General Assessment (Physical assessment)

In this video we’re going to talk about the general portion of your head to toe assessment. This is the first 2 minutes of interaction with your patient and it can tell you a LOT of information before you even lift a finger to assess them!
The first thing you’ll do is walk in the room and introduce yourself to your patient.

You’ll already be noticing their level of alertness, general appearance, posture, etc. Then you’re gonna ask for your 2 patient identifiers. If they give you correct answers, you know they’re likely not confused, they can hear you, and you can assess their speech quality as well.

Then, ask them how they’re feeling or if they’re in any pain. This is a huge part of the assessment. If the patient says “I feel great”, but they’re tearful and look upset – we know something’s off. So we can assess their emotions and whether or not their affect is appropriate based on what they’re telling us.

We also can observe if they’re in any distress – how’s their breathing? Are they grimacing? Do they visibly look uncomfortable. We can see the patient here looks nice and calm, isn’t breathing heavy, and doesn’t look like she’s in any distress.

While you’re talking to them, make sure you’re looking at their general posture, are they sitting upright? How’s their hygiene? Do they appear to be unkempt? And, of course, we can see their basic skin color – looking for jaundice, cyanosis, paleness, or if they seem flushed. This patient looks tan with a normal skin tone for her ethnicity, so that’s a normal finding. Once you’ve completed your observations, take a full set of vital signs.

Big points to note here – if you note any distress, stop your assessment and intervene. If you have any abnormal vital signs, stop your assessment and address them. If there are any communication barriers to overcome, make sure you do that before you continue. And, of course, make note of any abnormal findings so that you can document them later.
So that’s your general health assessment, make sure you watch the other health assessment videos and you’ll be an expert at a full head to toe assessment in no time. Now, go out and be your best self today. And, as always, happy nursing!