NCHA 101

Health
Assessment
Allan Paul A. Caabay, RN, MSNc

PPT 3
Learning Objectives
At the end of a 2-hour lecture-discussion, students will be able to:
1.Describe the components of a holistic nursing assessment, including
general status, vital signs, mental status, psychosocial, cognitive, moral
development, and nutritional status.
2.Differentiate assessment approaches for mental status across children,
adolescents, and adults, incorporating considerations for pain, violence,
culture, and ethnicity.
3.Analyze the role of spirituality, religious practices, and cultural diversity in
conducting a comprehensive and client-centered nursing assessment.
4.Apply principles of holistic assessment to evaluate a client's nutritional
status and psychosocial well-being, integrating knowledge of developmental
and cultural influences.
5.Apply Trinitian values.
Holistic Nursing Assessment
A. General Status and Vital Signs The general survey includes:
a. Physical development and body build
General survey: b. Gender and sexual development
• the first part of the physical c. Apparent age as compared to reported
examination that begins the moment age
the nurse meets the client. d. Skin condition and color
e. Dress and hygiene
• outcome of the general survey f. Posture and gait
provides the nurse with an overall g. Level of consciousness
impression of the client’s whole being. h. Behaviors, body movements, and affect
i. Facial expression
j. Speech
k. Vital signs
Holistic Nursing Assessment
A. General Status and Vital Signs
Vital signs
• the body’s indicators of health.
• Include: 1. temperature, 2. pulse, 3. respirations, 4. blood pressure, and 5.
pain
• Usually when a vital sign (or signs) is abnormal, something is wrong in at least
one of the body systems.
• Note that activity, talking, gum chewing, and anxiety affect pulse, respirations,
and blood pressure.
• Allow 5 minutes of rest before beginning to take vital signs.
Holistic Nursing Assessment
A. General Status and Vital Signs
1. TEMPERATURE
• Core body temperature must be maintained between 36.5°C and 37.7°C
(96.0°F to 99.9°F orally) for proper cellular function, with readings at various
sites being approximate.
• Normal temperature variations are influenced by factors such as time of day,
exercise, stress, and ovulation, being lowest in the early morning and highest
in the evening.
• Hypothermia (<36.5°C or 96.0°F) may result from prolonged cold exposure,
hypoglycemia, hypothyroidism, or starvation.
• Hyperthermia (>38.0°C or 100°F) may occur due to infections, malignancies,
trauma, or blood, endocrine, and immune disorders.
Sequence of events in fever
Types of fever patterns
Let fever do its job (Wrotek et al., 2020)
• Fever is a regulated increase in body temperature and a key part of
the acute phase response to infection.
• It enhances immune cell performance, stresses pathogens,
and provides nonspecific immune defense.
• Studies suggest fever offers a survival benefit, and reducing it may
hinder the body's natural defense.
• During COVID-19, allowing fever to run its course may be more
beneficial than suppressing it.
Holistic Nursing Assessment
A. General Status and Vital Signs
2. PULSE
• a shock wave produced by the heart's contraction and blood ejection into the aorta, traveling
along arterial fibers.
• Radial pulse - a commonly used site for assessing overall health status, with other arterial
pulse sites also available.
• Key characteristics to evaluate in the radial pulse include rate, rhythm, amplitude and
contour, and elasticity.
• Pulse amplitude is graded on a scale:
• 0 (absent)
• 1+ (weak, easily obliterated)
• 2+ (normal, moderate pressure to obliterate)
• 3+ (bounding, requires firm pressure or not obliterated)
Holistic Nursing Assessment
A. General Status and Vital Signs
3. RESPIRATIONS
• Observe respirations without alerting the client by watching chest movement
while continuing to palpate the radial pulse.
• Notable characteristics of respiration are rate, rhythm, and depth
Holistic Nursing Assessment
A. General Status and Vital Signs
4. BLOOD PRESSURE
• a measurement of the pressure of the blood in the arteries when the ventricles
are contracted (systolic blood pressure) and when the ventricles are relaxed
(diastolic blood pressure)
• reflects the pressure exerted on the walls of the arteries. This pressure varies
with the cardiac cycle, reaching a high point with systole and a low point with
diastole.
• expressed as the ratio of the systolic pressure over the diastolic pressure.
FACTORS CONTRIBUTING TO BLOOD
PRESSURE
1. Cardiac Output. The more blood the heart pumps, the greater the pressure in the
blood vessels. For example, blood pressure increases during exercise.
2. Peripheral Vascular Resistance. An increase in resistance in the peripheral
vascular system, as happens with people who have circulatory disorders, will
increase blood pressure.
3. Circulating Blood Volume. An increase in volume will increase blood pressure. A
sudden drop in blood pressure may indicate a sudden blood loss, as with internal
bleeding.
4. Viscosity. When the blood becomes thicker or more viscous (as with
polycythemia), the pressure in the blood vessels will increase.
5. Elasticity of Vessel Walls. An increase in stiffness of the vessel walls (e.g.,
atherosclerotic changes) will increase blood pressure.
Holistic Nursing Assessment
A. General Status and Vital Signs
5. PAIN
• Unpleasant sensory sensation
• Assessment:
• Pain scale – pain severity from 0 (lowest) to 10 (highest): ex. “PS of 7/10”
• PQRST
• COLDSPA
• Wong-Baker FACES Pain Rating Scale – for pediatric clients (3-18 yo)
• FLACC Scale – for 2 months and 7 years or individuals who are unable to
verbally communicate their pain.
Holistic Nursing Assessment
B. Mental Status
• refers to a client’s level of cognitive functioning (thinking, knowledge, and
problem solving) and emotional functioning (feelings, mood, behaviors,
and stability).
• Healthy mental status is needed to think clearly, respond appropriately,
and function effectively in all activities of daily living (ADLs).
• reflected in one’s appearance, behaviors, speech, thought patterns,
decisions, and ability to function in an effective manner in relationships
in home, work, social, and recreational settings
Holistic Nursing Assessment
B. Mental Status
• Essential assessment areas for mental status:
1. Appearance
2. General behavior
3. Cognitive function and memory
4. Thought processes
Use appropriate questionnaires or tests as indicated.
(See p. 238 to 253 and 256)
Holistic Nursing Assessment
B. Mental Status
Abnormal Levels of Consciousness:
• Lethargy: Client opens eyes, answers questions, and falls back asleep.
• Obtunded: Client opens eyes to loud voice, responds slowly with confusion, and
seems unaware of environment.
• Stupor: Client awakens to vigorous shake or painful stimuli but returns to
unresponsive sleep.
• Coma: Client remains unresponsive to all stimuli; eyes stay closed.
Holistic Nursing Assessment
C. Psychosocial, Cognitive and Moral Development:
Developmental theories:
1. Psychosocial - Erik Erikson
2. Cognitive - Jean Piaget
3. Moral Development - Lawrence Kohlberg
Erik Erikson’s
Stages of
Psychosocial
Development
Jean Piaget’s Stages of Cognitive Development
Lawrence
Kohlberg’s
Stages of
Moral
Development
Holistic Nursing Assessment
C. Psychosocial, Cognitive and Moral Development:
Developmental theories– see Assessment procedure
1. Psychosocial - Erik Erikson on p. 295-298
2. Cognitive - Jean Piaget on p. 298-302
3. Moral Development - Lawrence Kohlberg on p.302-305
Holistic Nursing Assessment
D. Violence
Violence - “the use of physical force to harm someone, to damage
property, etc.” (Merriam-Webster Online, 2015).
Domestic violence - “a pattern of abusive behavior in any relationship
that is used by one partner to gain or maintain control over another
intimate partner.”
Holistic Nursing Assessment
D. Violence
• Five theories related to domestic violence for why men batter women
(McCue, 2008)
(1)Psychopathology theory (batterers suffer personality disorders);
(2)Social learning theory (violence is a learned behavior from childhood);
(3)Biologic theory (physiologic changes from childhood trauma, head
injuries, or through heredity cause violent behavior);
(4)Family systems theory (violence grows through family system
function, but some criticize this theory as blaming the victim); and
(5)Feminist theory (male/female inequity in patriarchal societies leads to
violence).
Holistic Nursing Assessment
D. Violence
• Types of Family Violence:
1. Physical Abuse: Includes acts like hitting, slapping, kicking, choking, burning,
and using weapons; involves restraining or abandoning the victim and neglecting
their needs.
2. Psychological Abuse: Encompasses verbal insults, threats, isolation,
humiliation, manipulation, stalking, and behaviors that diminish identity, dignity,
and self-worth.
3. Economic Abuse: Involves controlling finances, restricting job opportunities,
misusing assets, forging documents, or coercing financial decisions; often
underreported, especially among elders.
4. Sexual Abuse: Includes forced sexual acts, violence during sex, and assaults by
both family members and acquaintances; majority of perpetrators are known to
victims.
Holistic Nursing Assessment
D. Violence
• Categories of Family Violence
1. Intimate Partner Violence (IPV): Encompasses physical,
sexual, and psychological harm, often escalating over time;
affects both women and men, including LGBT individuals, with
severe physical, emotional, and societal impacts.
2. Child Abuse: Defined as acts or omissions causing harm or risk
of harm; includes neglect, emotional, sexual, and physical
abuse
Holistic Nursing Assessment
D. Violence
• Perform a General Survey – p. 450- 457
Holistic Nursing Assessment
E. Culture and Ethnicity
• Nurses need to understand culture to provide effective and
equitable care, as clients may have diverse beliefs and practices
regarding health, illness, and decision-making, even within
seemingly similar communities.
• To provide high-quality health care, nurses must know how to
assess what is normal or abnormal for all persons who seek care.
This necessitates cultural competence.
Holistic Nursing Assessment
E. Culture and Ethnicity
Main purposes of assessing culture in a health care setting:
1. To learn about the client’s beliefs and usual behaviors associated with health
and illness
2. To compare and contrast the client’s beliefs and practices to standard Western
health care
3. To compare the client’s beliefs and practices with those of other persons from
a similar cultural background (to avoid stereotyping)
4. To assess the client’s health relative to diseases prevalent in the specific
cultural group
Holistic Nursing Assessment
E. Culture and Ethnicity
OBSERVATIONS TO BE MADE DURING THE CLIENT INTERVIEW AND
PHYSICAL EXAMINATION (p.499)
1. Eye contact and face positioning
2. Body language and hand gestures
3. Silence
4. Touch
5. Expression of pain
Holistic Nursing Assessment
E. Culture and Ethnicity

Culturally insensitive and culturally sensitive

communication (example on p. 501-504)
Holistic Nursing Assessment
F. Spirituality and Religious Practices
• Spirituality and religious beliefs and practices influence health
decisions, lifestyle practices, dietary practices, end-of-life decisions,
and many other elements of health care.
• Nurses, though not specialized in spiritual care, play a vital role by
screening for spiritual needs, referring clients to appropriate
spiritual resources, and integrating spiritual care within their
practice to support client well-being.
Holistic Nursing Assessment
F. Spirituality and Religious Practices
FOUNDATIONAL KNOWLEDGE FOR SPIRITUAL ASSESSMENT:
RELIGION SPIRITUALITY
Definition: Rituals, practices, and experiences Definition: A search for meaning and purpose
involving a search for the sacred (e.g., God, in life that seeks to understand life’s ultimate
Allah) that are shared within a group. questions in relation to the sacred.
Characteristics Characteristics
• Formal • Informal
• Organized • Nonorganized
• Group oriented • Self-reflective
• Ritualistic • May involve spiritual experiences
• Objective, as in easily measurable (e.g., • Subjective, as in difficult to consistently
church attendance) measure (e.g., daily spiritual experiences,
spiritual well-being)
Holistic Nursing Assessment
F. Spirituality and Religious Practices

SPIRITUAL ASSESSMENT SPIRITUAL CARE

Definition: Active and ongoing Definition: Addressing the spiritual
conversation that assesses the needs of the client as they unfold
spiritual needs of the client. through spiritual assessment.
Characteristics Characteristics
• Formal or informal • Individualistic
• Respectful • Client oriented
• Nonbiased • Collaborative
Holistic Nursing Assessment
F. Spirituality and Religious Practices

Major World Religions and Common Health Beliefs

(p. 535-536)
Holistic Nursing Assessment
F. Spirituality and Religious Practices
Incorporating Religion and Spirituality into Care:
• Nurses play a key role in addressing clients' spiritual concerns, as
nursing's holistic approach considers body, mind, and spirit.
• This long-standing practice, rooted in the profession's history and
theories, allows nurses to incorporate spiritual care through
silence, prayer rituals, and family involvement.
Holistic Nursing Assessment
G. Nutritional Status
• Nutritional assessment identifies risk factors for obesity (excessive
body fat) and for dietary deficits (malnutrition and undernutrition),
and is also used to guide health promotion and disease prevention
activities.
• Hydration status assessment is another important aspect of the
nutritional assessment and an important indicator of the client’s
general health.
• Food safety is also an essential component of nutritional assessment
to determine how clients store and prepare food in addition to their
understanding of food contamination and allergies.
Holistic Nursing Assessment
G. Nutritional Status

Collecting Subjective Data: The Nursing Health History (p. 564-567)

• Client’s 24-Hour Diet Recall (p. 568)

Collecting Objective Data: Physical Examination (p. 571-598)

References:
Weber, J. R., & Kelley, J. H. (2022). Health assessment in nursing (7th
ed.). Wolters Kluwer.
Wrotek, S., LeGrand, E. K., Dzialuk, A., & Alcock, J. (2020). Let fever do its
job: The meaning of fever in the pandemic era. Evolution, medicine,
and public health, 9(1), 26–35. https://doi.org/10.1093/emph/eoaa044
Assignment #2:
Understanding Gordon’s 11 Functional Health Patterns
• Objective: To familiarize nursing students with Gordon's Functional
Health Patterns by analyzing their descriptions and identifying possible
subjective and objective assessment cues for each pattern.
• Instructions:
1. Using your textbook or lecture materials, complete the table by:
1. Writing the description of each pattern in the second column.
2. Listing subjective and objective cues for assessment in the third column.
2. Ensure your answers are specific and aligned with clinical practice.
3. Submit your completed table as part of your assignment.
Assignment #2:
Pattern Book Description Possible Subjective and Objective Cues
1. Subjective:

Objective:

2. Subjective:

Objective:
3. Subjective:

Objective:
4. Subjective:

Objective:
5. Subjective:
Assignment #2:
• Submission Deadline: January 23, 2025
• Format: Handwritten (neatly), in a table format using whole short
bond paper (stapled).
• Evaluation Criteria:
1. Completeness of the table (all patterns addressed) (11 points)
2. Accuracy and relevance of descriptions and cues (11 points)
3. Clarity and organization (8 points)
Total = 30 points
Questions?
Concerns?
Thank you!
 Nurse’s Prayer
Oh My God,
Teach me to receive the sick in Your Name.
Give to my effort’s success,
For the glory of Your holy Name.
It is Your work; without You, I cannot succeed.
Grant that the sick You have placed in my care,
Closing May be abundantly blessed,
And not one of them be lost,
Prayer Because of any neglect on my part.
Help me to overcome, every temporal weakness
And strengthen in me,
Whatever may enable me to bring joy to the lives
of those I serve.
Give me grace, for the sake of Your sick ones,
And those lives that will be influenced by them.
Amen.