Functional Health Patterns Assessment Tool

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FUNCTIONAL HEALTH PATTERNS

ASSESSMENT TOOL
Nursing Practicum_____ Student_________________________
Date________
Patient's Initials____ Male____ Female_____ Age______
Medical Diagnosis_____________________________________________________
Reason for seeking health care___________________________________________
1. HEALTH PERCEPTION-HEALTH MANAGEMENT

Past medical history:


Illnesses:_________________________________________________
Surgery:___________________________________________________
History of chronic disease__________________________________________
Immunization History: ____ Tetanus______ Pnemonia_____ Influenza_____ MMR______
____ Polio ______ Hepatitis B
Use of Tobacco:____ None -Quit(date_____<1ppd____1-2ppd___ >2pks/day ___Pks/yr history__
_____smokeless tobacco)____pipe_____cigar
Alcohol: Amount/type___________________________ Date of last drink__________________
Frequency of use ____________________________
Other drugs: Amount/Type :______________________Freq. Of Use :________________________
Medication (prescription/Nonprescription)
Name Dose Frequency of Use Last Dose

Allergies_________________________________________________NKA_____________
Perception of health:______good____ fair________poor
Health Management Habits: Exercise on a regular basis? ___Yes___No
Follow prescribed regimen? ___Yes __No
Safety:____Special Equipment ___precautions:____Siderails___Restraints
___question for following: use of seat belt, car seats for kids, breasts/testicular self examination, safe working
conditions.______________________________________________________
Home Health in last semester safe environment in home i.e.: smoke detectors, access to home (stairs), throw rugs/carpets,
cleanliness, health issues observed :__________________________

2. NUTRITIONAL-METABOLIC
____Not Assessed
____Ht.____Wt._______________________Weight fluctuations last 6 months
Type of Diet/Restrictions:____ Regular____Lo Salt____Diabetic__ Other Supplements_______
Appetite____Normal___Increased___Decreased___Decreased taste___Food intolerance:_____
_____Nausea_____Vomiting Describe:_____________________
______Swallowing difficulties_____gag reflex_______chewing difficulties
Feeding ____self____Assist
Condition of mouth:_____pink______inflammed_____moist______dry
_______lesions/ulcerations describe__________________ teeth /gums___________________
______Dentures____upper (partial/full)_______lower(partial/full)
______Intravenous fluids type/amt__________________________________________________.
Insertion Site:____________________________________________________________
______NG________ Gastrostomy
Skin Condition:____color: pallor, ashen, pink, jaundice, cyanotic, ruddy
____ temperature: warm, cool, hot
____dry, moist, clammy, diaphoretic
____edema:pitting/non-pitting
____turgor: good, poor, tenting
____pruriitis
____intact
____bruises/lesions describe: (size, location)___________________________
Body temperature:______ tympanic ______oral _____rectal
3. ELIMINATION
____Not Assessed
Bowel Habits Describe:_________________________________________________________
(consistency, color, amount)
_______#BM's/day______ Date of last BM
_______Constipation_____Diarrhea_______Incontinence
Bladder Habits Describe:___________________________(color, clarity, amount)
_____Frequency ____Dysuria____Nocturia_____Urgency_______Hematuria
____Retention _____ Burning______Hesitancy________Pressure
Incontinency:___No ___Yes______daytime ________nighftime
________occasional______difficulty delaying voiding
Assistive Devices:_____intermittent catheterization______indwelling cath
______external catheter____________ incontinent briefs
Ostomy: type: ________ ____Appliance ______self-care
Inspect Abdomen:_____ symmetry_____ flat_____ rounded_______ obese
Auscultate Abdomen:______ normal bowel sounds______Hypoactive______ Hyperactive
Palpate abdomen:_____ soft____ firm_____ tender : describe______________________
_____ distention: describe:_____________________________________

4. ACTIVITY-EXERCISE
______Not Assessed
A. Musculoskeletal:______tremors ____atrophy ______swelling
Self-Care Ability: 0=Independent 1=Assistive device 2=Assistance from others
3=Assistance from person and equipment 4=Dependent/Unable

Eating 0 1 2 3 4
Bathing
Dressing
Toileting
Bed Mobility
Transferring
Ambulating
Stairs
Shopping
Cooking
Home Maint.

Assistive Devices:___ none____ crutches ______Bedside commode______ Walker


____cane_____ splint/brace _____wheelchair________ other
Gait:_____normal______abnormaI_______________________________(describe)
Range of Motion______normal______limited_______________________(describe)
Posture:______normal_______Kyphosis_________Lordosis
Deformities_____no ______yes:__________________________________(describe)
Amputation________________________Prosthesis_________________________
Physical Development Assessment:_______________normal__________abnormal
describe:______________________________________
B. CV
_____Not Assessed
Pulse:_____regular ____irregular______strong _____weak
_____radial rate_____apical rate
Blood Pressure:______ standing_______lying________sitting
Extremities: Temperature: ___cold ___cool ____warm_____hot
Capillary Refill:_____brisk ____sluggish
Color:_____________________(describe)
Homan's Sign:______Negative_________Positive
Nails: _______Normal________ Thickened _______other: ________(describe)
Hair distribution:_____normal________abnormal________________(describe)
Pulses:_______Femoral_______Popliteal_________Post-tibial_________Dorsalis
________Palpable________Doppled
Claudication:______yes_______no

C. Respiratory
nspect chest:________symmetrical ___________asymmetrical
Respirations ___rate ___depth (shallow, deep, abdominal, diaphragmatic
___regular ___irregular_______________periods of apnea
____dyspnea at rest____orthopnea____dyspnea on exertion
_______Cough:dry/productive describe_____________________________
_______Sputum: describe_______________________________________

Auscultate chest:_______crackles_______rhonchi ______friction rub_______wheezing


describe:___________________________________________ -
Other:_______chest tube_______ tracheostomy Describe:________________________
______________________________________________________________________
Oxygen:_______________________________________________________________
5. SLEEP-REST
________Not Assessed
Usual Sleep Habits: _____hours per night _________consecutive hours slept per noc
____a.m. nap ________p.m. nap
feel rested after sleep__yes__no awakening during night __yes __no insomnia __yes __no
Methods used to promote sleep: __medication:___________________________________
__________warm fluids
_____rituals: (bathing, reading, tv, music)
6. COGNITIVE-PERCEPTUAL
_______Not Assessed
Level of Consciousness:____alert___ lethargic___drowsy____stuporous______comatose
Mood (subjective):___pleasant___irritable___calm___happy____euphoric
_____ anxious_____ fearful_____ other:__________________________
Affect (objective):__surprise__anger__sadness__joy___disgust___fear___ flat__ blunted__ full___
Orientation Level:___person___place____time ____significant other
Memory: recent:___yes ___no Remote: __yes __no
Pupils:____size ____Reaction (brisk/sluggish)
Reflexes:_____normal _____absent
Grasps:______Right: strong/weak ______left: strong/weak
Push/Pulls:______right: strong/weak _____left: strong/weak
Other:_____numbness _____tingling
Pain:____Denies
____Location: describe: ________________________
____Radiation: describe:________________________
____Intensity: (0-10 scale)
____Timing (how often, events that percipitate)
When did pain begin?________________________________________
What alleviates pain?________________________________________
What increases pain?________________________________________
Thought Content:_________________________________________________________________
Senses: Visual Acuity:_____wnl_____glasses______ contacts_____blind (R/L)
Prosthesis: (artificial eye) R/L
Hearing:_____wnl____impaired (R/L)_____deaf(R/L) ______hearing aid
_______tinnitus______drainage from ears
Touch: ________wnl______ abnormal: describe________ tingling _____numbness
Smell______normal ________ abnormal
Ability to: communicate: language spoken______ read____clear___, articulate____
Ability to make decisions__easy ___moderately easy ___moderately difficult ___difficult (subjective)
7. SELF-PERCEPTION-SELF-CONCEPT
_______Not Assessed
Appearance:____calm____anxious____irritable_____withdrawn_____restless
_____appropriate dress _______hygiene
Level of anxiety: (subjective) Rate on 0-10 scale______________________
(objective) face reddened: ______no _____yes
voice volume changes ___no ___yes(loud/soft) voice quality ___no ___
yes(quavering/hesitation) muscle tenseness: relaxed fists/teeth clenched
Body language describe________________________________________________________
Eye contact:
Answers questions: _________readily__________hesitantly
Usual view of self_____ positive ______neutral _______somewhat negative (subjective)
Level of control in this situation____________(0-10) (subjective)
Usual level of assertiveness_______________(0-10) (subjective)
Body Image: Is current illness going to result in a change in body structure or function? _____no _______unsure _____yes
describe: ________________________________(subjective)
8. ROLE-RELATIONSHIP
______Not Assessed
Does patient live alone ____yes ____no: with whom________________________________________________
Married____________ Children__________________________
Next of Kin_____________________________________________
Occupation:_____________________________________________
Employment Status:___employed ____short-term disability_____long-term disability
______retired______unemployed
Support System: _____spouse ______neighbors/friends________none
_____family in same residence -family in separate residence
Family: Interaction: (describe)___________________________________ __________
Question patient regarding:
Concerns about illness:______________________________________________________
_________________________________________________________________________
Will admission cause signifcant changes in usual role?______________________________
__________________________________________________________________________
Social activities:_______active ________limited _______none
Activities participated in:____________________________________________________________
Comfort in social situations (subjective)________comfortable___________uncomfortable
**** if patient is dependent on others for care note any evidence of physical or
psychosocial abuse
9. SEXUALITY-REPRODUCTIVE
________Not Assessed
Female:______date of LMP ___Para ____Gravida_______Pregnant
______Menopause ____no______yes _______year
Contraception______no_______yes_______________Type
Hx. of vaginal bleeding _____no ____yes (describe)_____________________
Last Pap Smear___________
History of sexually transmitted disease ____no _____yes:_________________
Male: History of Prostate problems _____yes ______no History of penile discharge, bleeding, lesions; ______no ______yes
describe:_____________________________
___________________________________________________________________________
Last prostate exam:_______________________
History of sexually transmitted disease ________no _______yes:
Both: Problems with sexual functioning?____________________________________________
Sexual concerns at this time?____________________________________________________
1 0. COPING-STRESS TOLERANCE
_________Not Assessed
Overt signs of stress (crying, wringing of hands, clenched fists)
Describe:____________________________________________________________________
Question patient regarding:
Primary way you deal with stress?
____________________________________________________________________________________________________
_____________________________________________
Concerns regarding hospitalizaton/illness: (financial, self-care)_________________________
Major loss within last year ____yes _____no Describe:________________________________
___________________________________________________________________________
11. VALUE-BELIEF
_______Not Assessed

Religion:_____Protestant ____Catholic ___ Jewish __Muslim ___Buddhist ___None ___other:


Question Tatient regarding:
Religious Restrictions:_________________________________________________________
Religious Practices:___________________________________________________________
Concerns related to ability to practice usual spiritual or religious customs?
___________no ___________ yes Describe:_______________________________________
___________________________________________________________________________

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