Mental Health (WHO)- “state of well-being in
I. Holistic Nursing Assessment
General Survey
 Health Assessment begins with a general survey
that involves observation of the client’s general
appearance, level of comfort and mental status and
measurement of vital signs, height, and weight.
 Many components of the general survey are
assessed: client’s history (body build, facial
expressions, body posture, gait, hygiene like clothing,
odor of breath, and body, and mental status)
Assessing The General Status &
Vital Signs
 General appearance and behavior of an individual
must be assessed in relation to the patient’s culture,
educational level, socio-economic status and current
circumstances.
 Client’s age, sex, and race are factors in interpreting
findings that suggest increased risk for known
conditions
 Includes: health status, height, weight, personal
hygiene
 Height and Weight- nurse measures the height
using measuring stick attached to the weighing scale
or the wall; the client should remove the shoes and
stand erect, eyes should be looking straight ahead;
weight are measured in pounds (lb) or kilograms (kg);
1 kg is equal to 2.2 lbs
 Vital Signs- measured to establish (1) baseline data
to compare measurements (2) detect actual and
potential health problems. The following vital signs
are (1) temperature (2) pulse rate (3) respiratory rate
(4) blood pressure (5) oxygen saturation
Assessing the Mental Status:
Children, Adolescent and Adults
 Mental Status- refers to the client’s cognitive
functioning (thinking, knowledge, problem solving)
and emotional functioning (feelings, mood, behavior,
stability) A person cannot be totally healthy without
mental health.
 Mental Health- essential part of one’s total
health and is more than just the absence of
mental disabilities or disorders.

which an individual realizes his/her own abilities,
can cope with the normal stresses of life, can
work productively and able to make contribution
to his or her community.”
Factors Affecting Mental Health
 Economic and Social Factors (rapid changes,
stressful work conditions, and isolation)
 Unhealthy lifestyle choices (sedentary lifestyle,
substance abuse)
 Exposure to violence (victim of child abuse,
rape, maltreatment)
 Personality factors (poor decision-making skills,
low self-concept, poor self-control)
 Spiritual factors (Wright, 2005: suffering,
beliefs, and spirituality are three close
cousins)
 Suffering (psychological or physical)-
often associated with illness.
 Belief- cause and meaning of
suffering/pain affect the illness
 Spiritual beliefs- about the meaning of life
affect the course of illness and how the
person handles suffering and pain as well
Assessing Appearance and
Mental Status
 Observe the signs of distress in posture or
facial expression
 Normal- no distress noted
 Deviations from normal- bending over
because of abdominal pain, wincing,
frowning, or labored breathing
 Observe body build, height, and weight in
relation to the client’s age, lifestyle, and health.
 Normal- proportionate, varies with lifestyle
 Deviation from Normal- excessively thin
or obese
 Observe client’s posture and gait, standing, sitting,
and walking
 Normal- relaxed, erect posture, coordinated
movements
  Deviation from Normal- tense, slouched, bent
posture, uncoordinated movement, tremors,
unbalanced gait
 Observing client’s overall hygiene and grooming
 Normal- clean and neat
 Deviation from Normal- dirty, unkept
 Note body and breath odor
 Normal- no body odor or minor body odor relative
to work or exercise; no breath odor
 Deviations from Normal- foul body odor,
ammonia odor. Acetone breath odor, foul breath
odor (halitosis: bad breath)
 Note obvious signs of health or illness (skin color or
breathing)
 Normal- well-developed, well-nourished, intact
skin, easy breathing
 Deviations from Normal- pallor (paleness),
weakness, lesions, cough
 Assess the client’s attitude (frame of mind)
 Normal- cooperative, able to follow instructions
 Deviations from Normal- negative, hostile,
withdrawn, anxious
 Note the client’s affect or mood; assess the
appropriateness of the client’s responses
 Normal- appropriate to situations
 Deviations from Normal- inappropriate to
situations, sudden mood change, paranoia
 Listen for quantity of speech (amount and pace)
quality (loudness, clarity, inflection)
 Normal- understandable, moderate pace, clear
tone and inflection
 Deviations from Normal- rapid or slow pace,
overly loud or soft
 Listen for relevance and organization of thoughts
 Normal- logical sequence, makes sense, has
sense of reality
 Deviations from Normal- illogical sequence, flight
of ideas, confusions, generalization, vague
Psychosexual, Psychosocial,
Cognitive and Moral
Development
 Having basic understanding on: Sigmund Freud,
Erik Erikson, Jean Piaget, and Lawrence
Kohlberg- fundamental to performing a holistic
nursing assessment
 The concepts of these theorists will describe
methods for assessing the various
developmental levels across lifespan
Freud Theory of Psychosexual
Development
 Postulated the psychosocial nature of human
beings that is determined by the result of
conflict between biologic drives (instincts) and
social expectations
 “People are generally not aware of the
underlying reasons for their behavior.
 Conceived the concept of mental qualities
which influence behavior and occurs at 3 levels
of awareness
 Consciousness: 1st level- refers to
whatever a person is sensing, thinking
about or experiencing at any given
moment; Freud considered this level to be
limited since only a small amount of
thought exist at one time
 Preconciousness: 2nd level- involves all
a person’s memories and stored
knowledge that can be recalled and
brought to the conscious level
 Unconsciousness 3rd level- largest and
most influential; level corresponds to the
socially unacceptable sexual desires,
shameful impulses, and irrational
wishes, as well as anxieties and fears
 Freud revised this theory to include the 3 basic
structures in his anatomy of personality: ID,
EGO, and SUPEREGO
 ID- inherited system, containing the
motivational drives such entities as air,
water, warmth, and sex; it seeks instant
gratification and supplies the psychic
 energy for the ego and superego; He
added that ID knows no perception of
reality and morality (what is right or
wrong), until ego begins to develop in very
late infancy, the infant performs only at the
level of the ID.
 EGO- emerges to act initially as an
intermediary between the ID and the
external world or reality; includes
processes such as learning, perception,
memory, problem solving, and
decision-making; according to Freud, the
ego must attempt to postpone or redirect
ID satisfaction; since this is a source of
much conflict, Freud contended that
people make use of variety of “defense
mechanism” (denial, rationalization,
repression) to protect the ego
 SUPEREGO- refers as the moral
component of personality (lay terms
one’s conscience), provides feedback to
the person regarding how closely his/her
behavior conforms to the external value
system; it strives for perfection,
disregards reality, usually operates at the
unconscious level, and insistent force
against the desire of the ID; He also
believes that the superego originates in
the learned rules of conduct imposed
by a person’s parents; In some forms,
the ID is always seeking pleasure and
avoiding pain. The superego is trying to
reconcile the instincts of the ID while
discouraging the expression of undesirable
behavior, and encouraging correct goals.
Erikson Theory of Psychosocial
Development
 Erik Erikson was a psychoanalyst who adapted
and expanded Freud’s psychosexual theory
 Theory became popular known as psychosocial
theory which is defined as the intrapersonal and
interpersonal responses of a person to external
events
 He is best known for identifying the 8 stages of
the life span through which a person may
sequentially develop
Erik Erikson’s Stages of
Psychosocial Development
 Developmental Level: Infant
 Central Task: Basic Trust vs. Basic Mistrust
 Focal Relationship/Issues: mother,
primary caregivers, feeding, “feeling and
being comforted”, sleeping, teething, “talking
in”, trusting self, others and environment
 Negative resolution: suspicious, fearful
 Positive resolution (Basic Virtues): drive
and hope
 Developmental Level: Toddler
 Central Task: Autonomy vs. Shame and
Doubt
 Focal Relationship/Issues: parents,
primary caregivers, toilet training, bodily
functions, experimenting with “holding on
and letting go”, having control without loss of
self-esteem
 Negative Resolutions: doubts abilities,
feels ashamed for not trying
 Positive resolution (Basic Virtues): self-
confidence and well-power
 Developmental Level: Pre-schooler
 Central Task: Initiative vs. Guilt
 Focal Relationship/Issues: Family, play,
exploring and discovering, learning how
much assertiveness influence others and the
environment, developing a sense of moral
responsibility
 Negative Resolution: May fear disapproval of
own powers
 Positive Resolution (Basic Virtues): direction
and purpose
 Developmental Level: School-aged Child
 Central Task: Industry vs. Inferiority
  Focal Relationship/Issues: school, teachers,
friends, experiencing physical 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
 Negative Resolution: may feel sense of failure
 Positive Resolution (Basic Virtues): method and
competence
 Developmental Level: Adolescent
 Central Task: Identity vs. Role Confusion
 Focal Relationship/Issues: peers and groups,
experiencing emotional independence from
parents, seeking to be the same as others yet
unique, planning to actualize abilities and goals
fusing several identities into one
 Negative Resolution: confused, non-confused
 Positive Resolution (Basic Virtues): Devotion
and fidelity
 Developmental Level: Young Adult
 Central Task: Intimacy vs. Isolation
 Focal Relationship/Issues: Friends, lovers,
spouses, community, work connections
(networking), committing to work relationships,
committing to social relationships, committing to
intimate relationships
 Negative Resolutions: loneliness, poor
relationships
 Positive resolution (Basic virtues): affiliation and
love
 Developmental Level: Middle-aged adult
 Central Task: Generativity vs. Stagnation
 Focal Relationship/Issues: younger generation-
often children (whether one’s own or those of
others), family, community, mentoring others,
helping to care for others, discovering new
abilities/talents, continuing to create, “giving back” 
 Negative Resolution: shallow involvement
with the world in general, selfish, little
psychosocial growth
 Positive Resolution (Basic Virtues):
production and care
 Developmental Level: Older Adult
 Central Task: Ego Integrity vs. Despair
 Focal Relationship/Issues: all mankind,
reviewing one’s life, acceptance of self-
uniqueness, acceptance of worth of others,
acceptance of death as an entity
 Negative resolution: regret, disconnect
pessimism
 Positive Resolution (Basic Virtues):
Renunciation and wisdom
Piaget Theory of Cognitive
Development
 Dr. Jean Piaget (1970) described himself as a
genetic epistemologist (one who studies the
origin of knowledge)
 His theory is a description and an explanation
of the growth and development of intellectual
structures
 He focused on how the person learns, not what
the person learns.
 Cognition- is the process of obtaining
understanding about one’s world (Schuster &
Ashburn. 1992)
 Piaget acknowledged that interrelationship of
physical maturity, social interaction,
environmental stimulation and experience in
general were necessary for cognition to occur
(Piaget and Inhelder, 1969)
 Primary focus: “Biology of Thinking”
 Piaget postulated that a person may progress
through four major stages of intellectual
development
 He theorized that intellectual development
begins the moment a baby is born. He did not
believe that absolute ages should be attached
to these stages, since individual’s progress at
their own rate.
Each new stage, previous stages of thinking are
incorporated and integrated.
 Piaget acknowledged that a person may at times,
display intellectual behaviors suggestive of more
than one developmental level
 If a person attains formal operational thinking, he
declared that qualitative changes in thinking cease
and quantitative changes in the content and function
of thinking may continue
Piaget Stages of Cognitive
Development
 Stage: Sensorimotor
 Approximate age: 0-2 years
 Significant characteristics: thoughts are
demonstrated by physical manipulation of
objects/stimuli
 Substages (read the Substages): (1) 0-1 month
old: making use of ready-made reflexes (pure
assimilation (2) 1-4 months’ old: primary circular
reactions (assimilation, accommodation, and
equilibrium are now used as individual grows and
develop) (3) 4-8 months old: secondary circular
reactionary (4) 8-12 months: coordination of
secondary circular reactions in new situations (5)
12-18 months old: tertiary circular reaction (6) 18-
24 months old: invention of new means through
mental combinations
 Stage: Preoperational Stage
 Approximate age: 2-7 years
 Significant characteristics: increasing ability to
make mental representation for something not
immediately present using language as a major
tool. Eventually, the child is able to give reasons
for beliefs and rationales for actions however, they
remain biased and immature
 Substages: (1) 2-4 years old: preconceptual- the
child inconsistently assigns any word to several
similar stimuli (e.g. child calls a 4-leged mammals
by his pet’s name) (2) 4-7 years old: the child
begins to realize the ability of a word to truly
represent a specific object, event, or action
 Stage: Concrete Operational
 Approximate Age: 7-11 years’ old
 Significant Characteristics: (1) Begins to
think and reasons logically about objects in
the environment (2) Can perform actions
that previously carried out in actuality (3)
Can consider viewpoints of others (4)
Understand and uses time in a clock (5)
Understand days of week, month of year (6)
Can reverse thoughts and other
characteristics of this age
 Stage: Formal Operational
 Approximate Age: 11-15 years old and
above
 Significant Characteristics: (1) Develops
ability of problem-solving both real-world
and theoretical situations (2) Can think
about past, present, and future (3) Ability to
think about symbols (4) Able to envision and
test many possible combinations in reaching
a conclusion (5) Able to generate multiple
potential solutions
Kohlberg’s Theory of Moral
Development
 Lawrence Kohlberg: a psychologist expanded
Piaget’s thought on morality
 Proposed 3 levels of moral development: (1)
preconventional level (2) conventional level (3)
postconventional level
 Preconventional Level (Premoral)
- Orientation to punishment and obedience
; Average age: pre-school to early school
age
- Orientation to instrumental relativism
(individual purpose)
; Average age: late pre-school to late
school-age
 Conventional Level
- Orientation to interpersonal concordance
(unity and mutuality)
; Average Age: school age to adulthood
- Orientation to maintenance of social
order (law and order)
; Average Age: Adolescence to
adulthood
 Postconventional Level
- Maintaining internal principles of self
- Orientation to social contract legalism
; Average Age: Middlescence to older
adulthood
- Orientation to universal ethical principles
; Average Age: Middlescence to older
adulthood