Holistic Nursing Assessment

• Holistic nursing assessment

Health History Review

• Gathering assessment data involves collecting both objective and subjective data.
• Patient interviews are best conducted in a private setting.
• Choose words carefully without using medical jargon.
• Use appropriate body language.
• Conform patient statements.
• Utilize open-ended questions.

Effective Communication

• Be comfortable using silence.
• Encourage responses.
• Use repetition and reflection to clarify meaning.
• Use clarification to eliminate misunderstandings.
• Summarize and conclude with "Is there anything else?".

Components of Health History

• Key components include biographic data such as name, address, birth date, and emergency contact information.
• Record the chief complaint.
• Include past and current health acre.
• Enquire about the patient's family health.
• Include the psychological history (feelings about self, place in society and relationships with others).
• List activities of daily living.

Structure and Systems Review

• Head: Check for headaches and past or present head injury
• Eyes: Check for vision problems, use of glasses or contacts, glaucoma, cataracts, color blindness, tearing, or blurred vision.
• Ears: Check for hearing and balance issues, ear surgery history, hearing aid use, ear pain/swelling, and discharge
• Nose: Assess nasal surgery history, breathing or smelling difficulties, and sinusitis or nosebleeds
• Mouth and Throat: Assess dentures, mouth sores/dryness, loss of taste, toothache/bleeding gums, and throat soreness/difficulty swallowing
• Neck: Look for swelling, soreness, or limited movement.
• Respiratory: Check for shortness of breath, pain/wheezing during breathing, cough, and history of respiratory conditions.
• Cardiovascular: Investigate chest pain, palpitations, irregular heartbeat, breath shortness, cough, ECG results, and related history.
• Breasts: Women should check for monthly breast self-examination, lumps, changes in breast contour/pain/discharge, cancer history, and mammogram results; men check for pain, lumps, or contour changes.
• Gastrointestinal: Assess recent weight changes, bowel movements, laxative use, nausea, vomiting, appetite loss, heartburn, abdominal pain/gas, hemorrhoids/rectal bleeding, hernias, and gallbladder/liver disease.
• Urinary: Check for color changes in urine, nighttime urination, burning, incontinence, urgency, retention, reduced flow, or dribbling
• Reproductive: Women - menstruation/menopause, pregnancies, birth control, Papanicolaou test results. Men - monthly testicular self-exams, prostate exam results, STD's, birth control, penile pain/discharge/lesions, and testicular lumps.
• Musculoskeletal: Check for balance issues, difficulty walking/sitting/standing, and history of arthritis, gout, back injury, or muscle issues.
• Neurological: Assess for tremors, twitching, numbness, tingling, or loss of sensation, as well as seizure history.
• Hematologic: Check for anemia, blood abnormalities, or transfusions, as well as fatigue/bruising
• Psychological: Mood swings, memory loss, anxiety/depression, and stress/coping mechanisms are important to assess
• Endocrine: Check for fatigue, thirst, weight changes, heat/cold tolerance, hair loss/texture changes, and hormone medications

General Survey

• This includes overall client impression, mental status examination, and vital signs.

Overall Impression

• This includes systematically examining and recording general characteristics.
• Observe the client and environment quickly before interacting.
• Observe for abnormalities in skin, dress, hygiene, posture, gait, and body.
• Assess LOC, comfort, body movement, affect, facial expression, speech, and mental acuities.

Mental Status Exam

• This includes determining LOC, noting posture/body movements, evaluating dress/grooming/hygiene, facial expression, mood, feelings, expression, thought process, perception, and cognitive abilities.
• Mini-mental health status exams may be used.

Pain

• Screening is vital for a comprehensive care plan.
• Identify location, intensity, duration, and factors that alleviate or aggravate the pain when present.

COLDSPA Pain Assessment

• It is important to memorize key questions for pain:
• C: Character (Sharp, dull, stabbing or burning)
• O: Onset (When did the pain start and what provoked it?)
• L: Location (Where is the pain and does it radiate?)
• D: Duration (How long does the pain last?)
• S: Severity (Rate the pain on a scale of 0-10).
• P: Pattern (What makes the pain better or worse?)
• A: Associated factors (Are there any associated factors such as, nausea, vomiting or not being able to eat?)

Collecting Objective Data

• Prepare the client for examination.
• Start with the nurse meeting the client.
• Observe the client's posture, movements, and overall appearance.
• Arrange a comfortable sitting position in a chair on the examination table to begin the mental status examination.

Physical Assessment

• Assess physical and sexual development normal findings.
• Appropriate development for gender and age is a normal finding/
• Delayed puberty or male clients with female characteristics vice versa are considered abnormal findings.
• Client appears to be the stated chronologic age is a normal finding/
• Determine client's stated age with their apparent age and developmental stage and whether this is in line with normal or abnormal findings.
• Observe for skin colour condition, normal findings include no obvious lesions, Extreme pallor, flushed or yellow in light skinned client, loss of red tones and ashen gray cyanosis in dark skinned clients.
• Asses dress appropriateness to the the occasion and weather, uncoordinated clothing, or extremely warm clothing for the weather conditions may be seen in mentally ill.

Hygiene

• Check if client is clean, and groomed appropriately for the the visit.
• Stains on the hands and dirty nails.
• Check posture which should be straight and comfortable for the age.
• Curvatures of the spine like scoliosis, Kyphosis and Lordosis are abnormal.

Assessing Body Build

• Observe the clients body build, muscle mass and fat distribution. a wide variety of body types fall within a normal range; from small amounts of both fat and muscle to large amounts of muscle and/or fat. In general the normal body is proportional.

Assessing Mental Status

• Alert and oriented to what is happening at the time of the interview is normal.
• Alert, responds immediately and fully to commands may or may not be fully oriented is considered waking consciousness.
• Confused: Inability to think rapidly and clearly with impaired judgment.
• Disoriented: Loss of consciousness with impaired memory.
• Lethargic: Drowsy, sleeps a lot, but is easily aroused with minimal stimuli. Obtundation: Can be aroused by stimuli (not pain).
• Stuporous: Deep sleep or unresponsiveness; needs to external stimulation (painful).
• Comatose: No motor response to the external environment, no arousal.
• Speech is clear, moderately paced, and culturally appropriate, if the speech is disorganised it may be due to mental illness.
• Assess Dysarthria or Dysphasia which can make understanding the client difficult.
• Dysphasia is a disorder of language that can occur as a result of stroke

Anthropometric Measurements

• These measurements identify nutritional problems in overweight or underweight patients.
• Use a calibrated balance beam to weigh the client.
• Measure the height using the height bar.

Ideal Weight

• Ideal weight refers to standard weights associated with various heights on a reference table
• Body weight 120%or more of the ideal body weight indicates obesity
• Below 90% indicates less than adequate weight/

Weighty Terms

• Normal weight is 10% above or below recommended weight
• Overweight is 10%-20% above recommended weight
• Obese is 20% or more above recommended weight
• Underweight is 10%-20% below your recommended weight.
• Seriously underweight is 20% or more below recommended weight

Nutritional Assessment

• Weakness and fatigue can be an indicator of an anemia or electrolyte imbalance
• Weight loss can be and indicator of decreased caloric intake
• Dry, flaky skin can be an indicator of a Vitamin A, Vit B complex or linoleic acid deficiency
• Bruises or petechiae (Ecchymosis)
• Spoon-shaped brittle or ridged nails (Koilonychia) is a a sign of iro deficiency
• a Bitot spot is a white or gray lesion on the conjunctiva of the eye and is a sign of vitamin A deficiency
• Foods rich in riboflavin and Niacin are key to a well balanced diet
• B12 is obtained from natural sources like salmon and eggs