Holistic Nursing Assessment
Mental status – refers to a client’s level of cognitive
functioning and emotional functioning.
Mental health – is an essential part of one’s total health
and is more than just the absence of mental disabilities
or disorders.
Mental disorder – is any condition characterized by
cognitive and emotional disturbances, abnormal
behaviors, impaired functioning.
Factors Affecting Mental Health
 Economic and social factors, such as rapid changes,
stressful work conditions, and isolations.
 Unhealthy lifestyle choices, such as sedentary
lifestyle or substance abuse
 Exposure to violence, such as being a victim of
child abuse, spouse or significant other abuse,
active military, veterans and refugees and
immigrants from violent environments
Factors Affecting Mental Health
 Personality factors such as poor decision-making
skills, low self-concept, and poor self-control.
 Spiritual factors
 Cultural factors
Factors Affecting Mental Health
Changes of impairments in the structure and function of
other neurologic system
Psychosocial development level and issues
Collecting Subjective Data: The Nursing Health
History
 Biographic data
 History of present health concern
 Personal health history
 Family health history
 Lifestyle and health practices
Collecting Objective Data: Physical Assessment
a. Level of consciousness and mental status
 Observe the client’s level of consciousness
-ask client’s name, address and phone number
- ask the client to identify where they currently
are, the day, and the
-approximate time
 Observe behavior and affect
 Observe dress and grooming
 Observe hygiene
 Observe facial expressions, eye contact, and affect
 Assess speech
 Observe mood, feelings, and expressions
Collecting Objective Data: Physical Examination
b. Cognitive abilities
 Assess orientation
 Assess concentration
 Assess recent memory
 Assess remote memory
 Assess abstract reasoning
Mental Health of Adolescents
Globally, one in seven 10-19-year-olds experiences a
mental disorder, accounting for 13% of the global
burden of disease in this age group.
Depression, anxiety and behavioral disorders are among
the leading causes of illness and disability among
adolescents.
Suicide is the fourth leading cause of death among 15-29
year-olds.
The consequences of failing to address adolescent
mental health conditions extend to adulthood, impairing
both physical and mental health and limiting
opportunities to lead fulfilling lives as adults.
Mental Health of Adolescents
WHO Response
Helping Adolescents Thrive (HAT) Initiative
developed a module on Child and Adolescent Mental
and Behavioural Disorders
WHO is developing and testing scalable psychological
interventions
WHO’s Regional Office for the Eastern Mediterranean
has developed a mental health training package for
educators.
Selected client concerns
Opportunity to improve health
 Opportunity to improve health associated with
requesting information on assistance for substance
abuse
Risk for client concerns
 Risk for suicide associated with depression, suicidal
tendencies, developmental crisis, lack of support
systems, loss of significant others, and poor coping
mechanisms and behaviors
 Risk for delayed growth and development
associated with living in a confined unhealthy
environment that restricts stimulation and activity.
Selected client concern
Actual client concerns
 Anxiety associated with awareness of increasing
memory loss
 Fear associated with memory loss
 Poor coping skills associated with sudden stroke
and loss of use of extremities
 Confusion associated with dementia, head injury,
stroke, and alcohol or drug abuse
 Decreased memory recall associated with dementia,
stroke, head injury, and alcohol or drug abuse
 Inability to dress and groom self associated with
confusion and lack of caregiver resources/support.
Assessing Psychosocial, Cognitive, and Moral
Development
Erikson Theory of Psychosocial Development
 Erik Erikson was a psychoanalyst
 Erikson concluded that societal, cultural, and
historical factors – as well as biophysical processes
and cognitive function- influence personality
development.
 He declared that ego not only mediates between the
id’s abrupt impulses and the superego’s moral
demands but that it can positively affect a person’s
development as more skills and experience are
gained.
 He believed that personality development continues
to evolve throughout the life span.
Erikson’s Stages of Psychosocial Development
Stage 1: Trust vs. Mistrust (Infancy from birth to 18
months)
Stage 2: Autonomy vs. Shame and Doubt (Toddler years
from 18 months to three years)
Stage 3: Initiative vs. Guilt (Preschool years from three
to five)
Stage 4: Industry vs. Inferiority (Middle school years
from six to 11)
Stage 5: Identity vs. Confusion (Teen years from 12 to
18)
Stage 6: Intimacy vs. Isolation (Young adult years from
18 to 40)
Stage 7: Generativity vs. Stagnation (Middle age from
40 to 65)
Stage 8: Integrity vs. Despair (Older adulthood from 65
to death)
Piagets’s Theory of Cognitive Development
 Dr. Jean Piaget described himself as a genetic
epistemologist.
 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 the
person learns.
 Cognition – is the process of obtaining
understanding about one’s world.
 Piaget acknowledged that interrelationships of
physical maturity, social interaction. environmental
stimulation, and experience in general were
necessary for cognition to occur.
 Primary focus was the biology of thinking
Kohlberg’s Theory of Moral Development
 Lawrence Kohlberg- a psychologist, expanded
Piaget’s thoughts on morality; in doing so; he
developed, a comprehensive theory of moral
development.
 He proposed individual morality has been viewed
as a dynamic process that extends over one’s
lifetime, primarily involving the affective and
cognitive domains in determining what is “right”
and “wrong”.
 Dr, Kohlberg 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.
Kohlberg’s Stages of Moral Development
Possible client concerns:
Opportunity to improve
 Opportunity to improve healthy relationships
 Opportunity to improve mental health
Risk for client concerns
 Risk for violent behaviors towards self
 Risk for violent behaviors towards others
 Risk for poor relationships
 Risk for suicide
Possible client concerns:
Actual client concerns
A client concern is determined depending on the
individual’s level of assessed development
Assessing Pain
PAIN
“An unpleasant sensory and emotional experience,
which we primarily associate with tissue damage or
describe in terms of such damage.”
International Association for the Study of Pain (2017)
“Pain is whatever the experiencing person says it is,
existing whenever he says it does.”
Pasero (2018)
Assessing Pain
Pathophysiology of Pain
 Pain are associated with the central and peripheral
nervous system.
 The source of pain stimulates peripheral nerve
endings (nociceptors), which transmit the
sensations to the central nervous system.
 They are sensory receptors that detect signals from
damaged tissue and chemicals released from the
damaged tissue.
 Nociceptors are located at the peripheral ends of
both myelinated nerve endings of type A fibers and
unmyelinated type C fibers.
There are 3 types that are simulated by different stimuli.
 mechanosensitive nociceptors
 temperature sensitive nociceptors
 polymodal nociceptors
Pathophysiology of Pain
Some nociceptors may respond to more than one type of
stimulus.
Nociceptors are distributed in the body, skin,
subcutaneous tissue, skeletal muscle joints, peritoneal
surfaces, pleural membranes, dura meter, and blood
vessel walls.
They are not located in the parenchyma of visceral
organs.
Physiologic processes involved in pain perception:
 Poor mobility associated with persistent recurring
pain
“Constant attention by a good nurse may be just as
important as a major operation by a surgeon.”
-Dag Hammarskjöld, Swedish economist and
diplomat

 Transduction

 Transmission

 Perception

 Modulation

2 Types of Pain

Acute pain can be momentary or last up to three months,

is treatable.

Chronic pain lasts longer than three months, and the

impact can be lifelong.

Selected client concerns

 Opportunity to enhance health

 Opportunity to improve comfort level

Risk for client concerns

Risk for inability to exercise associated with chronic

pain and immobility

Risk for ongoing constipation associated with

nonsteroidal anti-inflammatory agents or opiates intake
or poor eating habits

Risk for feeling powerless associated with chronic pain,

health care environment, prescribed pain treatment-
related regimen

Selected client concerns

Actual client concerns

 Intense pain associated with injury agents (biologic,

chemical, physical, or psychological)

 Persistent recurring pain associated with chronic

inflammation from rheumatoid arthritis

 Poor breathing pattern associated with abdominal

pain and anxiety

 Prolonged fatigue associated with stress of

persistent recurring pain