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Initial Holistic Nursing Assessment, Study notes of Nursing

The registered nurse will assess the patient if he / she is symptomatically dehydrated, and consider artificial hydration if it is in the patient's best ...

Typology: Study notes

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Patient’s Name:………………..……… D.O.B.:…………NHS/hospital no.:………..………
NESCN Caring for the Dying Patient (CDP) document 2015
Page N 1 of 4
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.
Assessment completed by:
Name (print) …………………….…. Designation ………….……... Signature ..………………..
Completed and discussed with: (please circle) patient / relative / carer: Name ………………….
Date completed: …………………………………….…..…. Time: ………………………………..
Physical Problems
Social / environmental concerns
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? ………………………………….
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? ………………………………….
Emotional wellbeing
Spiritual / religious needs
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 / frustrat
ed
Other? ………………………………….
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? ………………………………….
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NESCN Caring for the Dying Patient (CDP) document 2015

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.

Assessment completed by: Name (print) …………………….…. Designation ………….……... Signature ..……………….. Completed and discussed with: (please circle) patient / relative / carer : Name ………………….

Date completed: …………………………………….…..…. Time: ………………………………..

Physical Problems Social / environmental concerns 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? ………………………………….

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? ………………………………….

Emotional wellbeing Spiritual / religious needs 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? ………………………………….

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? ………………………………….

NESCN Caring for the Dying Patient (CDP) document 2015

Initial Nursing Assessment Summary

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.

Date & Time

Problem Identified / Care plan

Summary of Assessment

Signature & Designation

NESCN Caring for the Dying Patient (CDP) document 2015

Nursing Communication with Patient and / or Relative / Carer

Please document discussions with the patient and / or relative / carer regarding:

  • Patient / relative / carer understanding of the current situation
  • The plan of care
  • Any questions or concerns which have been raised
  • Who to speak to or contact if worried or concerned

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Completed by:

Name (print) ………….………….…. Designation ……….…….....…. Signature ………………..............

Discussed with: (circle) patient / relative / carer Name …………….…...… Date: ………..... Time: ……...

Written information

What written information / leaflets have been given to the patient and / or relative / carer?

……………………………………………………………………………………………………………

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