Holistic Assessment
Physical: Head to toe / Systems / 5 Dimensions of Health
Date of assessment:
please date changes from week 1-4 in the relevant
section
Biographical details:
Name (use pseudonym)
NHI
XXX123
D.O.B (use year only)
Gender
Occupation (previous)
Ethnicity / Preferred Language
Family / Social support
Next of Kin
Date of Admission
Marital status
Reason for admission /seeking care
History of present complaint
Past medical / surgical history
Current medications
(list and expand on the final page)
Allergies:
Physical assessment
General survey
“ First observations“
Baseline data:
Height
Temperature normal rate 36-38 C ◦
weight
BMI
estimate height
Pulse : rate / characteristics: regular-irregular / strong /weak
Respiration:
rate / characteristics: regular / shallow / deep / laboured /nose breather
Oxygen saturation
Blood pressure
? Oxygen therapy rate:
delivery method:
1
Head to toe / systems assessment
Colour / moisture / temperature / texture / turgor / vascularity
Skin
/capillary refill / oedema / scars /lesions /
bruises/skin tears / pressure areas? Stage?
Hair & scalp
Type of hair / colour / distribution / thickness / texture / scalp / dry skin / flakey
Nails
Shape / colour –redness / yellow / clubbing? / pigmentation / capillary refill / fingers / toes
Eyes / vision
Symmetric /Colour / moist / dry / lacrimal discharge?
Vision: wears spectacles /wears contacts/ blurring / close vision / distance vision / blind spots / artificial eye/ can
watch TV / read /
Ears / hearing
Symmetrical / discharge
?impairment / hearing aids? L/R
Nose
/olfaction
?congestion / nostrils clear /discharge / ?deviation of septum / sinus pain
Mouth /taste
Lips /dry /cracked / moist membranes /pink /tongue: moist /furry / halitosis / ulcers / teeth / dentures? / gums
Neck
Range of motion? Visible lumps? /pain/ able to hold head erect
Back
Able to sit straight erect / skin? bruises skin tears etc needs support when sitting scoliosis /kyphosis
Abdomen
Distended / soft / firm / bowel sounds / ?reflux/ pain
Cardiovascular
Refer to baseline data : rate / regular / irregular / strength / Colour of extremities feet / red / pale /lips / edema
Respiratory
Refer to baseline data : rate/ SOB / SOBOE / shallow / wheeze / pain on respirations / cough / productive / nonproductive / oxygen therapy / sitting position
Digestive
Nutritional
intake
Food likes/ dislikes / normal food intake /no. of times per day / food quantity/ changes in appetite / allergies
food?/ special diets :pureed / soft foods / multi-textured foods / fortified fluids/diabetic / dysphagia
2
Fluid intake
Approx. intake / usual fluids /favourite fluids/ volume / fluid balance chart? / ? restricted fluids / ?thickener
required / fortified fluids
Elimination
Voiding
Continent /incontinent / normal frequency / dysuria / amount approx./ colour / incontinence pads /type / catheter
Bowel motion
Normal pattern / frequency/ type of stools: description /recent changes/ colour / shape / ? melena
Pain
OLD CART: onset / location / duration / character / antecedent / aggravating / relieve /radiating /timing /
treatment
Reproductive
Genitalia
*Not appropriate in this context / menopause /
Burning / itching / rashes /
Muscular skeletal
Arms / legs /Equal / bilateral / paralysis / weakness / “tingling”/ tremors/ ROM/ shoulders / elbows/ wrists / hips
General
/ knees / ankles / metal implants / prostheses / amputations
muscle tone /
strength
General
posture Gait /
mobility
Back straight /gait / ?kyphosis / scoliosis / walks straight /weight bears/Walks independently /mobility aids:
walking frame/walking stick/ two assist / shoe supports /Hoist / Assist / Supervise / Independent transferring / 2
assist / 1 assist
Risk assessments
Morse
falls Score / RISK of FALLs / ACTION
assessment
Score RISK of pressure areas : ACTION
Waterlow
Cognitive
Orientated to time / place / person. Confusion/ Memory (long term / short term) remembers names / dementia /
understanding of illness and treatments / ability to express self and feelings / ability to make decisions
Social
Joins in activities / likes : “eg bingo / relationships / family / visitors / hobbies and activities
Emotional
ability to express self and feelings / body image / labile / private
Cultural
Cultural beliefs / important routines/ rituals / practices
3
Spiritual
Values / goals / source of hope and strength / religion/ religious practices / how they find peace /
Activities of daily living
Personal grooming / Usual routine / bath / shower / time/ hair wash / nails / cleans own teeth? Uses dentures /
Hygiene
uses soap / uses fatty cream only / shaving electric / blade / hairdresser / needs shower chair / independent /
needs assistance with upper / lower body.
Refer to musculoskeletal and
mobility
Feeding
Independent / assist / uses spoons /knife and fork / needs help to “cut up” only / preferred breakfast food/ lunch
/ dinner /snacks / sits in dining room/ stays in bedroom / cultural requirements / restrictions. Vegetarian / vegan
/ reduction diet / calorie restriction diet / dysphagia /fluid balance chart
Refer to nutritional intake
Fluids
Preferences / tea /coffee milk & sugar/ thickened fluids / water / juice / independent / needs assistance / fluid
restriction / fluid balance chart
Refer to fluid intake
Elimination
Independent / incontinent / wears incontinence pads day / night /
Dressing
Independent / needs assistance / special requests eg no tight necks / likes to wear lip stick / necklaces / choose
colours/ wears slippers(rubber soles)
Refer to musculoskeletal and
mobility
Mobility:
Moving and
handling
Independent / needs assistance / uses walker x1 assist / gait belt / needs hoist / daily exercise
LITE special considerations
Refer to musculoskeletal and
mobility
Sleep and rest
Usual pattern / bedtime routine / day “naps”? rest time / preferred position / wears bed socks
Refer to elimination
4
Summary of problems from assessment (actual and potential)
Nursing Care Plan
Assessment /
problem
Medication
Goal
SMART
Interventions
Dose
Rationale
Reason for use
Evaluation
Possible side effects
5
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