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Holistic Patient Intake Form and Nursing Resource Handout

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Holistic Patient Intake Form and Nursing Resource Handout

  1. Holistic Nursing Principles

Holistic nursing integrates the physical, emotional, social, and spiritual aspects of care to treat the whole person. One of the key philosophical foundations is Barbara Dossey’s Theory of Integral Nursing to heal the entire person through an integrative modality of body-mind-spirit-environment (Garmy et al., 2021). Ethically, holistic nursing embraces the American Holistic Nurses Association’s (AHNA) core values, particularly honoring the dignity, worth, and uniqueness of every human being. Nurses have the mandate of creating a healing environment, self-care, and self-awareness as essential ethical responsibilities: Holistic Patient Intake Form and Nursing Resource Handout.

  1. Integrative Nutrition

Integrative nutrition is centered on the blending of nutrition and holistic practice. It encompasses whole food, personalized meal planning, and attention to lifestyle, cultural, and spiritual belief systems. Nutrition is viewed as the cornerstone of holistic practice since food choices affect physical health, mental clarity, emotional balance, and spiritual well-being (Goyal & Chauhan, 2024). Through the integration of nutrition into care plans, nurses can facilitate prevention, healing, and long-term wellness.

  1. Holistic Caring Strategy

One evidence-based holistic caring strategy is the use of guided imagery. Guided imagery can reduce stress, manage pain, and support emotional healing (Zemla et al., 2023). Nurses can incorporate this practice during procedures or teach patients how to use it for self-care at home. It allows patients to engage actively in their healing process and enhances patient autonomy and resilience.

  1. Therapeutic Communication Strategy

Mindful listening is a core therapeutic communication strategy in holistic nursing. It involves being fully present, maintaining eye contact, offering silence, and acknowledging the patient’s feelings without interruption or judgment (Kwame & Petrucka, 2021). This strategy helps build trust and encourages patients to express their concerns, which enhances the accuracy of assessments and the quality of care.

  1. Enhancing Nursing Practice Through Holistic Environments

Creating evidence-based, integrative, and holistic caring environments improves patient satisfaction, outcomes, and staff well-being. Practices such as aromatherapy, healing touch, mindfulness rooms, and nature-inspired design have been shown to reduce stress, lower pain perception, and enhance immune function (Ambushe et al., 2023). Holistic environments promote collaboration, compassion, and innovation in healthcare delivery.

  1. Self-Reflective Practice and Its Influence

Self-reflection is essential in holistic nursing. It allows nurses to examine their biases, emotions, and behaviors, leading to enhanced self-awareness and improved patient relationships. Engaging in practices such as journaling, meditation, or peer discussions supports personal growth, reduces burnout, and enhances professional practice. A nurse who is centered and mindful provides more compassionate, individualized care.

Holistic Patient Intake Form

Holistic Nursing Intake – Whole-Person Wellness Assessment
Patient Name: ________________________
Date of Birth: ____________
Date of Visit: ____________
Primary Nurse: ____________________
Contact Number: ____________________

I Nutritional Assessment

  1. How would you describe your current eating habits?
  1. Do you follow any specific dietary practices (e.g., vegetarian, kosher, diabetic)?
    ☐ Yes ☐ No
    If yes, please describe: ______________________________________
  2. Do you have food allergies, intolerances, or sensitivities?
    ☐ Yes ☐ No → If yes: ______________________________________
  3. How many meals do you eat per day? _____
  4. Approximate daily water intake: _____ cups
  1. Physiological Assessment
  1. What are your current health conditions or diagnoses?
  1. List all medications and supplements currently taken:
  1. Do you have any current physical symptoms or concerns (pain, fatigue, etc.)?
    ☐ Yes ☐ No
    If yes, please describe: ______________________________________
  2. Pain level today (0 = no pain, 10 = worst pain): _______

III. Emotional Assessment

  1. In the past two weeks, how often have you felt:
    • Stressed? ☐ Rarely ☐ Sometimes ☐ Often ☐ Always
    • Anxious? ☐ Rarely ☐ Sometimes ☐ Often ☐ Always
    • Depressed or down? ☐ Rarely ☐ Sometimes ☐ Often ☐ Always
  2. Who or what helps you cope emotionally?
  1. Sociological Assessment
  1. Living situation:
    ☐ Alone ☐ With family/partner ☐ Assisted Living ☐ Other: ___________
  2. Do you have a strong social support system? ☐ Yes ☐ No
  3. Current employment or social role: ____________________________
    Work stress level (1–10): _____
  1. Developmental Assessment
  1. Do you have any age-related concerns (e.g., memory, mobility, independence)?
    ☐ Yes ☐ No → If yes, explain: _____________________________
  2. Do you use assistive devices (e.g., cane, hearing aid, glasses)? ☐ Yes ☐ No
  1. Spiritual Assessment
  1. Do you have any religious or spiritual practices that are important to your care?
    ☐ Yes ☐ No
    If yes, please describe: ______________________________________
  2. Would you like to speak with a chaplain/spiritual care provider? ☐ Yes ☐ No

VII. Cultural Assessment

  1. Preferred language: ____________________
    Do you need an interpreter? ☐ Yes ☐ No
  2. Are there any cultural or traditional practices that should be honored in your care?

VIII. Family Assessment

  1. Are family members involved in your care or decision-making? ☐ Yes ☐ No
    If yes, who: _______________________________________________
  2. Any family health history we should be aware of?
  1. Environmental Assessment
  1. Is your home environment safe and comfortable? ☐ Yes ☐ No
    If no, explain: _____________________________________________
  2. Are you exposed to environmental factors such as smoke, noise, allergens, or chemicals?
    ☐ Yes ☐ No → If yes: ______________________________________
  1. Practical Assessment
  1. Do you face any challenges with transportation, housing, or finances?
    ☐ Yes ☐ No → If yes: ______________________________________
  2. Do you require help managing daily tasks (shopping, bathing, medications)?
    ☐ Yes ☐ No
  1. Prevention Assessment
  1. Do you regularly attend check-ups and screenings? ☐ Yes ☐ No
  2. When was your last:
    • Physical exam: __________
    • Dental check-up: __________
    • Vision check: __________
    • Vaccinations updated? ☐ Yes ☐ No

XII. Community Assessment

  1. Are you involved in any community groups or activities? ☐ Yes ☐ No
  2. Would you like help connecting to local resources or wellness programs?
    ☐ Yes ☐ No

Patient-Centered Treatment Planning

Conventional Treatment Preferences

Please check all that you currently use or are open to using:
☐ Prescription Medications
☐ Surgery
☐ Physical Therapy
☐ Counseling or Psychotherapy
☐ Occupational Therapy
☐ Other: _______________________

Complementary and Integrative Treatment Preferences

☐ Acupuncture
☐ Aromatherapy
☐ Herbal Supplements
☐ Healing Touch or Reiki
☐ Massage Therapy
☐ Guided Imagery or Meditation
☐ Yoga/Tai Chi
☐ Music/Sound Therapy
☐ Other: _______________________

Personal Health Goals

Please list 1–3 goals you would like to focus on during your care:

Nurse/Provider Notes:
(For nursing staff use to document relevant findings or referrals)

Signature – Patient: ____________________ Date: ____________
Signature – Nurse/Clinician: ___________________ _ _

References

Ambushe, S. A., Awoke, N., Demissie, B. W., & Tekalign, T. (2023). Holistic nursing care practice and associated factors among nurses in public hospitals of Wolaita zone, South Ethiopia. BMC Nursing, 22(1). https://doi.org/10.1186/s12912-023-01517-0

Garmy, P., Clausson, E. K., Janlöv, A., & Einberg, E. (2021). A philosophical review of school nursing framed by the holistic nursing theory of Barbara Dossey. Journal of Holistic Nursing, 39(3), 216–224. https://doi.org/10.1177/08980101211006615

Goyal, M. R., & Chauhan, A. (2024). Holistic approach of nutrients and traditional natural medicines for human health: A review. Future Integrative Medicine, 000(000). https://doi.org/10.14218/fim.2023.00089

Goyal, M. R., & Chauhan, A. (2024). Holistic approach of nutrients and traditional natural medicines for human health: A review. Future Integrative Medicine, 000(000), 000. https://doi.org/10.14218/fim.2023.00089

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158. https://doi.org/10.1186/s12912-021-00684-2

Zemla, K., Sedek, G., Wróbel, K., Postepski, F., & Wojcik, G. M. (2023). Investigating the impact of guided imagery on stress, brain functions, and attention: A randomized trial. Sensors, 23(13), 6210. https://doi.org/10.3390/s23136210

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Question 

Scenario

You are the chair of a newly formed Holistic Nursing Committee at the healthcare setting where you are currently employed (if not currently employed, base it on previous clinical experience). You were recently asked to create a holistic patient intake form that will transform current nursing practice in your facility and enhance the holistic healing environment.

Instructions

Create a holistic patient intake form and a resource handout for nursing staff that attends to the items below:

  1. Create a resource handout for nursing staff that provides background knowledge about holistic nursing practices. Your handout should address the following:
    • a. Describe at least 1 holistic philosophical, theoretical, and ethical principle in professional nursing practice.
    • b. Define integrative nutrition and explain why it is the foundation for holistic practice.
    • c. Provide at least 1 holistic caring strategy that nurses could incorporate in their daily practice.
    • d. Provide at least 1 therapeutic communication strategy nurses can use in their daily practice.
    • e. Explain how creating evidence-based integrative, holistic, caring environments will enhance nursing practice in your facility.
    • f. Explain how self-reflective practice influences an individual’s self-care and professional practice.

      Holistic Patient Intake Form and Nursing Resource Handout

      Holistic Patient Intake Form and Nursing Resource Handout

  2. Create an intake form for patient care that documents a holistic assessment of your patients. You have the freedom to design the intake form in a traditional way (questions that assess your patients), or you may want to develop an alternate approach (using a visual graphic for patients to circle areas of wellness/concern). Whatever approach you choose, your intake form must be clearly organized, well designed, and assess all of the following domains of care:
    • g. Nutritional Assessment
    • h. Physiological Assessment
    • i. Emotional Assessment
    • j. Sociological Assessment
    • k. Developmental Assessment
    • l. Spiritual Assessment
    • m. Cultural Assessment
    • n. Family Assessment
    • o. Environmental Assessment
    • p. Practical Assessment
    • q. Prevention Assessment
    • r. Community Assessment
    • s. Patient Treatment Plan
      • Conventional Treatment Preferences
      • Complementary Treatment Preferences
      • Health Goals
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