This section contains assessment guidelines based on the health pattern definitions. Functional health patterns provide a format for the admission assessment and a database for nursing diagnoses. There are two phases in assessment: history taking and examination. A nursing history provides a description of a client’s functional patterns. The description is from the individual (or parent/guardian), family, or community representative’s perspective. It provides subjective data in the form of verbal reports. These reports are elicited by questions that assist clients to tell the history and current status of their health and health management. Observations in the examination phase provide data on pattern indicators and verification of information obtained during history taking. This is referred to as objective data.

The formats for assessment that follow are designed to elicit information in a systematic manner. They are screening formats for the collection of a basic nursing database in any specialty, for any age group, and at any point in the wellness-illness continuum. Questions and examination items tap into areas of all current nursing diagnoses. If data indicate that a problem or potential problem (dysfunctional pattern) may be present, diagnostic hypotheses (nursing diagnoses) should be generated to direct further information collection. This directs the search for the diagnostic or critical characteristics of each possibility.

Nurses practicing in a specialty area may desire in-depth assessments of certain patterns. Both the history (subjective data) and the examination (objective data) can be expanded relative to disease, disability, age, and other client-specific factors. For example, a client’s activity-exercise pattern requires an in-depth assessment when the client has a disease that affects this pattern.

Diagnoses are grouped under the same pattern areas as they are in the assessment guidelines and are used to label tentative judgments in a pattern area. As discussed previously,
this facilitates the process of moving from assessment data to diagnosis.