Lippincott Nursing Pocket Card - May 2023

General Assessment



Focused general assessment begins with taking a health history regarding constitutional symptoms. This examination involves a general survey of the patient, measurement of vital signs, and pain assessment.

Optimal Patient Positioning
  • Examine the patient in a position of their choosing to promote patient comfort.
  • This may be performed with the patient fully dressed.­


Exam methods

  • Observational Assessment
    • Note patient’s level of consciousness, mood, and behavior, as well as any type of distress.
    • Note patient’s gait and any movement abnormalities, such as limping.
    • Include general appearance, grooming, dress, facial expressions, eye contact, odors, and posture.
    • Document the patient’s description of their current state of health.
    • Describe the patient’s distinguishing characteristics, such as tattoos, scars, amputations, or other unique features.
    • Observe for distress, noting type and response.
  • Vital Signs
    • Measure height and weight to determine body mass index (BMI).
    • Measure blood pressure in both upper extremities, ensuring properly sized cuff.
      • Isolated hypertension may be situational, such as “white coat syndrome.”
      • Home BP monitoring may reveal better control.
    • Measure orthostatic blood pressure if indicated.
    • Examine pulse rate and rhythm by palpating the radial pulse.
      • Normal rate falls between 60-90 beat per minute, although it may be altered due to medications or medical conditions.
      • Pulse should be counted for a full minute, particularly if irregular.
      • Rhythm should be regular. Abnormalities include irregularly irregular and regularly irregular.
    • Examine the quality of peripheral pulses.
      • Radial pulse is most commonly assessed due to accessibility.
      • Pulses should be strong, but not bounding.
    • Observe respiratory rate and quality of breathing.
      • Normal respiratory rate is 12-20 breaths per minute in an adult.
      • Breathing should be regular, although an occasional sigh is normal.
    • Measure and note temperature.
      • Temperature may be measured in several ways.
        • Oral and rectal temperatures remain the most common, with oral temperatures usually slightly lower than the core temperature and rectal being more accurate to the core temperature.
        • Temporal and tympanic temperatures can be variable, and dependent on the user.
        • Axillary temperatures are the least accurate and take at least 5-10 minutes to register.
  • Pain Assessment
    • Onset/Timing
      • Note circumstances and timing of pain.
      • Note causes of pain.
    • Location
      • Note where the pain is located.
      • Note if the pain radiates to other areas.
    • Duration
      • Constant
      • Intermittent
    • Chronicity
      • Acute pain defined as a predicted response to noxious stimulus.
      • Chronic pain defined as lasting longer than 1 month beyond illness/injury recovery, lasting longer than 3-6 months due to chronic illness.
    • Aggravating/Alleviating Factors
      • Note if the patient experiences relief or aggravation with movement, rest, cold/heat, etc.
      • Note if the pain has been relieved with any medications.
    • Type of pain
      • Somatic – emanates from muscles and soft tissues
      • Neuropathic – emanates from nerves
      • Visceral – emanates from deep structures/organs
      • Document the pain as the patient describes it.
    • Severity
      • Utilize rating scales to assist in obtaining baseline.
      • Utilize same scale to evaluate the effectiveness of interventions.
      • Note patient’s baseline level of pain in those with chronic pain.


  • Provide privacy for the patient; interview the patient alone to allow for personal questions they might be reluctant to discuss with others present.
  • Orthostatic blood pressures may be indicated in patients presenting with syncope or near-syncope, dizziness, tachycardia, or palpitations.
  • Ensure the use of a properly sized cuff, as erroneous values can be obtained with a cuff that is either too small or too large.
  • In documenting the general assessment, be as descriptive as possible to create a visual depiction of the patient.
  • Elicit from the patient what expectations they have for pain relief.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.