Health Assessment Lec

Holistic Nursing Assessment Collecting Objective Data: Physical Assessment
Mental status – refers to a client’s level of cognitive a. Level of consciousness and mental status
functioning and emotional functioning.
 Observe the client’s level of consciousness
Mental health – is an essential part of one’s total health -ask client’s name, address and phone number
and is more than just the absence of mental disabilities - ask the client to identify where they currently
or disorders. are, the day, and the
-approximate time
Mental disorder – is any condition characterized by
cognitive and emotional disturbances, abnormal  Observe behavior and affect
behaviors, impaired functioning.
 Observe dress and grooming
Factors Affecting Mental Health
 Observe hygiene
 Economic and social factors, such as rapid changes,
stressful work conditions, and isolations.  Observe facial expressions, eye contact, and affect
 Unhealthy lifestyle choices, such as sedentary  Assess speech

lifestyle or substance abuse
 Observe mood, feelings, and expressions
 Exposure to violence, such as being a victim of
child abuse, spouse or significant other abuse, Collecting Objective Data: Physical Examination
active military, veterans and refugees and
immigrants from violent environments b. Cognitive abilities
Factors Affecting Mental Health  Assess orientation
 Personality factors such as poor decision-making  Assess concentration

skills, low self-concept, and poor self-control.
 Assess recent memory
 Spiritual factors
 Assess remote memory
 Cultural factors
 Assess abstract reasoning
Factors Affecting Mental Health Mental Health of Adolescents
Changes of impairments in the structure and function of Globally, one in seven 10-19-year-olds experiences a
other neurologic system mental disorder, accounting for 13% of the global
burden of disease in this age group.
Psychosocial development level and issues
Depression, anxiety and behavioral disorders are among
the leading causes of illness and disability among
Collecting Subjective Data: The Nursing Health adolescents.
History
Suicide is the fourth leading cause of death among 15-29
 Biographic data year-olds.
 History of present health concern The consequences of failing to address adolescent

mental health conditions extend to adulthood, impairing
 Personal health history both physical and mental health and limiting
opportunities to lead fulfilling lives as adults.
 Family health history
 Lifestyle and health practices

Mental Health of Adolescents Assessing Psychosocial, Cognitive, and Moral
Development
WHO Response
Erikson Theory of Psychosocial Development
Helping Adolescents Thrive (HAT) Initiative
 Erik Erikson was a psychoanalyst
developed a module on Child and Adolescent Mental
and Behavioural Disorders  Erikson concluded that societal, cultural, and
historical factors – as well as biophysical processes
WHO is developing and testing scalable psychological and cognitive function- influence personality
interventions development.
WHO’s Regional Office for the Eastern Mediterranean  He declared that ego not only mediates between the
has developed a mental health training package for id’s abrupt impulses and the superego’s moral
educators. demands but that it can positively affect a person’s
development as more skills and experience are
Selected client concerns gained.
Opportunity to improve health  He believed that personality development continues

to evolve throughout the life span.
 Opportunity to improve health associated with
requesting information on assistance for substance Erikson’s Stages of Psychosocial Development
abuse
Stage 1: Trust vs. Mistrust (Infancy from birth to 18
Risk for client concerns months)
 Risk for suicide associated with depression, suicidal Stage 2: Autonomy vs. Shame and Doubt (Toddler years
tendencies, developmental crisis, lack of support from 18 months to three years)
systems, loss of significant others, and poor coping
mechanisms and behaviors Stage 3: Initiative vs. Guilt (Preschool years from three
to five)
 Risk for delayed growth and development
associated with living in a confined unhealthy Stage 4: Industry vs. Inferiority (Middle school years
environment that restricts stimulation and activity. from six to 11)
Selected client concern Stage 5: Identity vs. Confusion (Teen years from 12 to
18)
Actual client concerns
Stage 6: Intimacy vs. Isolation (Young adult years from
 Anxiety associated with awareness of increasing 18 to 40)
memory loss
Stage 7: Generativity vs. Stagnation (Middle age from
 Fear associated with memory loss 40 to 65)
 Poor coping skills associated with sudden stroke Stage 8: Integrity vs. Despair (Older adulthood from 65
and loss of use of extremities to death)
 Confusion associated with dementia, head injury, Piagets’s Theory of Cognitive Development
stroke, and alcohol or drug abuse
 Dr. Jean Piaget described himself as a genetic
 Decreased memory recall associated with dementia, epistemologist.
stroke, head injury, and alcohol or drug abuse
 His theory is a description and an explanation of the
 Inability to dress and groom self associated with growth and development of intellectual structures.
confusion and lack of caregiver resources/support.
 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 Risk for client concerns
physical maturity, social interaction. environmental
stimulation, and experience in general were  Risk for violent behaviors towards self
necessary for cognition to occur.
 Risk for violent behaviors towards others
 Primary focus was the biology of thinking
 Risk for poor relationships
 Risk for suicide
Possible client concerns:
A client concern is determined depending on the

Kohlberg’s Theory of Moral Development individual’s level of assessed development
 Lawrence Kohlberg- a psychologist, expanded Assessing Pain

Piaget’s thoughts on morality; in doing so; he
developed, a comprehensive theory of moral PAIN
development.
“An unpleasant sensory and emotional experience,
 He proposed individual morality has been viewed which we primarily associate with tissue damage or
as a dynamic process that extends over one’s describe in terms of such damage.”
lifetime, primarily involving the affective and International Association for the Study of Pain (2017)
cognitive domains in determining what is “right”
and “wrong”. “Pain is whatever the experiencing person says it is,
existing whenever he says it does.”
 Dr, Kohlberg was most concerned with examining Pasero (2018)
the reasoning a person used to make a decision, as
opposed to the action that resulted after that Assessing Pain
decision was made.
Pathophysiology of Pain
Kohlberg’s Stages of Moral Development
 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.
Possible client concerns:
There are 3 types that are simulated by different stimuli.
Opportunity to improve  mechanosensitive nociceptors
 temperature sensitive nociceptors
 Opportunity to improve healthy relationships  polymodal nociceptors
 Opportunity to improve mental health Pathophysiology of Pain
Some nociceptors may respond to more than one type of

stimulus.
Nociceptors are distributed in the body, skin,  Poor mobility associated with persistent recurring
subcutaneous tissue, skeletal muscle joints, peritoneal pain
surfaces, pleural membranes, dura meter, and blood
vessel walls. “Constant attention by a good nurse may be just as
important as a major operation by a surgeon.”
They are not located in the parenchyma of visceral
organs. -Dag Hammarskjöld, Swedish economist and
diplomat
Physiologic processes involved in pain perception:
 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
 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

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Holistic Nursing Assessment Collecting Objective Data: Physical Assessment

 Unhealthy lifestyle choices, such as sedentary  Assess speech

Factors Affecting Mental Health  Assess orientation

 Personality factors such as poor decision-making  Assess concentration

Factors Affecting Mental Health Mental Health of Adolescents

 History of present health concern The consequences of failing to address adolescent

 Lifestyle and health practices

Opportunity to improve health  He believed that personality development continues

 Cognition – is the process of obtaining

 Risk for suicide

Possible client concerns:

Actual client concerns

A client concern is determined depending on the

 Lawrence Kohlberg- a psychologist, expanded Assessing Pain

 The source of pain stimulates peripheral nerve

 They are sensory receptors that detect signals from

 Nociceptors are located at the peripheral ends of

 Opportunity to improve mental health Pathophysiology of Pain

Some nociceptors may respond to more than one type of

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

Chronic pain lasts longer than three months, and the

Selected client concerns

 Opportunity to enhance health

 Opportunity to improve comfort level

Risk for client concerns

Risk for inability to exercise associated with chronic

Risk for ongoing constipation associated with

Risk for feeling powerless associated with chronic pain,

Selected client concerns

Actual client concerns

 Intense pain associated with injury agents (biologic,

 Persistent recurring pain associated with chronic

 Poor breathing pattern associated with abdominal

 Prolonged fatigue associated with stress of

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