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