, trapeze