Chapter III: HOLISTIC NURSING ASSESSMENT

Holistic Nursing- focuses on treating the whole person.

- Recognizes that a person is not simply his or her illness- addresses with
interconnectedness of the mind, body, spirit, social, cultural, emotions,
relationships, context and environment.
- Knowledge, Theory, Intuition, Experience

GENERAL STATUS & VITAL SIGNS

1.1 General Survey- provides all the information acquired and observed by the nurse as
he/she meets the client.

a. Physical development & body build

b. Gender and Sexual Development
c. Apparent Age compared to repeated age
d. Skin condition and color
e. Dress & hygiene
f. Posture and Gait
g. Level of consciousness
h. Behaviors, body movements and affect
i. Facial expression
j. Speech
k. Vital signs

1.2 VITAL SIGNS - Common, non-invasive physical assessment procedure that most
clients are aware of.
- Provide data that reflect the status of several body parts.

Temperature

Body Temperature – is the difference between the amount of heat produced by body
processes and the amount of heat loss to the environment.
- Aimed at obtaining a representative average temperature of core body parts.
Core Temperature – refers to the temperature of deep tissues.
- Relatively constant.
- Taken at various sites ( Normal: 36.5 ºC – 37.7 ºC)
Thermoregulation- balance between heat loss and heat produced, regulated by
physiological and behavioural mechanism.
Hypothalamus - located between the cerebral hemispheres, controls the body
temperature.
- Anterior hypothalamus controls the heat loss and posterior hypothalamus controls the
heat production.

HYPERTHERMIA- higher than 38 ºC

- seen in viral or bacterial infections, malignancies, trauma & various blood,
endocrine and immune disorders.

HYPOTHERMIA- lower than 36.5 ºC

- seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism or
starvation.
 PULSE
- A shock wave produced when the heart contracts and forcefully pumps blood
out of the ventricles into the aorta.
- Will increase with excitement, crying or anxiety.
Radial Pulse – provides a good overall picture of the client’s health status.
Characteristics: Rate, Rhythm, Amplitude and contour, Elasticity
Amplitude:
0 Absent
1+ Weak, diminished (Easy to obliterate)
2+ Normal (obliterate with moderate pressure)
3+ Bounding (unable to obliterate /requires firm pressure)

Respirations – acquired by observing the client’s chest movement while

continuing to palpate the radial pulse. Note the rate, rhythm and depth.
Blood Pressure- reflects the pressure exerted on the walls of the arteries.
- Measurement of the pressure of the blood in the arteries when the ventricles
are contracted (systolic BP) and when ventricles relaxed (diastolic BP).
Factors Affecting Blood Pressure:
a. Cardiac Output/Pumping action of the Heart – the more the heart pumps,
the greater the pressure in blood vessels. Example: Exercise= increase in
BP
b. Peripheral vascular Resistance – increase in resistance in the peripheral
vascular system. Example: Circulatory disorders
c. Viscosity – the more the blood becomes thicker or more viscous, the
pressure in the blood vessels will increase.
d. Elasticity of Vessel Walls – an increase in the stiffness of the vessel walls
will increase the blood pressure.
Pain
Location
Intensity – 1 to 10 Likert Scale
Quality – dull, sharp, throbbing
Duration
Alleviating/Aggravating factors

Health Assessment
Subjective Data Objective Data
1. General Survey: Biographic data 1. Preparation of the Client:
2. History of Present Health Comfortable Position; Sitting in a
Concern: health concern at the chair/ on the examination table, on a
moment bed
- Occurrence of high fevers - Posture
- Alterations in heartbeat or - Movements
skipping beat - Overall Appearance
- Difficulty breathing or trouble in 2. Equipment:
catching breath - Sphygmomanometer
- Pain (COLDSPA) - Stethoscope
3. Personal History - Thermometer
- Usual blood pressure - Watch
- When and where the BP is 3. Physical Assessment
taken - Vital signs
- Awareness of the condition(
 fast or slow heartbeats)
- Medications
- Allergies to medications,
foods, insects or
environment
4. Lifestyle & Health Practices
- Educational Background
- Occupation
- Satisfaction
- Check-ups
- Alcohol Consumption
- Smoking
- Special Diet
- Exercise

MENTAL STATUS
- Refers to a client’s level of cognitive functioning (thinking, knowledge,
problem solving) and emotional functioning (feelings, mood, behaviors,
stability).
Mental Health: “ a state of well-being in which an individual realizes his own
abilities, can cope with the normal stresses of life, can work productively and is
able to make contribution to his/her community”, (WHO, 2014).

Factors affecting Mental Health:

1. Economic and social factors: rapid changes, stressful conditions, work or
school)
2. Unhealthy lifestyle choices: Sedentary lifestyle/substance abuse
3. Exposure to violence (victim of child abuse)
4. Personality Factors: poor decision making skills, low self-concept, poor self-
control
5. Spiritual factors
6. Cultural Factors
7. Changes or Impairments in the structure and function of the neurologic
system (cerebral abnormalities, emotional behaviors)
8. Psychosocial developmental level & issues

Mental Disorder is defined as: (Diagnostic and Statistical Manual of Mental Disorders –
DSM)
a. A behavioural or psychological syndrome or pattern that occurs in an
individual
b. That reflects an underlying psychobiologic dysfunction
c. The consequence of which is clinically significant distress (painful symptom)
or disability (impairment in one or more important areas of functioning).
d. Must not merely an expectable response to common stresses and losses
(loss of a loved one) or a culturally sanctioned response to a particular event.
e. That is not primarily a result of social deviance or conflicts with society
Substance Abuse- describes as the harmful or hazardous use of psychoactive
substances, including alcohol and illicit drugs (WHO).
- This leads the client to develop dependence, a strong desire to take the drug,
difficulty controlling its use and need to continue taking it.
Health Assessment
- Interview the client and observe behavioural cues during the process

Subjective Data Objective Data

1. Biographic data Physical Examination: Mental Status
- Name Examination
- Address 1. Preparation
- Telephone Number 2. Equipment: Pencil & paper
- Age Glasgow Coma Scale
- Marital Status Questionnaire: Depression
- Educational level & employment Questionnaire; Saint Louis
status University Mental Status
To provide baseline data: level of Assessment; CAGE Questionnaire;
consciousness, memory, speech patterns, SAD PERSONS Suicide Risk
articulation. Assessment, etc.
2. History of Present Health Concern 3. Physical Examination
- Present concern 3.1 General Routine Screening
- Reason of Seeking health care - Level of consciousness
- Other health problems: - Posture, gait, body movements
headaches, breathing problems, - Behaviour and affect
palpitations, insomnia, irritability - Dress and grooming
or mood swings, fatigue, suicidal - Speech
thoughts - Orientation
- Thoughts of hurting someone - Concentration
3. Personal Health History 3.2 Focused Specialty Assessment
- Hospitalization (Mental Health - GCS
Disorder) or counselling services - CAGE Self-Assessment
- Head injury, meningitis, - SLUMS Dementia or
encephalitis or stroke Alzheimer’s Test Examination
- Served on active duty in the
Armed forces (Posttraumatic
syndrome)
4. Family History
- History of mental health problem
in the family
- Treatments
5. Lifestyle & Health Practices
- Describe her day
- Energy level
- Eating habits over 24 hour
period
- Sleep patterns
- Exercise regimens
- Caffeine, beverages
- Prescribed or over-the-counter
drugs
- Alcohol consumption
- Recreational drugs: Marijuana,
tranquilizers, cocaine,
methamphetamine
- Environmental toxins:
 pesticides, herbicides,
occupational chemicals
- Religious activities/affiliations
- Concept of Self
- Support system
- Role in the family/relationships
- Current stressors
- Future plans

PSYCHOSOCIAL, COGNITIVE & MORAL DEVELOPMENT

FREUD THEORY OF PSYCHOSEXUAL DEVELOPMENT

 Developed by Sigmund Freud (1935), a Viennese Physician
 He originated the concept of psychoanalysis and believed that personality
development was based on understanding the individual life history of a person.
3 Basic Structures of Personality
1. Id
 Completely unconscious. It is the inherited system.
 Has no perception of reality or morality (what is right and wrong).
 It seeks instant gratification and supplies the psychic energy for the ego and the
superego.
2. Ego
 An intermediary between id and the external world, or reality.
 It includes many processes such as learning, perceptions, memory, problem
solving and decision making.
 Attempts to postpone or redirect id satisfaction.
 It is a source of much conflict an in order to be protected, people use a variety of
defense mechanisms.
3. Super ego (conscience)
 Provides feedback to the person regarding how closely his or her behavior
conforms to the external value system.
 It drives for perfection, disregards reality, usually operates at unconscious level
and is an insistent force against the desires of the id.
 Originates from the learned rules of conduct imposed by a person’s parents

ERIKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT

 He concluded that societal, cultural and historical factors – as well as biophysical
processes and cognitive function – influence personality development.
 He declared that the ego positively affect a person’s development as more skills
and experience are gained.
 Unlike Freud, he believed that personality development continues to evolve
throughout the lifespan

Level Task Issues Negative Positive

Resolution Resolution
INFANT Trust vs. Mother / primary Suspicious, Drive and
Mistrust caregivers. Fearful Hope
• Feeding “feeling
and being
comforted
 • Sleeping, Teething
“taking in”
• Trusting self, others
and environment
TODDLER Autonomy Parents / Primary Doubts Self-
vs. Shame caregivers. abilities, confidence
and doubt a. Toilet Training feels and
b. Bodily Functions ashamed for willpower
c. Experimenting with not trying.
“Holding on and
letting go” – having
control without loss
of self esteem
PRESCHOOLER Initiative vs. • Family May fear Direction
Guilt • Play disapproval and Purpose
• Exploring and of own
discovering, powers
learning how
much
assertiveness
influence
others and the
environment
• Developing a
sense of moral
responsibility
SCHOOL- Industry vs. School, Teachers, May feel Method and
AGED CHILD Inferiority Friends experiencing sense of Competence
physical failure
independence from
parents,
neighborhood,
wishing to
accomplish, learning
to create and
produce, accepting
when to stop working
on a project, learning
to complete a project,
learning to
cooperate,
developing an
attitude toward work.
ADOLESCENT Identity Peers and groups Confused, Devotion
vs. experiencing emotional Nonfocused and Fidelity
Role independence from
Confusion parents, seeking to be the
same as others yet
unique, planning to
actualize abilities and
goals, fusing several
 identities into one.
YOUNG Intimacy vs. Friends, lovers, spouses, Loneliness, Affiliation
ADULT Isolation community, work poor and Love
connections (networking), relationships
committing to work
relationships, social
relationships, intimate
relationships.
MIDDLE- Generativity Younger generation- often Shallow Production
AGED ADULT vs. children (whether one’s involvement and care
Stagnation own or those of others) with the
family, community, world in
mentoring others, helping general,
to care for others selfish, little
discovering new abilities/ psychosocial
talents, continuing to growth
create, “giving back”
OLDER Ego All mankind reviewing Regret, Renunciation
ADULT integrity vs. one’s life, acceptance of discontent, and wisdom
despair self-uniqueness, pessimism
acceptance of worth of
others, acceptance of
death as an entity

JEAN PIAGET THEORY OF COGNITIVE DEVELOPMENT

 His theory is a description and an explanation of the growth and development of
intellectual structures.
 He focused on how a person learns, not what a person learns.
 He acknowledged that interrelationships of physical maturity, social interaction,
environmental stimulation, and experience in general were necessary for
cognition to occur.
 His primary focus was the biology of thinking
Cognition – is the process of obtaining information about ones world ( Schuster and
Ashburn)
CONCEPTS APPLIED TO EXPLAIN JEAN PIAGETS THEORY
Schema- is a unit of thought and a classification for a phenomenon,
behavior or event.
- This may consist of a thought, emotional memory, movement of the
body part, or a sensory experience.
Categories:
A. Assimilation – an adoptive process whereby a stimulus or information is
incorporated into an already existing schema ( People
change reality into what they know)
B. Accommodation – is the creation of a new schema or the modification of
an old one to differentiate more accurately a stimulus or a
behavior from an existing schema
Equilibration – is the balance between assimilation and accommodation.
KOHLBERG THEORY OF MORAL DEVELOPMENT
 Was most concerned with examining the reasoning a person used to make a
decision, as opposed to the action that resulted after that decision was made.
 Viewed justice as the goal of moral judgment
Health Assessment

Subjective Data
Biographic data
- Birthplace & other places lived in
- Age
- Marital Status
- Cultural groups the client can
identify
- Language
-
- Educational Background &
employment status
To provide baseline data: level of
consciousness, memory, speech patterns,
articulation.
History of Present Health Concern
- Present concern/feeling
- Body weight concerns
- Major stressors
- Coping with stress
- Support system
- Decision making
- Adaptability to changes
Personal Health History
- Describe self. Strengths and
weaknesses?
- Mode of learning
- Current or past treatment of
psychological or psychiatric
problem
- Medications, Herbs,
Supplements
- Changes in weight, eating ,
elimination patterns and sleep.
- Presence of chronic illness

Family History
- Describes how the client grows
up
- Family members: sister, brother
or parents and relatives
- Genetic predisposition
Lifestyle & Health Practices
- Describe her day
- Energy level
- Eating habits over 24 hour
period
- Sleep patterns
- Exercise regimens
- Caffeine, beverages
 - Prescribed or over-the-counter
drugs
- Alcohol consumption
- Recreational drugs: Marijuana,
tranquilizers, cocaine,
methamphetamine
- Environmental toxins:
pesticides, herbicides,
occupational chemicals
- Religious activities/affiliations
- Concept of Self
- Support system
- Role in the family/relationships
- Current stressors
- Future plans
Lifestyle & Health Practices

FREUD
Young Adult - Live with parents?
- Roles and responsibilities in the
residence
- Experience growing with one
parent
- Unresolved issues with parents
- Relationship with a significant
other
- Gainful employment

Middle-Aged - Demonstrate nervous

mannerism
- Pleasure from selected activities
- Coping with stress
- Sexual Relationship
- Physical changes affect any
relationship

Older Adults - Sexual Activity

- Positive coping with loss
- Changes in cognition
- Any significant changes have
occurred in interests

ERIC ERIKSON(Psychosocial)
Young Adult - Self-Acceptance- physically,
cognitively & emotionally
- Independence from the Parental
home
- Express love responsibly,
emotionally and sexually
- Close or intimate relationships
with a partner
 - Social group of friends
- Physiology of living and life
- Profession
- Independence from parental
home

Middle-aged - Healthful life patterns

- Satisfaction from contributing to
growth and development of
others
- Maintain a stable home
- Pleasure in work or profession
- Take pride in self, family
accomplishments
- Contribute to community

Older Adult - Adjust to physical changes

PIAGET (Cognitive Development)
Young Adult
- Transition from retirement to
satisfying activities
- Maintain relationships with
children, grandchildren and
other relatives
- Establish relationship with those
who are his own age
- Meaning in past life and face
inevitable mortality
- Review accomplishments and
recognize meaningful
contributions he/she has made
- Assume responsibility for
independence
- Realistically self-evaluate
strengths & weaknesses
- Identify and explore multiple
options and potential outcomes
- Long-range context in decisions
- Realistic plan
- Career mentors

Middle-Aged - Differentiate
discrepancies(goals, wishes and
realities)
- Factors that give life meaning
and continuity
- Share knowledge and
experience with others
- Separate emotional issues from
cognitive domain in decision
making
 - Seek to improve and add
knowledge
- Adapt to change quickly

Older Adult - Maintain maximal independence

with ADLs (activities of daily
living)
- Look for ways to find satisfaction
with life
- Determine realistic plans for the
future, including own mortality

LAWRENCE KOHLBERG (Moral

Development)

Young Adult - Priorities in making a moral

decision
- Perceive approval from the
family
- Approval from peers
- Approval of supervisors
- Approval of significant other
- Consider self as “good person”
- Ability to judge the intention of
others

Middle-Aged - Consider priorities before a

moral decision
- Focus more on law and order
- Willingness to stop unhealthy
behaviour to foster wellness

Older Adult
- Priorities before a moral
decision making
- Changeable rules & regulations
- Consistent decision making on
rules & conscience
- Believe in equality for every
person
PAIN: the FIFTH VITAL SIGN
- An unpleasant sensory and emotional experience, which we primarily
associate with tissue damage or describe in terms of such damage (IASP-
International Association for the Study of Pain, 2011).
- “Pain whatever the person says it is (McCaffery and Pasero, 1999)”.
Nociceptors- are peripheral nerve endings that transmit painful stimuli from the
Peripheral Nervous System to the Central Nervous System.

3 types of Nociceptors

Mechanosensitive nociceptors – sensitive to intense mechanical stimulation

Thermosensitive nociceptors - sensitive to intense heat and cold.
Polymodal nociceptors – sensitive to noxious stimuli of mechanical, thermal, or
chemical nature.

Nociception – Perception of pain

4 Physiological Processes of Nociception

Transduction – Injured tissue release chemicals that affect nociceptors sending pain
message up sensory neuron
Transmission – Pain impulse from the nociceptors relay the pain from the spinal cord
to the brain
Perception – Pain perceived in the brain.
Modulation – Pain message is inhibited by brain stem neuron. Neuron releases
endongenous neurotransmitters.

Classification of Pain
By Cause Nociceptive - response to injury of tissues

Neuropathic –
caused by a primary lesion, disease in the somatosensory nervous syst
em

Inflammatory –
A result of activation and sensitization of the nociceptive pain by a variet
y of mediators released at a site of inflammation
By Duration Acute Pain – recent injury
and Etiology
Chronic nonmalignant pain –
specific cause, constant and persists more than 6 months

Cancer Pain –
due to damage, compression of peripheral nerves and meninges followi
ng surgery, chemotherapy, radiation, tumor, growth and infiltration

Intractable Pain – defined by its high resistance to pain relief

By Location Cutaneous Pain – Pain on the skin or subcutaneous tissue
 Visceral Pain – Pain on the visceral organs

Deep Somatic Pain –

Pain from nerves, ligaments, tendons, bones, blood vessels.

Phantom Pain –
can be perceived in nerves left by a missing, amputated or paralyzed bo
dy part.
How to Assess Pain
a. Self-Report – always try to get a self-report but consider if patient is able

b. Search for potential causes of Pain –Pathologic conditions, procedures such as

surgery, wound care, positioning, skin invasion by needle or catheter, other
known painful procedures or disease

c. Observe Patient Behavior – Many scales reflect pain-related behaviors of

different types Surrogate Reporting of Pain / activity changes

d. Attempt an Analgesic trial – a full protocol is recommended. After an analgesic is

ordered the nurse needs to observe for changes in self-report or behavior

Pain Assessment Tools

1. Simple Descriptive Pain Intensity Scale

The Simple Descriptive Scale

Exhibits degrees of pain intensity

No Pain
Mild Pain
Moderate Pain
Severe Pain
 2. Wong-Baker FACES Pain Rating Scale

Developed by Donna Wong and Connie Baker. The scale shows a series of
faces ranging from happy face at 0, or “not hurt”, to a crying face at 10, which
represents “hurts like the worst pain imaginable”.

3. Face, Legs, Activity, Cry Consolability (FLACC) Behavioral Scale

Patients who are awake Patients who are asleep

Observe for at least 2-5 minutes
Observe legs and body uncovered.
Reposition patient or observe activity;
assess body for tenseness and tone.
Initiate consoling interventions if needed.
Observe at least 5 minutes or longer.
Observe body and legs uncovered.
If possible reposition the patient.
Touch the body and assess for tenderness
and tone.
4. Self-Assessment: Memorial Pain Assessment Card
5. McCaffrey Initial Pain Assessment Tool
Health Assessement
Subjective Data Objective Data
History of Present Concern Physical Examination
- Presence of pain (Asses the Inspection:
pain) a. Posture
Character – client describes the pain b. Facial Expression
Onset – start of pain c. Asses face, legs , activity, cry &
Location- where the pain occurs; radiate consolability using Assessment tool
Duration – how long the pain lasts; does it d. Joints & Muscles
recur? e. Skin
Severity – Rate the pain Vital Signs
Pattern – continuous or intermittent; asses a. Heart Rate (60 – 100 bpm (beats
the episodes it occur and how long it will per minute)
last
Associated factors- how it affects the b. Respiratory Rate (12 – 20 cpm
client; accompanying (cycles per minute)
c. Blood Pressure
- Factors that relieve the pain Systolic: 100-130 mmHg
- Factors that increase the pain Diastolic: 60 – 80 mmHg
- Medications, therapy, surgery
Personal Health history
- Previous experience of pain
- Medications
- Family members experiencing
the same pain
- Does it affect the family?
Lifestyle and Health Practices
- Concerns about the pain
- Does it interfere with:
a. General activity
b. Mood/emotions
c. Concentration
d. Physical ablity
e. Work
f. Relations with other people
g. Sleep
h. Appetite
i. Enjoyment of life

Role: Validate and document findings