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At the end of the session, the student shall be able

to:
a. discuss the concept of holistic assessment
b. explain the purpose of health assessment
b. describe suggested sequencing to conduct a physical health
examination in an orderly fashion.
c. discuss variations in examination techniques appropriate for clients of
different ages.
d. describe factors that may affect health assessment procedures
Cory Manuel-Balganion, MSN
NCM 101 - Health Assessment
First Semester, AY 2020-2021

• Holistic patient assessment is used in nursing to inform

Holistic (adj.) the nursing process and provide the foundations of
patient care.
• describes things related to the idea that the whole is more
than the sum of its parts. • A holistic approach acknowledges and addresses the
physiological, psychological, sociological,
developmental, spiritual and cultural needs of the
patient.

https://www.dictionary.com/browse/holistic

Assessing a client’s health status is a major

component of nursing care and has two aspects:

Why assess?? (1) the nursing health history

(2) the physical examination

Kozier and Erb's (2016)

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These are some of the purposes of the physical examination:

ASSESSMENT AREAS:
• To obtain baseline data about the client’s functional abilities.
• To supplement, confirm, or refute data obtained in the nursing • General Status and Vital signs
• Mental Status
history.
• Children and Adolescent Adults
• To obtain data that will help establish nursing diagnoses and plans • Psychosocial , Cognitive and Moral Development
of care. • Pain
• To evaluate the physiological outcomes of health care and thus the • Violence
progress of a client’s health problem. • Culture and Ethnicity
• To make clinical judgments about a client’s health status. • Spirituality and Religious Practices
• Nutritional Status
• To identify areas for health promotion and disease prevention.

Performance

1. Prior to performing the procedure, introduce self and verify the

client’s identity using agency protocol.
2. Explain to the client what you are going to do, why it is necessary,
and how he or she can participate. GENERAL SURVEY and
3. Discuss how the results will be used in plan_x0002_ning further MENTAL STATUS
care or treatments.
4. Perform hand hygiene and observe other appropriate infection
prevention procedures.
5. Provide for client privacy.

2

Age
§ Normal: the person appears his/her stated age.
§ Abnormal: Appears older than stated age
Sex
§ Normal: sexual development is appropriate for
gender and age
§ Abnormal: Delayed or precocious puberty.
Facial Features
§ Normal: Facial features are symmetric with movement;
no signs of acute distress are present
§ Abnormal: immobile, masklike, asymmetric drooping;
respiratory signs, objective data for pain
https://i.pinimg.com/originals/1d/03/9f/1d039f90bd5ecac2ba045e1d2c10de2a.gif
Stature
§ Normal: The height appears within normal
range for age, genetic heritage.
§ Abnormal: Excessively short or tall
Weight
§ Normal: The weight appears within normal range for
height and body build; body fat distribution is even
§ Abnormal: Cachectic, emaciated; simple obesity, with
even fat distribution; centripetal (truncal) obesity
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Level of Consciousness
§ Normal: The person is alert and oriented,
attends to your questions appropriately
§ Abnormal: Confused, drowsy, lethargic
Skin Color
§ Normal: Color tone is even, pigmentation varying
with genetic background, skin is intact with no
obvious lesions
§ Abnormal: Pallor, cyanosis, jaundice, erythema, any
lesions
Symmetry
§ Normal: Body parts look equal bilaterally and are in
relative proportion to each other.
§ Abnormal: Unilateral atrophy or hypertrophy;
asymmetric location of a body part.
Posture
§ Normal: The person stands comfortably erect as
appropriate for age; note the normal “plumb line”
§ Abnormal: Rigid spine and neck; moves as one unit; stiff
and tense, ready to spring from chair, fidgety movements;
shoulders slumped, looks deflated
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Position
§ Normal: the person sits comfortably in a chair or on the
bed or examination table, arms relaxed at sides, head
turned to examiner
§ Abnormal: Tripod; sitting straight up and resists lying down;
curled up in fetal position
Body build, contour-proportions
§ Normal: Arm span equals height; body length from crown to
pubis roughly equal to length from pubis to sole.
§ Abnormal: Elongated arm span, arm span greater than height;
missing extremities or digits webbed digits; shortened limb.

http://files.englishportfolio1.webnode.es/200000037-2fc8530c02/big_islcollective_worksheets_beginner_prea1_elementary_a1_preintermediate_a2_intermediate_b1_upperintermediate_b2_advanced_c_301804f324dbf167fd0_12299543.jpg

Gait
§ Normal: The base is as wide as the shoulder width;
foot placement is accurate; the walk is smooth, even,
well-balanced; and associated movements such as
symmetric swing, are present.
§ Abnormal: Exceptionally wide base. Staggered
stumbling; shuffling, dragging, nonfunctional leg;
limping with injury, propulsion(difficulty stopping)

Range of Motion
§ Normal: Note full mobility for each joint, and that
movements is deliberate, accurate, smooth and
coordinated; No involuntary movements
§ Abnormal: Limited joint range of motion;
paralysis; jerky, uncoordinated movement; ticks,
tremors, seizures.

https://www.google.com/url?sa=i&url=https%3A%2F%2Fsamarpanphysioclinic.com%2F2019%2F02%2F21%2Frange-of-motion-of-all-
joints%2F&psig=AOvVaw0my9qG_tCTurkuMi78VB9r&ust=1599558676108000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCNjUm83i1usCFQAAAAAdAAAAABAJ

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http://1.bp.blogspot.com/_OrY_6G0srrw/Sv3HSKDRlLI/AAAAAAAAANA/k-RgHCEjrIU/s400/Facial+Expressions+colored.jpg

Facial expression
§ Normal: The person maintains eye contact, expressions are
appropriate to the situation
§ Abnormal: Flat depressed, angry, sad, anxious.
Mood and Affect
§ Normal: The person is comfortable and cooperative with the
examiner and interacts pleasantly
§ Abnormal: Hostile, distrustful, suspicions, crying

Speech
§ Normal: Articulation is clear and understandable; the
stream of talking is fluent, with an even pace; conveys ideas
clearly; word choice is appropriate to culture and education;
§ Abnormal: Dysarthria and dysphagia; speech defect;
monotone, garbled speech; extremes of few words or
constant talking

https://busyteacher.org/uploads/posts/2012-10/1349554637_sem-ttulo.jpg

Personal Hygiene
§ Normal: The person appears clean and groomed
appropriately for his/her age, occupation, and
socioeconomic group; hair is groomed, brushed; make-up is
appropriate for age and culture
§ Abnormal: In a previously carefully groomed woman,
unkempt hair and absent make-up may indicate malaise or
illness

https://clipground.com/images/hygiene-clipart-5.jpg

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VITAL SIGNS
The traditional vital signs are

VITAL SIGNS body temperature (T),

VITAL SIGNS VITAL SIGNS

The traditional vital signs are The traditional vital signs are

pulse (PR)/Cardiac Rate (CR), respirations (RR), and

VITAL SIGNS VITAL SIGNS

The traditional vital signs are
Pain
blood pressure (BP).
Oxygen Saturation

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VITAL SIGNS VITAL SIGNS

• To obtain baseline data
• Vital signs, which should be looked at in total, are • When a client has a change in health
checked to monitor the functions of the body. status or reports symptoms
• Before and after surgery or an invasive
• Vital signs are often considered to be the procedure
baseline indicators of a patient’s health status. • Before and/or after the administration of a
medication Before and after any nursing
intervention that could affect the vital
signs

Refences:
• Wallace, Sonya. (2013). The importance of holistic assessment – A nursing
student perspective. Nuritinga. 24-30.
• Vital Signs retrieved at http://www.sickkids.ca/Nursing/Education-and-
learning/Nursing-Student-Orientation/module-two-clinical-
care/vitals/index.html
• Weber, J (2014) Health assessment in nursing - 5th Edition, Wolters Kluwer
Health | Lippincott Williams & Wilkins.
• Berman, Audrey (2016) Kozier & Erb’s fundamentals of nursing : concepts,
practice, and process, Pearson Education, Inc.