client self assessment
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Stick a photo of<br />
your<strong>self</strong> here<br />
My Needs<br />
Assessment<br />
This <strong>assessment</strong> was assisted by the following staff; (Signature & P.I.N.)<br />
……………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………<br />
I was able to participate in my <strong>assessment</strong>; Yes □ No □<br />
If no please provide some explanation below (Staff)<br />
……………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………
Nursing Assessment Framework<br />
To best capture and promote individual uniqueness St Joseph’s<br />
Intellectual Disability Service uses the Roper, Logan and Tierney’s<br />
Activities of Living Nursing Model combined with the Orem’s Self Care<br />
Nursing Model. This combination of evidence based frameworks<br />
incorporates key aspects of an individual’s life to promote best practice<br />
and a more person centred approach to the person’s needs.<br />
This <strong>assessment</strong> has also been informed by<br />
<br />
<br />
The OK Health Check list<br />
The Individual’s Risk Assessments<br />
Once completed it will in turn inform the completion of a Hospital<br />
Passport, which will accompany the person to any external hospital.<br />
The Aims of the Assessment<br />
To engage with the person in helping them to promote their needs<br />
To provide staff with information to highlight strengths and needs, to<br />
promote choice and independence or to identify resources required to<br />
enhance the quality of life of the person they care for<br />
To promote a consistent approach by the care team when supporting<br />
the person’s needs and decisions when creating a plan of care
My height and weight:<br />
My date of birth:<br />
My next of kin:<br />
Name and how to contact them.<br />
Any allergies I have:<br />
My weight<br />
date weighed<br />
Your height and date measured::<br />
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Page 5<br />
Section 1<br />
This Assessment has 3 Sections<br />
Some background information page 4 and<br />
5 This is some information that is important to<br />
me, and helps to<br />
Today……………..<br />
My Height………<br />
My Weigh….….<br />
Section 2<br />
My Self Assessment– pages 6 and 7<br />
This is where you tell us what level of<br />
support you require and in what areas<br />
I’m all good here, I do<br />
not need your help<br />
I could do with some<br />
assistance or advice<br />
I need your help<br />
Section 3<br />
Important information about me<br />
My Nursing Assessment- pages 8 to 26.<br />
This is where we describe the supports you require<br />
in greater detail, and summarize your goals<br />
It is important to keep this document up to date.<br />
You can make changes or ask staff to make changes whenever you need to
Section 1<br />
My Name and Address<br />
Contains private<br />
and confidential<br />
Information.<br />
Date first written:<br />
Dates when updated:
Health History<br />
Current Diagnoses<br />
Intellectual Disability __________________<br />
Mental Illness________________________<br />
Physical Illness : Refer to OK Health Check_<br />
Immunisations<br />
Name of Drug________________________<br />
Date Given ________________________<br />
Name of Drug________________________<br />
Date Given ________________________<br />
Name of Drug________________________<br />
Date Given ________________________<br />
Known Drug Allergies<br />
I am allergic to________________________<br />
I am allergic to _______________________<br />
Known Food /Product Allergies<br />
I am allergic to _______________________<br />
I am allergic to _______________________<br />
Refer to my current Medication Kardex
Section 2<br />
• I’m all good here, I do<br />
not need your help<br />
• I could do with some<br />
assistance or advice<br />
• I need your help<br />
Please colour the to indicate the level of support you<br />
would like or need in the following areas.<br />
Personal Grooming<br />
Eating & Drinking<br />
Communication<br />
Toileting<br />
Mobility
Breathing<br />
Sleeping<br />
Maintaining Personal Safety<br />
Work<br />
Leisure<br />
Sexuality & Relationships<br />
Mood<br />
Medication<br />
Anything you would like to add
Section3<br />
1 Maintaining Safety Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
2 Communication Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
3 Breathing and Circulation Name ……………………………….<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
4 Eating, Drinking & Nutrition Name ……………………………..<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
5 Personal Hygiene, Dressing Name ………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
6 Elimination Name ………………………………………….<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
7 Mobilisation Name ………………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
8 Leisure and Social Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
9 Sleep Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
10 Pain Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
11 Behaviour Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
12 Mood / Emotions Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
13 Thoughts /Perceptions Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
14 Self Concepts/ Independence Name<br />
……………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
15 Motivation Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
16 Expressing Sexuality Name ………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
17 Dying and Bereavement Name …………………………...<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
15 Motivation Name …………………………………<br />
Personal<br />
When discussing personal safety, consider and discuss aspects of life such as<br />
Personal safety and <strong>self</strong> harm, cognitive impairment (carelessness), substance<br />
use/misuse.<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally Independent<br />
□<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….<br />
Environmental<br />
When discussing environmental safety, consider and discuss aspects of life such<br />
as<br />
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment<br />
(carelessness),<br />
Assistance & Supports required<br />
Partial □ Full □ Support/Education only required □ Totally<br />
Independent □<br />
Nursing Care Plan required; Yes □ No □ ……………………………………………………………<br />
Referral required to; Yes □ No □ ……………………………………………………………………..<br />
Risk Assessment required; Yes □ No ………………………………………………………………….
My Goals<br />
My Priority Goals for the next<br />
three months are in the following<br />
Areas<br />
_________________________________________________<br />
_________________________________________________<br />
_________________________________________________<br />
_________________________________________________<br />
_________________________________________________<br />
_________________________________________________<br />
Please carry these goals forward into my care<br />
plan which will be reviewed on -----/------/--------