3/1/2022

HOLISTIC
NURSING
ASSESSMENT

Holistic Nursing Assessment

General Status &
01 Vital Signs

02 Mental Status
05 Culture & Ethnicity
03 Pain
Spirituality & Religious
04 Violence 06 Practices

07 Nutritional Status

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GENERAL
STATUS &
VITAL SIGNS

General
Status

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General Status
- a study of the whole person, covering the general
health state and any obvious physical
characteristics.
- introduction for the physical examination that will
follow
- includes objective parameters that apply to the
whole person, not just one body system.
- Requires the use of observation skills while
interviewing and interacting with the client.

General Status
WHEN IS THIS DONE?
- begins from the moment the nurse meets the
client.

PURPOSE?
- It gives an overall impression of the client’s whole
being.

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Areas of Assessment
01 Apparent State of Health

02 Level of Consciousness
Dress, Grooming, Personal
03 Signs of Distress 05 Hygiene
04 Skin Color & Obvious Lesions 06 Facial Expression

07 Odors of the Body and Breath

08 Posture, Gait & Motor Activity

Apparent State of Health

- General Judgement through observation
- Frail? Acutely Ill? Fit? Robust?

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Level of Consciousness
 Alert – With spontaneous eye opening and response.
 Lethargic – Appears drowsy but open his/her eyes when called
out with a loud voice.
 Obtunded – Opens eyes and looks at you upon vigorous
stimulation. Responds slowly and is confused.
 Stuporous – Responds only when there is painful stimulation.
Verbal response may be absent or slow. When stimuli is absent,
patient goes back to an unresponsive state.
 Coma – Patient remains unarousable even when there is a painful
stimuli.

Level of Consciousness
GLASGOW COMA SCALE
- commonly used index for evaluating the
level of consciousness and overall status of the
CNS.

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Level of Consciousness
GLASGOW COMA SCALE
- commonly used index for evaluating the
level of consciousness and overall status of the
CNS.

Signs of Distress
Cardiac/Respiratory Distress
Pain
Anxiety / Depression

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Dress, Grooming & Personal Hygiene

 Suitability of clothing
 Shoes
 Jewelries
 Hair, Fingernails, Use of Make –up
 General Appearance

Odors of the Body & Breath

 May suggest diagnostic clues

Body Built, Posture, Gait and Motor

Activity
 Preference (posture)
 Involuntary movements
 How the patient walks

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Body Built
 ECTOMORPH – long, lean, with little
body fat and muscle

 ENDOMORPH – Lots of body fats and

muscles

 MESOMORPH – Athletic, solid and

strong

Types of Gait
 Spastic
- Arm is immobile against the body, with
flexion of the shoulder, elbow, wrist, and
fingers and adduction of shoulder; does
not swing freely. Leg is stiff and extended
and circumducts with each step (drags toe
in a semicircle).
- May be caused by stroke or trauma

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Types of Gait
 Ataxic
- Staggering, wide-based gait; difficulty
with turns; uncoordinated
movement
- Can be caused by alcohol or
barbiturates, cerebellar tumor or MS

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Types of Gait
 Steppage
- AKA Foot drop
- Slapping quality—Looks as if walking up
stairs and finding no stair there. Lifts knee
and foot high and slaps it down hard and
flat to compensate for footdrop
- Commonly seen in poliomyelitis

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Types of Gait
 Parkinsonian
- Posture is stooped; trunk is pitched
forward; elbows, hips, and knees are
flexed. Steps are short and shuffling.
Hesitation to begin walking, and difficult to
stop suddenly. The person holds the body
rigid. Walks and turns body as one fixed
unit. Difficulty with any change in direction.

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Types of Gait
 Scissors
- Knees cross or are in contact, like
holding an orange between the
thighs. The person uses short steps,
and walking requires effort.

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Types of Gait
 Waddling
- Weak hip muscles—When the person
takes a step, the opposite hip drops,
which allows compensatory lateral
movement of pelvis. Often the person
also has marked lumbar lordosis and
a protruding abdomen.

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VITAL SIGNS

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Blood
Pressure

Blood Pressure
- Force of the blood pushing against the side of its
container (vessel wall).
- BP is measured with a stethoscope and an aneroid
sphygmomanometer
 SYSTOLIC – maximum pressure felt on the artery

during left ventricular contraction.

 DIASTOLIC – elastic recoil/resting pressure that the

blood exerts constantly between each contraction.

 PULSE PRESSURE – the difference between the

systolic and diastolic pressures (reflects stroke

volume)

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Blood Pressure
 MEAN ARTERIAL PRESSURE
- Pressure forcing blood into the tissues averaged
over the cardiac cycle.
- Affected by many factors:
 Age
 Sex
 Race
 Diurnal Rhythm
 Weight
 Exercise
 Emotions
 Stress

Factors Affecting Level of Blood Pressure

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Blood Pressure
 NORMAL VALUES

CATEGORY SYSTOLIC DIASTOLIC

Normal <120 <80

Prehypertension 120-139 80-89

Stage 1 Hypertension 140-159 90-99

Stage 2 Hypertension 160 and above 100 and above

Blood Pressure ; Phases of Korotkoff’s

Sound
- faint, clear, repetitive tapping sounds
PHASE I

- muffled/swishing
PHASE II - softer and longer than phase I sounds
- may temporarily subside
- return of distinct, crisp, and louder
PHASE III
sounds

PHASE IV - muffled, less distinct and softer

PHASE V - silence

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Blood Pressure
GENERAL GUIDELINES
1. Select appropriate cuff.
2. Check for any arm precautions.
3. Allow patient to rest before taking blood
pressure.
4. Take blood pressure at heart level.

Pulse

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Pulse

Pulse Rate
Normal: 60-100bpm
- Varies with age and gender

BRADYCARDIA – Less than 50 bpm resting

heart rate
TACHYCARDIA – Over 100 bpm

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Pulse Rate
FACTORS AFFECTING PULSE RATE
1. Age
2. Sex
3. Exercise
4. Fever
5. Medication

Pulse Rate

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Pulse Rhythm

Normal: Regular & Even

tempo

Pulse Force
Shows the strength of the heart’s
stroke volume.

3+ Full, bounding,
2+ Normal
1+ Weak, thready
0 Absent

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Respirations

Respirations NORMAL: relaxed, regular,

automatic and silent
Depth: 500-800mL

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Respirations PATTERNS

Respirations PATTERNS

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Respirations PATTERNS

Respirations PATTERNS

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Respirations PATTERNS

Respirations PATTERNS

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Respirations PATTERNS

Temperature

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Temperature
Core temperature = 36.5 - 37.7 ˚C

Influenced by:

 Diurnal Cycle
 Menstruation Cycle
 Exercise
 Age

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Temperature

Temperature

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Temperature

Temperature

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MENTAL
STATUS

PAIN

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Pain
- Tiggers the SNS (results to
physiologic responses such as fear,
anxiety, mental confusion,
increased heart rate, etc.)
- May be associated with
abnormality in VS.

Pain
TRANSDUCTION - begins when a
stimulus results in tissue injury or
damage stimulating the nociceptors.
- Release of chemicals leading to the
nociceptors to send pain message up
the sensory neuron

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Pain
TRANSMISSION – pain impulse from
the nociceptors relays the pain from
the spinal cord to the brain

PERCEPTION - Pain perceived in the

brain

Pain
MODULATION - pain message is
inhibited by brain stem neuron
neuron release of endogenous
neurotransmitters

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Pain
WHAT TO ASSESS??

P
Q
R
S
T

Pain
PROVOKING/PALLIATING
FACTORS
- factors which affects the pain or what
were they doing when the pain started.

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Pain
QUALITY

- Refers to how the pain feels like

Pain
REGION/RADIATION

- Location and if there is a presence of

radiation

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Pain
JAA1

SEVERITY
- Pain scale
 ADULT: Numeric Pain Intensity
 CHILDREN: Wong-Baker Grimace Scale
 INFANT: FLACC

Pain
SEVERITY
Wong-Baker Grimace Scale

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Slide 69

JAA1 Joy Adrianne Alagon, 2/25/2022

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Pain
SEVERITY
FLACC

Pain
SEVERITY
PAINAD
ITEM 0 1 2 Score
Breathing Occasional labored Noisy labored breathing. Long
independent of Normal breathing. Short period of period of hyperventilation. Cheyne-
vocalization hyperventilation stokes respirations
Occasional moan or
Negative groan. Low-level of speech Repeated troubled calling out. Loud
None
vocalization with a negative or moaning or groaning. Crying.
disapproving quality

Facial Smiling or
Sad, frightened, frown Facial grimacing
expression inexpressive

Rigid. Fists clenched. Knees pulled

Tense. Distressed
Body language Relaxed up. Pulling or pushing away.
pacing. Fidgeting
Striking out
No need to Distracted or reassured by Unable to console, distract or
Consolability
console voice or touch reassure
TOTAL*

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Pain
TIMING

- Duration

VIOLENCE

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Violence
THEORIES OF FAMILY ABUSE
1. Psychopathy Theory
2. Social Learning Theory
3. Biologic Theory
4. Family Systems Theory
5. Feminist Theory

Violence
CYCLE NATURE OF VIOLENCE
PHASE 1 – Tension-Building Phase
PHASE 2 – Acute- Battering Stage
PHASE 3 – Honeymoon Phase

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Violence
TYPES OF FAMILY VIOLENCE
1. Physical Abuse
2. Psychological Abuse
3. Economical Abuse
4. Sexual Abuse

Violence
CATEGORIES OF FAMILY VIOLENCE
Intimate Partner Violence
- “pattern of assaultive behavior and coercive
behavior that may include physical injury,
psychologic abuse, sexual assault,
progressive isolation, stalking, deprivation,
intimidation, and reproductive coercion”
(Family Violence Prevention Fund,2010)

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Violence
CATEGORIES OF FAMILY VIOLENCE
Child Abuse
- “any recent act or failure to act on the part
of a parent or caretaker which results in
death, serious physical or emotional harm,
sexual abuse or exploitation”
- “an act or failure to act that presents an
imminent risk of serious harm”

Violence
CATEGORIES OF FAMILY VIOLENCE
Child Abuse
 Neglect
 Emotional Abuse
 Sexual Abuse
 Physical Abuse

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Violence
CATEGORIES OF FAMILY VIOLENCE
Elder Mistreatment
- neglect, physical abuse, sexual abuse,
financial abuse, psychological abuse,
exploitation, abandonment, or prejudicial
attitudes that decrease quality of life and are
demeaning to those over the age of 65 years

Violence
ASSESSMENT
General Guidelines (Interview)
1. Creating a safe and confidential
environment
2. Prior to screening, discuss any
legal, mandatory reporting
requirements or other limits to
confidentiality

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Violence
ASSESSMENT
General Guidelines (Interview)
3. Allow client to answer completely.
4. Convey a concerned and
nonjudgemental attitude
5. Show appropriate empathy.

Violence
ASSESSMENT
INTERVIEW
1. Ask:

2. For intimate partner violence, begin

screening by telling the client it is important
to routinely screen all clients for intimate
partner violence because it affects so many
women and men in our society.

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Violence
ASSESSMENT
INTERVIEW
3. Prior respiratory problems/thoracic
surgery/trauma
4. Any harmful experiences he/she had with
the family
5. Family history of abuse
6. Problems with usual daily activities
7. Stress and how it affects breathing
8. Participation of activities outside the house

Violence
ASSESSMENT
CONSIDERTIONS IN ASSESSING CHILD
ABUSE
1. Do not coerce the child by offering a
reward.
2. Establish child’s understanding or
developmental stage
3. Use direct questions.
4. Avoid questions that are answerable by
yes or no.

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Violence
ASSESSMENT
WHAT TO OBSERVE/PHYSICALLY ASSESS?
1. General Appearance
& Built 10. Genitalia & Anus
2. Grooming & Hygiene 11. Musculoskeletal
3. Mental Status System
4. Vital Signs 12. Neurologic System
5. Skin
6. Head & Neck
7. Eyes
8. Ears
9. Abdomen

CULTURE &
ETHNICITY

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Culture & Ethnicity

TERMINOLOGIES
CULTURE - “the totality of socially transmitted behavioral patterns, arts,
beliefs, values, customs, lifeways, and all other products of human work
and thought characteristic of a population or people that guide their
worldview and decision making”(Purnell & Paulanka, 2008)

VALUES- learned beliefs about what is held to be good or bad

NORMS – learned behaviors that are perceived to be appropriate or

inappropriate

ETHNOCENTRISM – The perception that one’s worldview is the only

acceptable truth and that one’s beliefs, values, and sanctioned
behaviors are superior to all others.

Culture & Ethnicity

TERMINOLOGIES
STEREOTYPING – Not being able to recognize that there are variations
of beliefs, values and accepted behaviors within any cultural group.

ETHNICITY/ETHNIC IDENTITY - describes subgroups that have a

common history, ancestry, or other cultural identity that may relate to
geographic origin, such as Southerners, Navajos, or Mexican Americans

RACE - socially constructed concept that has meaning to a larger

group

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Culture & Ethnicity

CULTURAL COMPETENCE
 Cultural Awareness
 Cultural Skill
 Cultural Knowledge
 Cultural Encounters
 Cultural Desires

Culture & Ethnicity

- Process of conducting a self-
examination of one’s biases towards
Cultural Awareness

other cultures & indepth exploration of

one’s cultural professional background
(Campinha-Bacote, 2011)
Stages:

1. Unconscious Incompetence
2. Conscious Incompetence
3. Conscious Competence
4. Unconscious Competence

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Culture & Ethnicity

- “the ability to collect relevant
cultural data regarding the client’s
presenting problem as well as
accurately conducting a culturally-
Cultural Skill

based physical assessment”

(CampinhaBacote, 2011)

- Involves learning how to complete

cultural assessments and culturally
based physical assessments and to
interpret data accurately.

Culture & Ethnicity

Cultural Knowledge

- “the process of seeking and

obtaining a sound educational
foundation concerning the various
world views of different cultures”
(Campinha-Bacote, 2011)

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Culture & Ethnicity

- “the process which allows the healthcare
provider to directly engage in face-to-face
Cultural Encounter

cultural interactions and other types of

encounters with clients from culturally
diverse backgrounds” (Campinha-Bacote,
2011)
- requires going beyond the study of a
culture and limited interaction with three
or four members of the culture

Culture & Ethnicity

Motivation to engage in
Cultural Desire

intercultural encounter and

acquire cultural competence.

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Culture & Ethnicity

FACTORS AFFECTING APPROACH TO PROVIDERS
 Ethnicity
 Generational Health Status
 Educational Level
 Religion
 Previous Health Care Experiences
 Occupation & Income level
 Beliefs about Time and Space
 Communication Needs/Preferences

SPIRITUALITY
& RELIGIOUS
PRACTICES

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Spirituality & Religious Practice

TERMINOLOGIES
RELIGION - rituals, practices, and experiences shared
within a group that involve a search for the sacred

SPIRITUALITY - search for meaning and purpose in

life

Spirituality & Religious Practice

IMPACT OF RELIGION AND SPIRITUALITY ON
HEALTH
- Religion and spirituality can be powerful coping
mechanisms when a person faces end-of-life
issues.
- Encourage greater mental & physical health
POSITIVE IMPACT: Encourage a lifestyle to mirror a
belief
NEGATIVE IMPACT: Failure to seek timely medical
care based on religious dogma

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Spirituality & Religious Practice

SPIRITUAL ASSESSMENT
• Approach
- No absolute timing of spiritual assessment
- May include during the initial assessment or
maybe after the nurse-client relationship has been
established.
- Assess objectively.
- Questions should be geared towards beliefs that
could affect client care.

Spirituality & Religious Practice

SPIRITUAL ASSESSMENT
Techniques
1. Non Formal
S
P
I
R
I
T

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Spirituality & Religious Practice

SPIRITUAL ASSESSMENT
Techniques
2. Formal
S
P
I
R
I
T

Spirituality & Religious Practice

SPIRITUAL ASSESSMENT
• Techniques
2. Formal
S
P
I
R
I
T

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Spirituality & Religious Practice

SPIRITUAL ASSESSMENT
• Techniques
2. Formal
S
P
I
R
I
T

NUTRITION

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Nutrition
SUBJECTIVE ASSESSMENT
 Food Safety
 Nutrition
 Hydration
 Nutritional Problems
• Malnutrition
• Overnutrition
• Dehydration
• Overhydration

Nutrition
OBJECTIVE DATA
 Food Intake (Nutritional Screening Tool)
 Appearance and Body built
 Height
 Weight

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Nutrition
OBJECTIVE DATA
 Food Intake (Nutritional Screening Tool)
 Appearance and Body built
 Height
 Weight
 BMI

Nutrition
OBJECTIVE DATA
 Food Intake (Nutritional Screening Tool)
 Appearance and Body built
 Height
 Weight
 BMI
 Waist Circumference
 Waist-To-Hip Ratio

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Nutrition
OBJECTIVE DATA
 Food Intake (Nutritional Screening Tool)
 Appearance and Body built
 Height
 Weight
 BMI
 Waist Circumference
 Waist-To-Hip Ratio
 Mid-Arm Circumference

Nutrition
OBJECTIVE DATA
 Food Intake (Nutritional Screening Tool)
 Appearance and Body built
 Height
 Weight
 BMI
 Waist Circumference
 Waist-To-Hip Ratio
 Mid-Arm Circumference
 Triceps Skin Fold Thickness

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Nutrition
OBJECTIVE DATA
 Input & Output
 Skin Turgor
 Edema
 Skin Moisture

CREDITS: This presentation template was created

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CREDITS: This presentation template was created

by Slidesgo, including icons by Flaticon and
infographics & images by Freepik

CREDITS: This presentation template was created

by Slidesgo, including icons by Flaticon and
infographics & images by Freepik

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