Assessment Tool: Functional Health Pattern

Student name: ------------------------------ PN#: ---------------Patient information:

Patients name: -----------------------------------------------------------------------------------Sex-------------- age: ------------- marital status: --------------- religion: ------------------Culture: ------------------------- language: --------------------- occupation: --------------Education: ---------------------- diagnosis: -------------------- surgeries: -------------------Allergies: ------------------------ physician: -------------------- bed#: ------------------------DOA: ----------------------------- history: --------------------------------------------------------1. HEALTH PERCEPTION AND HEALTH MANAGEMENT:

General state of health (client description): ------------------------------------------------------------------------------------------------------------------------------------------------------------------

Health practices: (responsibility for health restoration and maintenance:

Medication (at home) prescribed/non-prescribed and purpose of taking: --------------------------------------------------------------------------------------------------------------------------------Immunization status: ---------------------------------------------------------------------------------knowledge of disease and preventive behavior: -----------------------------------------------------------------------------------------------------------------------------------------------------------General appearance: ---------------------------------------------------------------------------------Current health problem for seeking health care: -------------------------------------------------Previous childhood/adult illnesses, accidents, injuries, hospitalization: ---------------------------------------------------------------------------------------------------------------------------------Nursing diagnosis: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2. ACTIVITY EXERCISE PATTERN:
Respiration:
Respiratory rate: -------------- rhythm: --------------------- depth: -------------------------------Use of accessory muscles: ---------------------------------- chest expansion: -------------------Cyanosis: ------------------ chest shape: ------------------------------------------------------------Palpation: tactile fremitus: ---------------------- respiratory expansion: -----------------------Page 1 of 5

Percussion: ---------------------------------- diaphr excursion: -----------------------------------Breath sounds: --------------------------------------------------------------------------------------Cough (dry/productive): ---------------- sputum: ---------------- color: -------------------------Consistency: ----------------------------------- odor: ----------------------------------------------Circulation:
Temperature: ------------ B.P: ----------- pulse rate: ------------- rhythm: ----------------------Pedal pulse: --------------- capillary refill: ------------------------ JVP: -------------------------Color of extremities: ---------------------- edema: ---------------- chest pain: ------------------heart sounds: ------------------------------- murmurs: ---------------------------------------------Medication: -------------------------------------------------------------------------------------------Special tests: ------------------------------------------------------------------------------------------Nursing diagnosis: -----------------------------------------------------------------------------------ACTIVITY:
Typical day activity: ---------------------------------------------------------------------------------Exercise pattern (type, frequency): ----------------------------------------------------------------Energy level: zero: independent (

) 1: require use of equipment or device (

2: require assistance or supervision of others (

another person and equipment (

) 3: require assistance or supervision of

) 4: dependant does not participate (

).

ROM: full limited: ------------------- edematous: ------------------ stiff: ----------------------Configuration: ------------------------- amputation: ----------------- accessory devices: -------Side rails: ------------------------------ comfort devices: --------------- casts: -------------------Prosthesis: ----------------------------- cane: --------------------------- walker: ------------------Medication: -------------------------------------------------------------------------------------------Special tests: ------------------------------------------------------------------------------------------Nursing diagnosis: -----------------------------------------------------------------------------------3. COGNITIVE PERCEPTUAL PATTERN:
LOC: --------------orientation: ----------------memory: recent: ------------ past: ----------Speech/voice: -------------------------------- language barrier: -------------------------------Sensory status: ------------------------------- pain tolerance scale (0-5):--------------------C-character: ---------------------------------------------------------------------------------------O-onset: -------------------------------------------------------------------------------------------l-location: -----------------------------------------------------------------------------------------D-duration: ----------------------------------------------------------------------------------------

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E-exacerbation: ----------------------------------------------------------------------------------R-relieving: ---------------------------------------------------------------------------------------A-associated: -------------------------------------------------------------------------------------Thought process: ---------------------------------------------------------------------------------Medication: --------------------------------------------------------------------------------------Special tests: --------------------------------------------------------------------------------------Nursing diagnosis: -------------------------------------------------------------------------------4. NUTRITION-METABOLIC PATTERN:
Weight: --------------- height: ------------------ skin: --------------- color: -----------------Turgor: ---------------- lesion: ----------------usual daily food/fluid intake: ---------------Fluid restrictions cc/day: ------------------- weight loss/gain in last 6 month: ------------DRIPS

DRESSINGS/WOUND:

ELECTROLYTES:

Type: ----------------

wound type: ---------------

Na: -------------------

I/V site: --------------

appearance: -----------------

K: --------------------

Rate of flow: ---------

drainage: --------------------

Ca: -------------------

Condition of site: ------------ type of dressing: ------------------

CL: -------------------HCO3:------------------

5. ELIMINATION PATTERN:
Gastrointestinal:
Oral cavity: ------------ dentures: ------------ diet: ---------------- preferences: ------------Dislikes: ----------------------------- ability to feed: -----------------------------------------Abdomen:

soft

Bowel sounds: present (

hypoactive (

Bowel function- normal (

constipation (

Incontinence

Abdominal girth

tender

) distended (

) hyperactive (

) diarrhea

Genitourinary:
Bladder: soft (
Oliguria (
Clear

) urgency (
) Polyuria (
) cloudy (

) Nocturia (

) incontinence (

) out put ------------------------ cc/day

) concentrated (

bloody (

Medication: ------------------------------------------------------------------------------Special tests: -----------------------------------------------------------------------------Nursing diagnosis: -----------------------------------------------------------------------

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6. SLEEP REST- PATTERN:

Usual sleep pattern: night hours: ----------- quality: ----------- afternoon nap: -----------In hospital: ----------------------------------------------------------------------------------------Sleep problems: ----------------------------------------------------------------------------------Use of sleep aids (drinks, medication, bath, relaxation techniques) ----------------------------------------------------------------------------------------------------------------------------Medication: ---------------------------------------------------------------------------------------Nursing diagnosis: -------------------------------------------------------------------------------7. SELF PERCEPTION/SELF CONCEPT PATTERN:
Feeling about self/self esteem: -----------------------------------------------------------------Body image: --------------------------------------------------------------------------------------Emotional state/affect: --------------------------------------------------------------------------Nursing diagnosis: -------------------------------------------------------------------------------8. COPING-STRESS TOLERANCE PATTERN:
Stressors/major life changes: -------------------------------------------------------------------Coping mechanisms/problem management: -------------------------------------------------Use of alcohol/tobacco/pan/cigarette/prescribed drug: -------------------------------------Support system: ----------------------------------------------------------------------------------Nursing diagnosis: -------------------------------------------------------------------------------9. ROLE- RELATIONSHIP PATTERN FAMILY:
Family: housing situation: ----------------------------------------------------------------------Family system: nuclear: ------------------------------------------------------------------------Family significant others: ----------------------------------------------------------------------Communication pattern (decision making): ------------------------------------------------Roles and responsibilities in family/problems: ----------------------------------------------Socialization: -------------------------------------------------------------------------------------Financial situation: ------------------------------------------------------------------------------Satisfaction with family/work social relationship: ------------------------------------------Nursing diagnosis: ------------------------------------------------------------------------------10. SEXUALITY/REPRODUCTION PATTERN:
Reproductive history (female):
Menstruation:
Cycle: regular ( ) irregular ( ) amount: ---------------- pain/problem: ------------------

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Frequency: ---------------------------------------------------------------------------------------Age of menopause (problem if any): ---------------------------------------------------------Pregnancy (gravida/para/outcome): ----------------------------------------------------------Number of children/sibling (ages): ------------------------------------------------------------Contraception: ------------------------------------------------------------------------------------Sexual relations: ---------------------------------------------------------------------------------Sexual satisfaction/dissatisfaction: ------------------------------------------------------------Medication: ---------------------------------------------------------------------------------------Special tests: --------------------------------------------------------------------------------------Nursing diagnosis: -------------------------------------------------------------------------------11. VALUE BELIEF PATTERN:
Satisfaction with life: ---------------------------------------------------------------------------Spirituality/religious beliefs: -------------------------------------------------------------------Religious practices: ------------------------------------------------------------------------------Current or anticipated needs for religious support: -----------------------------------------Value belief conflicts: ---------------------------------------------------------------------------Nursing diagnosis: --------------------------------------------------------------------------------

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