Nursing Grand Rounds Presentation Part 1: Holistic Assessment Form

Part A: Student and Participant Data

1. Student name:

2. Participant assessed (initials only):

3. Participant’s age:

4. Participant’s gender (select one): Male Female Nonbinary Other Prefer not to Disclose

5. Briefly explain how the student knows the participant:

Part B: Evaluating Medical History

6. Drug/medication allergy: Yes No If yes, please specify:

7. Food/material/environmental allergy: Yes No If yes, please specify:

8. Please complete the participant and family health history table below.

9. Are vaccinations up to date? Yes No

10. Does the participant participate in any complementary or alternative therapies, such as acupuncture, aromatherapy, hydrotherapy, etc.? Yes No If yes, please specify:

Part C: Medication and Other History

1. Please list all current medications and supplements the participant is taking, including the dose and frequency.

2. Past surgeries? (Please specify and include year)

3. Date of last dental exam?

4. Date of last eye exam?

a. Does the participant wear glasses or contacts?

b. Does the participant report other visual concerns? Yes No

5. Has the participant recently experienced unplanned weight loss or gain?

6. Additional screenings completed in the last two years:

a. Mammogram Yes No Date:

b. PSA Yes No Date:

c. Colonoscopy Yes No Date:

d. Other (please specify)

e. N/A

Part D: Physical Assessment Findings

7. Initial vital signs:

a. Pulse

b. Blood pressure (may be reported by the participant from last check)

c. Respiratory rate

d. Temperature

e. Pulse oximetry (if available, may be reported by the participant from last check)

8. Orientation:

9. Pupils:

10. Head, ears, eyes, nose, and throat:

11. Pulses:

12. Heart rate and rhythm:

13. Pulse strength:

14. Capillary refill:

15. Respiratory rate and effort:

16. Lung sounds:

17. Abdominal assessment:

18. Bowel sounds:

19. Date of last bowel movement:

20. Urinary status:

21. Skin color and temperature:

22. Wounds or bruises?

23. Assessment of mucous membranes:

24. Extremity strength and ROM:

25. Gait:

26. Presence of tubes or drains:

27. Pain assessment:

Part D: Cultural and Spiritual Assessment

28. What culture does the participant identify with?

29. Sexual orientation of the participant?

30. How does the participant describe their faith or belief system?

31. Is the participant part of a religious community? Yes No

a. If so, which one?

b. Does the participant have personal spiritual beliefs that are independent of organized religion?

32. What aspects of spiritual care are important to the participant?

33. Has the participant ever experienced bias or exclusion based on race, faith, culture, or sexuality?

a. Describe how the participant handled these bias’s or exclusions and how it impacted their health.

Part E: Social History

34. Occupation:

35. What is the highest level of education completed by the participant?

36. Tobacco use (type and frequency):

37. Alcohol use (average number of drinks per week):

38. Recreational drug use (type):

39. Is the participant sexually active? Yes No

a. Birth control method:

b. History of sexually transmitted infections:

40. How often does the participant exercise? What type?

41. Does the participant feel supported or have family/friends they can turn to? Yes No

a. If no, describe how the participant responds to and copes with stressful events?

b. What resources does the participant utilize for support?

Part F: Additional Health Considerations

42. How would you rate your current health? (Excellent, Good, Fair, Poor)

43. What factors contributed to your personal health rating?

44. What (if any) are your health goals?

45. What health care topic(s) do you want to learn more about?

Part G: Selected Health Alteration

Please state the participant’s selected health alteration that will be the primary focus of the Week 5 Nursing Grand Rounds Presentation: