Initial Holistic Nursing Assessment
Please complete with the patient and relative / carer if appropriate. If the patient is unable to contribute to their care assessment, complete on their behalf. Circle any identified problems and cross out those not present.
Physical Problems
Do you have any problems with your comfort?
Pain / discomfort Breathlessness
Mouth – sore / dry / painful
Chest secretions
Sputum
Cough
Swallowing difficulties
Feeling sick / being sick
Constipation / diarrhoea
Urinary problems
Catheter care
Sweats / hot / cold
Skin – sores / wound / dry / itch / weeping
Oedema (Swelling)
Personal care – washing / hair care
Sleep
Mobility
Other? ………………………………….
Emotional wellbeing
Do any of these words describe how you feel?
Distressed
Lack of dignity / respect
Upset / sad
Lack of privacy
Lack of peace / calm
Agitated / restless
Not listened to
Frightened / worried
Angry / frustrated
Other? ………………………………….
Social / environmental concerns
Do you feel the needs of yourself and your family / carers are being met?
Eating / drinking facilities Quiet environment
Comfortable surroundings
Worries / fears
Written information
Update on plan of care
Support for relative / carer / friend
Support for children
Financial concerns
Parking facilities
Other? ………………………………….
Spiritual / religious needs
Are the things important to you being considered?
Faith
Support from faith leader
Prayers / rights / rituals Culture
Music Values
Things that help you cope
Other? ………………………………….
Assessment completed by:
Please record your assessment of the patient’s identified problems below. Ensure that there is a care plan for each identified problem, including review date and time.
IKA SYAMSUL HUDA MZ