Brief General Physical Assessment

Fundamental Review 3-3

Brief General Physical Assessment

Assessment	Components
Safety	Assess: bed position, call bell location, appropriate emergency equipment, assistive devices, fall risk/hazards
Vital signs	Assess: temperature, pulse, respirations, blood pressure, oxygen saturation, pain assessment
Mental status	Assess: level of consciousness; orientation to person, place, and time; speech
Psychosocial	Assess: behavior and affect
Head, eyes, ears, nose, throat, neck	Assess: eyes, pupils, mouth, carotid arteries, swallowing, facial color, moisture, lesions, wounds, glasses, hearing aid, ability to hear conversation, ability to see
Chest	Assess: chest color, moisture, lesions, wounds, quality of respirations, heart sounds, lung sounds, cough, sputum
Abdomen	Assess: abdomen color, moisture, lesions, wounds, bowel sounds, tenderness, distention, pain/discomfort, ability to eat, urine elimination pattern and urine characteristics, bowel elimination pattern and stool characteristics
Upper and lower extremities	Assess: skin, color, pulses, temperature, tenderness, edema, capillary refill, strength, sensation, range of motion, lesions, wounds
Activity	Assess: movement and ambulation, ability to move in bed, ability to get out of bed, ability to walk and distance, gait
Therapeutic devices	Assess: peripheral and central venous access devices, supplemental oxygen setting, pacemaker, cardiac monitor, urinary catheters, gastric tubes, chest tubes, dressings, braces, slings

Nurses should use clinical judgment to adapt this generic assessment to the individual circumstances of an individual patient and to monitor for changes that might require further intervention (Henley Haugh, 2015).

Source: Adapted from Henley Haugh, K. (2015). Head-to-toe: Organizing your baseline patient physical assessment. Nursing, 45(12), 58-61. Used with permission; Anderson, B., Nix, E., Norman, B., & McPike, H. D. (2014). An evidence based approach to undergraduate physical assessment practicum course development. Nurse Education in Practice, 14(3), 242-246.

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Fundamental Review 3-3