Why Assess??: Holistic (Adj.)
Why Assess??: Holistic (Adj.)
Why Assess??: Holistic (Adj.)
https://www.dictionary.com/browse/holistic
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Performance
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Level of Consciousness
Age § Normal: The person is alert and oriented,
§ Normal: the person appears his/her stated age. attends to your questions appropriately
§ Abnormal: Appears older than stated age § Abnormal: Confused, drowsy, lethargic
Facial Features
§ Normal: Facial features are symmetric with movement;
no signs of acute distress are present
§ Abnormal: immobile, masklike, asymmetric drooping;
respiratory signs, objective data for pain
https://i.pinimg.com/originals/1d/03/9f/1d039f90bd5ecac2ba045e1d2c10de2a.gif
Symmetry
Stature § Normal: Body parts look equal bilaterally and are in
§ Normal: The height appears within normal relative proportion to each other.
range for age, genetic heritage. § Abnormal: Unilateral atrophy or hypertrophy;
§ Abnormal: Excessively short or tall asymmetric location of a body part.
Weight Posture
§ Normal: The weight appears within normal range for § Normal: The person stands comfortably erect as
height and body build; body fat distribution is even appropriate for age; note the normal “plumb line”
§ Abnormal: Cachectic, emaciated; simple obesity, with § Abnormal: Rigid spine and neck; moves as one unit; stiff
even fat distribution; centripetal (truncal) obesity and tense, ready to spring from chair, fidgety movements;
shoulders slumped, looks deflated
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Position
§ Normal: the person sits comfortably in a chair or on the
bed or examination table, arms relaxed at sides, head
turned to examiner
§ Abnormal: Tripod; sitting straight up and resists lying down;
curled up in fetal position
Body build, contour-proportions
§ Normal: Arm span equals height; body length from crown to
pubis roughly equal to length from pubis to sole.
§ Abnormal: Elongated arm span, arm span greater than height;
missing extremities or digits webbed digits; shortened limb.
http://files.englishportfolio1.webnode.es/200000037-2fc8530c02/big_islcollective_worksheets_beginner_prea1_elementary_a1_preintermediate_a2_intermediate_b1_upperintermediate_b2_advanced_c_301804f324dbf167fd0_12299543.jpg
Gait
§ Normal: The base is as wide as the shoulder width;
foot placement is accurate; the walk is smooth, even,
well-balanced; and associated movements such as
symmetric swing, are present.
§ Abnormal: Exceptionally wide base. Staggered
stumbling; shuffling, dragging, nonfunctional leg;
limping with injury, propulsion(difficulty stopping)
Range of Motion
§ Normal: Note full mobility for each joint, and that
movements is deliberate, accurate, smooth and
coordinated; No involuntary movements
§ Abnormal: Limited joint range of motion;
paralysis; jerky, uncoordinated movement; ticks,
tremors, seizures.
https://www.google.com/url?sa=i&url=https%3A%2F%2Fsamarpanphysioclinic.com%2F2019%2F02%2F21%2Frange-of-motion-of-all-
joints%2F&psig=AOvVaw0my9qG_tCTurkuMi78VB9r&ust=1599558676108000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCNjUm83i1usCFQAAAAAdAAAAABAJ
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http://1.bp.blogspot.com/_OrY_6G0srrw/Sv3HSKDRlLI/AAAAAAAAANA/k-RgHCEjrIU/s400/Facial+Expressions+colored.jpg
Facial expression
§ Normal: The person maintains eye contact, expressions are
appropriate to the situation
§ Abnormal: Flat depressed, angry, sad, anxious.
Mood and Affect
§ Normal: The person is comfortable and cooperative with the
examiner and interacts pleasantly
§ Abnormal: Hostile, distrustful, suspicions, crying
Speech
§ Normal: Articulation is clear and understandable; the
stream of talking is fluent, with an even pace; conveys ideas
clearly; word choice is appropriate to culture and education;
§ Abnormal: Dysarthria and dysphagia; speech defect;
monotone, garbled speech; extremes of few words or
constant talking
https://busyteacher.org/uploads/posts/2012-10/1349554637_sem-ttulo.jpg
Personal Hygiene
§ Normal: The person appears clean and groomed
appropriately for his/her age, occupation, and
socioeconomic group; hair is groomed, brushed; make-up is
appropriate for age and culture
§ Abnormal: In a previously carefully groomed woman,
unkempt hair and absent make-up may indicate malaise or
illness
https://clipground.com/images/hygiene-clipart-5.jpg
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VITAL SIGNS
The traditional vital signs are
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Refences:
• Wallace, Sonya. (2013). The importance of holistic assessment – A nursing
student perspective. Nuritinga. 24-30.
• Vital Signs retrieved at http://www.sickkids.ca/Nursing/Education-and-
learning/Nursing-Student-Orientation/module-two-clinical-
care/vitals/index.html
• Weber, J (2014) Health assessment in nursing - 5th Edition, Wolters Kluwer
Health | Lippincott Williams & Wilkins.
• Berman, Audrey (2016) Kozier & Erb’s fundamentals of nursing : concepts,
practice, and process, Pearson Education, Inc.