Functional Health Patterns Assessment Tool

Nursing Practicum ___________ Student Name __________

Date __________

Patient’s Initials __________Male ___________Female __________Age _________

Medical Diagnosis ______________________________________________________________

Reason for Seeking Health care ___________________________________________________

1. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN:

Past Medical History:

Illness: _______________________________________________________________

Surgery: ______________________________________________________________

History of Chronic Disease: _______________________________________________

Immunization History: _______Tetanus _______Pneumonia _______MMR ________

Influenza _______ 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 Use______ Frequency of Last Use ________

Other Drugs: Amount/Type__________ Frequency of Used Drug ___________________

Medication (Prescription/nonprescription)______________________________________

DRUG DOSE Frequency Of Use Last Dose

Allergies __________________________Not Known Allergy ________________________

 Perception of Health:_______ Good _______ Fair ________ Poor ________

Health Management Habits: Exercise on Regular Basis? Yes_____ No ______

Safety: ______ Special equipment ______ Precautions ______ Side rails ______

Further Questions: Use of seat belt, car seats for kids, breast/testicular self‐examination

Safe working Condition_______________________

Home Health in Last Semester Safe Environment in Home i.e. smoke detectors, access to

Home stairs, throw rugs/carpets, cleanliness, health issue observed __________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

2. NUTRITIONAL‐METABOLIC PATTERN:

Not Assessed ______________

Height _______ Weight _______Weight Fluctuation in Last 6 Months __________________

Type of Diet/Restriction _______ Regular _____Low Salt _____Diabetic _____Others_____

Appetite: ______ Normal _____ Increased _____ Decreased _____ Decreased Taste _____

Nausea_______ Vomiting _______

Describe: Swallowing Difficulties________ Gag Reflex _______ Chewing Difficulties ______

Condition Of Mouth:________ Pink ________Inflamed _______ Moist_______ Dry_______

Lesions ______Teeth/Gums______ Dentures _____Upper (partial/full)___________

Lower (partial/full)______

Intravenous Fluids Type/Amount _____________________

Insertion Site _______________ NG__________________ Gastrostomy ________________

Skin Condition: Color, pallor, ashen, pink, jaundice, cyanotic, ruddy

Temperature: Warm, cool, hot

 Dry, moist, clammy, diaphoretic

Edema: Pitting or non‐pitting Turgor: Good, poor, tenting Pruritus: _______

Intact _________ Bruises/lesions________ Describe size and Location _______________________

Body Temperature: __________ Tympanic_______ Oral________ Rectal __________

3. ELIMINATION PATTERN:

Not Assessed ______________

Describe Bowel Habits: _____Stool (consistency, color, amount)______ Number of BM/day______

Date of Last BM_________ Constipation ________ Diarrhea __________ Incontinence _________

Describe Bladder Habits :___________( color, clarity, amount)__________Frequency___________

Dysuria_______ Nocturnal _______ Urgency ________ Hematuria ________ Retention___________

Burning_______ Hesitancy _____ Pressure _____Incontinence (Yes/No)________Daytime________

Night Time_______ Occasional ________ Difficulty Delaying Voiding __________

Assistive Devices:_________ Intermittent catheterization _________ Indwelling Catheter________

External Catheter ______ Incontinence Brief _______ Ostomy (Type):_______ Appliance_________

Self‐care________ Inspect Abdomen:___________________ Symmetry __________Flat _________

Rounded ________ Obese _______ Auscultate abdomen:____________ Hypoactive ___________

‐‐‐‐ Hyperactive _________ Normal bowel Sound _______________Palpate Abdomen______________

Soft______ Firm _______ Tender _______Reason _______ Distension _________ Reason________

4. ACTIVITY‐EXERCISE PATTERN:

Not Assessed __________

A: Musculoskeletal:

Tremors __________Atrophy ____________Swelling ____________Self‐care Ability 0=Independent

1=Assistive device 2=Assistance from others 3 = Assistance from person or equipment 4=Dependant

Assistive devices: ____None ____Crutches _______Bedside commode __________Walker________

Cane______ Splint/Brace ______Wheel chair _______ Others______

Gait: ______Normal _______Abnormal ______ Describe _______Range of Motion __________

Normal ________ Limited _______ Describe _______ Posture________ Normal _______Kyphosis

_______ Lordosis ______ Deformities _______ Yes ______ No _______Amputation ____________

Prosthesis ________

Physical development Assessment:_________ Normal ________Abnormal _______Describe ______

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

B: Central Venous System:

Not Assessed__________

Pulse _______ Regular ________ Irregular ________Strong _______ weak _______ Radial Rate _______

Apical Rate ________Blood Pressure __________ Lying _________ sitting ________Standing ________

Extremities: Temperature _______ Cold ______ Cool ______ Warm ______ Hot ______ Capillary Refill

_______ brisk _______ Sluggish ______ Color: _______ Describe ________ Homan’s Sign ___________

Negative________ Positive ________Nails:________ Normal _______ Thickened ______Others _______

Describe ________ Hair Distribution: _________ Normal _______ Abnormal ______ Describe ________

Pulses:_________ Femoral ________ Popliteal _______ Post tibial _______ Dorsalis Pedis ___________

Palpable ___________ Doppler ___________ Claudication: _________Yes ___________ No __________

C: Respiration:

Not Assessed________

Inspect Chest: __________ Symmetrical _______ Asymmetrical ________ Respiration ______ 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 Hub _______ Describe

_______ Others: _________ Chest Tube ________ Tracheostomy ________ Describe _______________

Oxygen Inhalation: _____________________________________________________________________

5. SLEEP‐REST PATTERN:

Not Assessed _____________

Usual Sleep Habits _________ Hours per Night ________ Consecutive hours slept per nocturia _______

a.m. Nap _________p.m. Nap _______ Feel rested after sleep _______No awakening at night _______

Insomnia _______ Methods used to promote sleep: Medications ________________________________

Warm fluids ________ Rituals: _________ (Bathing, Reading, T.V, Music)

6. COGNITIVE‐PERCEPTUAL PATTERN:

Not Assessed ___________

Level of Consciousness ______ Alert _____ Lethargy _____ Drowsy _____ Stuporous _____ Comatose

______ Mood: (Subjective) :_______ Pleasant _______ Irritable _______ Calm _______ Happy _______

Euphoric ______ Anxious _______ Fearful ________ Others ______

Affect (Objective):_____ Surprise _____ Anger _____ Sadness ____ Joy _____ Disgust _____ Fear _____

Flat _____ Blunted ____ Full _____

Orientation Level: ______ Person ______ Place ______ Time _______ Significant Others ____________

Memory: Recent ______Yes ____ No _____ Remote:_______Yes _____ No ______Pupils:____________

Size _____ Reaction (brisk/sluggish) Reflexes: ______ Normal _______ absent ______ Grasps: ________

Right: Strong/weak______ Left: Strong/weak, Push and Pull_______ Right: Strong/weak _____________

Left: Strong/weak ______ others: _______ Numbness ________ Tingling ________Pain _____________

Denies _______ Location: ________ Describe _________ Radiation: ___________ Describe: __________
Intensity :( 0‐10 scale), Timing (how often, events that participate)

When did pain begin? __________________________________________________________________

Factors alleviate pain? __________________________________________________________________

Factors aggravating pain? ________________________________________________________________

Thought contents: ______________________________________________________________________

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‐CONCEPT AND SELF‐PERCEPTION PATTERN:

Not assessed ____________

Appearance: ________ Calm _____ Anxious ______ Irritable _______ Withdrawn _____ Restless ______

Appropriate dress ________ Hygiene ________

Level of Anxiety: (subjective) Rate on 0‐10 scale_____________ Objective: Face redness_____________

No______ Yes ______ Voice Volume changes _______ Yes _______ No ______Loud ______ Soft ______

Voice quality _______ Yes ______ No _____ Quavering/hesitation ______ Muscle tenderness ________

Relaxed fists/teeth clenched

Describe body language: ________________________________________________________________

Eye Contact: ______________________ Answer question: ________ Readily _______ Hesitantly ______
Usual view of self: _________ Positive _________ Negative ___________ Neutral ___________

Level of control in specific situation: ________________________ (0‐10 scale) subjective data

Usual level of assertiveness :_________________________________( 0‐10 scale) subjective data

Body Image: Is current illness going to result in a change in body structure or function? ______________

No ________ Yes _________ Unsure _________ Describe :( subjective)___________________________

8. ROLE AND RELATIONSHIP PATTERN:

Not assessed ___________

Does patient live alone _______ Yes ________ No ______ with or whom __________ Married ________

Children _________ Next of kin _________ Occupation _________Employment status: ______________

Employed ________ Short‐term disability _________ long‐term disability _________ Retired _________

Unemployment ___________ Support system _________ Spouse ________ Neighbour/friends _______

None _______ Family in same residence‐family in separate residence ____________________________

Family: Interaction (describe)_____________________________________________________________

Questions patient regarding:

Concerns about illness: __________________________________________________________________

Will admission cause significant changes in usual role? ________________________________________

Social activities:_______ Active _______ Limited _______ None _______

Activities participated in: ________________________________________________________________

Comfort in social situation (subjective) ________ comfortable _________ Uncomfortable ___________

If patient dependent on others for care note any evidence of physical or psychological abuse_________

_____________________________________________________________________________________

9. SEXUALITY‐REPRODUCTIVE PATTERN:

Not assessed_______________

Female: __________ date of LMP _________ Para _________Gravida __________ Pregnant _________

Menopause _________ No ________ Yes ________ Contraception ___________ No ______ Yes ______
Type ____________ History of vaginal bleeding ________ Yes _______ No ________ Describe ________

Last PAP smear _______________________ History of STIs _________ No __________ Yes ___________

Male: History of prostate problems _______________Yes _____ No _____ History of penile discharge

_________ Bleeding __________ Lesions __________ Yes ________ No _______ Describe____________

_____________________________________________________________________________________

Last prostate exam: ____________________________________________________________________

History of STIs ____________ Yes ___________ No ____________

Sexual functioning problems: _____________________________________________________________

Sexual concerns at this time? _____________________________________________________________

10. COPING‐STRESS TOLERANCE PATTERN:

Not assessed____________

Overt signs of stress (crying, wringing of hands, clenched fists) __________________________________

Describe: _____________________________________________________________________________

Question Patient Regarding:

Primary way you deal with stress __________________________________________________________

Concern regarding hospitalization/illness: (financial, self‐care) __________________________________

Major loss within last year _______Yes _______ No _______ Describe ____________________________

11. VALUE‐BELIEFS PATTERN:

Not assessed ______________

Religion ________ Protestant _______ Catholic ______ Jewish ______ Muslim ______ Buddhist _______

Others ______________ None ________

Questions Patient Regarding:

Religious restrictions:_________________________ Religious practices __________________________

Concerns relate to ability to practice usual spiritual or religious customs?__________________________

Yes _____________ No _______________ Describe __________________________________________

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