NUR 4033 Module 2 General Survey and Vital Signs Write-Up Example

General Survey and Vital Signs at a First Home Health Visit: An 81-Year-Old Woman Four Days After Discharge for Pneumonia

Student Name

American College of Education

NUR4033: Health Assessment

Module 2 Assignment

Instructor Name

March 9, 2026

Setting and Client

The client is an 81-year-old woman seen at 1030 in her single-story home for a first home health nursing visit, four days after a five-day hospital admission for community-acquired pneumonia. She lives alone; her son lives twenty minutes away and visits every evening. Discharge medications include oral amoxicillin-clavulanate with three days remaining, her usual lisinopril 20 mg daily and hydrochlorothiazide 25 mg daily, and acetaminophen as needed. The client, her family and the agency are composites written for this assignment. The visit included a general survey, a full set of vital signs with orthostatic measurements and a focused respiratory check; this write-up covers the general survey and vital signs.

The purpose of a first home visit after discharge is partly to confirm recovery and partly to find what the hospital could not see: how the client manages in her own environment. A general survey done in the home therefore includes the home, because the setting is part of what the nurse is observing.

General Survey

Physical appearance. The client appears approximately her stated age. She is seated in an upholstered chair in the living room, dressed in a cardigan over a nightgown, with hair combed. Skin color is even, with no visible pallor or cyanosis of the lips or nail beds. She has no apparent distress at rest.

Body structure and mobility. She is of slight build and estimates her weight at 118 pounds; her discharge weight was 52.4 kg. Posture in the chair is slightly kyphotic. She rose from the chair on the second attempt, pushing with both arms, and walked 20 feet to the kitchen with a four-wheeled walker, steady but slow, pausing once at the doorway. She reported feeling lightheaded after standing, which lasted about ten seconds.

Behavior. She knows who and where she is, gives today's date correctly and can explain why the nurse is visiting. Speech is clear and at a normal rate; she answered questions fully and asked two questions about her antibiotic. Facial expression changed appropriately during conversation. Hygiene appears adequate. The kitchen contained one bottle of water, half full, and the client said she had been drinking less than usual because getting up to use the bathroom is tiring. That single observation about the water bottle connects the general survey to the vital signs that follow.

Vital Signs and Method

Blood pressure was measured with an automated upper-arm device and an adult small cuff chosen after measuring her arm circumference at 24 cm, following the positioning described in the American Heart Association scientific statement on blood pressure measurement: seated with her back against the chair, both feet on the floor, the cuffed arm resting on a pillow at heart height, and silence during the reading (Muntner et al., 2019). After five minutes of rest seated, the right arm read 132/74 mm Hg with a pulse of 84. Orthostatic measurements were then obtained. After five minutes supine on the sofa, blood pressure was 138/76 mm Hg with a pulse of 82. At one minute after standing, with the walker in front of her and the nurse beside her, blood pressure was 114/66 mm Hg with a pulse of 98, and she reported lightheadedness. At three minutes standing, blood pressure was 116/68 mm Hg with a pulse of 96.

Radial pulse was 84 at rest, counted for a full 60 seconds because the first 15-second count seemed irregular; it was regular on the full count. Respirations were 20 per minute, counted while the nurse appeared to be counting the pulse, with no use of accessory muscles. Temperature was 37.1 degrees Celsius orally, taken 30 minutes after her last drink. Oxygen saturation was 94 percent on room air by fingertip pulse oximetry after the probe had been on for one minute with a stable waveform. Pain was 2 out of 10 in the right side of the chest with deep breaths.

Two of these numbers need interpretation. The drop of 24 mm Hg systolic from supine to standing at one minute, with symptoms, meets the consensus definition of orthostatic hypotension, a sustained fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes of standing (Freeman et al., 2011). The oxygen saturation of 94 percent is acceptable for her recovery, but the nurse also recorded that pulse oximeters have been shown to overestimate oxygen saturation more often in Black patients than in White patients (Sjoding et al., 2020); the client is Black, so the reading was interpreted alongside her respiratory rate, color and effort rather than on its own.

From Impression to Objective Language

The first draft of this note, written in the car after the visit, contained several statements that recorded impressions rather than observations. Revising them shows the difference the module asks students to learn. The draft said the client looked weak and tired. The revised note says that she rose from the chair on the second attempt using both arms, walked 20 feet with a walker with one pause, and closed her eyes briefly twice during the 40-minute visit. A second nurse reading the revised version can compare it directly with what she sees next week; the first version tells her only how the first nurse felt.

The draft also said the client seemed dehydrated. That is a clinical judgment, and it may be right, but it is not an observation. The revised note records the half-full water bottle, the client's statement that she was drinking less to avoid trips to the bathroom, the orthostatic readings and the thiazide diuretic on her medication list, and it leaves the judgment to the assessment section where it belongs. Finally, the draft said that the client was compliant with her antibiotic. The revised note says that the blister pack showed eleven of fourteen doses taken, consistent with the discharge date. Objective language does not mean removing the nurse's judgment; it means showing the evidence that the judgment rests on, so that someone else can reach it too. Jarvis and Eckhardt (2024) make the same point when they describe documentation as a record that another clinician must be able to act on without having been in the room.

What the Findings Mean for This Visit

Taken together, the general survey and vital signs suggest an older adult who is recovering from pneumonia without signs of worsening infection, but who has symptomatic orthostatic hypotension, likely reduced fluid intake and a thiazide diuretic that may be adding to both. Her fall risk is higher than her steady walk alone would suggest, because the lightheadedness occurs at the moment she stands, when she is least supported. She lives alone, and the bathroom trips she is trying to avoid are the trips she is most likely to take at night.

The nurse notified the client's primary care provider by phone during the visit, reporting the orthostatic readings, the symptoms and the reduced fluid intake, and asking whether the diuretic should be held while she recovers. The provider held the hydrochlorothiazide for one week and asked for a repeat orthostatic check at the next visit in three days. The nurse taught the client to pause seated at the bedside for a full minute before rising, placed a night light between the bedroom and bathroom and set a simple fluid goal of one glass of water with each meal and each medication. The son was called with the same plan. A general survey and vital signs are often treated as the routine start of a visit, but in this case they produced the most important finding of the day.

References

Freeman, R., Wieling, W., Axelrod, F. B., Benditt, D. G., Benarroch, E., Biaggioni, I., Cheshire, W. P., Chelimsky, T., Cortelli, P., Gibbons, C. H., Goldstein, D. S., Hainsworth, R., Hilz, M. J., Jacob, G., Kaufmann, H., Jordan, J., Lipsitz, L. A., Levine, B. D., Low, P. A., . . . van Dijk, J. G. (2011). Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research, 21(2), 69-72. https://doi.org/10.1007/s10286-011-0119-5

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.

Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T., Jr. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087

Sjoding, M. W., Dickson, R. P., Iwashyna, T. J., Gay, S. E., & Valley, T. S. (2020). Racial bias in pulse oximetry measurement. New England Journal of Medicine, 383(25), 2477-2478. https://doi.org/10.1056/NEJMc2029240