Functional Health Patterns Assessment Guidelines



Functional Health Patterns Assessment Guidelines






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.


ADULT ASSESSMENT


Nursing History


1. HEALTH-PERCEPTION-HEALTH-MANAGEMENT PATTERN



  • How has general health been?


  • Any colds in the past year? If appropriate, absences from work/school?


  • Most important things done to keep healthy? Did these things make a difference to health (include family folk remedies, if appropriate)? Breast self-examination? Use cigarettes? Drugs? Ever had a drinking problem? When was your last drink?


  • Accidents (home, work, driving)? Falls?


  • In past, easy to find ways to follow suggestions of doctors or nurses?


  • If appropriate, what do you think caused this illness? Action taken when symptoms perceived? Results of action?


  • If appropriate, what is important to you while you are here? How can we be most helpful?


2. NUTRITIONAL-METABOLIC PATTERN



  • Typical daily food intake? Describe. Supplements?


  • Typical daily fluid intake? Describe.


  • Weight loss/gain? Amount? Height loss/gain? Amount?


  • Appetite?


  • Food or eating discomfort? Swallowing? Diet restrictions? If appropriate, breastfeeding? Problems with breastfeeding?


  • Heal well or poorly?


  • Skin problems, such as lesions, dryness?


  • Dental problems?



3. ELIMINATION PATTERN



  • Bowel elimination pattern? Describe. Frequency? Character? Discomfort? Problem in control? Laxatives?


  • Urinary elimination pattern? Describe. Frequency? Discomfort? Problem in control?


  • Excess perspiration? Odor problems?


4. ACTIVITY-EXERCISE PATTERN



  • Sufficient energy for desired/required activities?


  • Exercise pattern? Type? Regularity?


  • Spare time (leisure) activities? Child’s play activities?


  • Perceived ability for the following (code level according to Functional Levels Code below)























Feeding


Grooming


Bathing


General mobility


Toileting


Cooking


Bed mobility


Home maintenance


Dressing


Shopping



Functional Levels Code

Level 0: Full self-care

Level I: Requires use of equipment or device

Level II: Requires assistance or supervision of another person

Level III: Requires assistance or supervision of another person and equipment or device

Level IV: Is dependent and does not participate


5. SLEEP-REST PATTERN



  • Generally rested and ready for daily activities after sleep?


  • Sleep-onset problems? Aids? Dreams (nightmares)? Early awakening?


  • Rest/relaxation periods?


6. COGNITIVE-PERCEPTUAL PATTERN



  • Hearing difficulty? Aid?


  • Vision? Wear glasses? Last checked?



  • Any change in memory lately?


  • Easy/difficult to make decisions?


  • Easiest way for you to learn things? Any difficulty learning?


  • Any discomfort? Pain? How do you manage it?


7. SELF-PERCEPTION-SELF-CONCEPT PATTERN



  • How would you describe yourself? Most of the time, do you feel good (not so good) about yourself?


  • Changes in your body or the things you can do? Are these problematic for you?


  • Changes in way you feel about yourself or your body (since illness started)?


  • Find things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? What helps?


  • Ever feel you lose hope? Not able to control things in life? What helps?


8. ROLE-RELATIONSHIP PATTERN



  • Live alone? Family? Family structure? Draw diagram.


  • Any family problems you have difficulty handling (nuclear/extended)?


  • How does the family usually handle problems?


  • Family depend on you for things? How are you managing?


  • If appropriate, how do family/others feel about your illness/hospitalization?


  • If appropriate, problems with children? Difficulty handling?


  • Belong to social groups? Close friends? Feel lonely (frequency)?


  • Things generally go well for you at work? School? If appropriate, income sufficient for needs?


  • Feel part of (or isolated in) neighborhood where living?


9. SEXUALITY-REPRODUCTIVE PATTERN



  • If appropriate to age/situation, sexual relationships satisfying? Changes? Problems?


  • If appropriate, use of contraceptives? Problems?



  • For females, when menstruation started? Last menstrual period? Menstrual problems? Para? Gravida?


10. COPING-STRESS-TOLERANCE PATTERN



  • Any big changes in your life in the last year or two? Crisis?


  • Who’s most helpful in talking things over? Available to you now?


  • Tense a lot of the time? What helps? Use any medicines, drugs, alcohol?


  • When (if) problems occur in your life, how do you handle them?


  • Most of the time, is this way(s) successful?


11. VALUE-BELIEF PATTERN



  • Generally get things you want out of life? Important plans for the future?


  • Religion important in your life? If appropriate, does this help when difficulties arise?


  • If appropriate, will being here interfere with any religious practices?


12. OTHER



  • Any other things that we have not talked about that you would like to mention?


  • Questions?


SCREENING EXAMINATION FORMAT

Add other pattern indicators to expand the examination as appropriate.

a. General appearance, grooming, hygiene _________

b. Oral mucous membranes (color, moistness, lesions) ______________________________

c. Teeth: Dentures _____ Cavities _____ Missing _________

d. Hears whisper? _______________________________

e. Reads newsprint? _________ Glasses? ____________

f. Pulse (rate) _____ (rhythm) _____ (strength) ______

g. Respiration _____ (depth) _____ (rhythm) _______


h. Breath sounds _______ Blood pressure ______________

i. Hand grip ________ Can pick up pencil? __________

j. Range of motion (joints) ______________________________ Muscle firmness (tone) _______________________________________

k. Skin: Bony prominences ________ Lesions ___________ Color changes _____________________________

l. Gait ______ Posture ______ Absent body part _______

m. Demonstrated ability for the following (code for level):

Feeding ____________ Grooming ______________

Bathing _____________ General mobility _____________

Toileting _____________ Cooking ____________________

Bed mobility _________ Home maintenance ___________

Dressing _____________ Shopping ___________________

n. Intravenous, drainage, suction, etc. (specify) ___________

o. Actual weight _________ Reported weight __________

p. Height ________________ Temperature _________________

During history and examination:

q. Orientation ___________ Grasp ideas and questions (abstract, concrete)? ____________________________

r. Language spoken; voice and speech pattern ________

s. Vocabulary level ___________________________________

t. Eye contact _____ Attention span (distraction) _______

u. Nervous (5) or relaxed (1) (rate from 1 to 5) _______

v. Assertive (5) or passive (1) (rate from 1 to 5) ________

w. Interaction with family member, guardian, other (if present) _____________________________________


INFANT AND YOUNG CHILD ASSESSMENT

When a new infant or child is added to a nurse’s caseload, a comprehensive assessment is done to establish a database for developmental assessment and for nursing diagnosis and treatment. Information is needed on (1) the development of each functional pattern and anatomical growth, (2) current health patterns, and (3) family health and the home environment in which the infant or child is developing. Minimally,
the admission nursing history and examination has to screen for high-incidence problems. The questions and items listed below can be used as a guide for a comprehensive parent-child health history or used selectively for problem screening.


Nursing History


1. HEALTH-PERCEPTION-HEALTH-MANAGEMENT PATTERN

Parent’s report of



  • Mother’s pregnancy/labor/delivery history (of this infant, of others)?


  • Infant’s health status since birth?


  • Adherence to routine health checks for the infant/child? Immunizations?


  • Infections in the infant/child? Child’s absences from school?


  • If appropriate, infant’s/child’s medical problem, treatment, and prognosis?


  • If appropriate, actions taken by parents when signs and/or symptoms were perceived?


  • If appropriate, has it been easy to follow doctor’s or nurse’s suggestions?


  • Preventive health practices (e.g., diaper change, utensils, and clothes)?


  • Do parents smoke? Around children?


  • Accidents? Frequency?


  • Infant’s crib toys (safety)? Carrying safety? Car safety?


  • Parents’ safety practices (e.g., household products and medicines)?

Parents (self)



  • Parents’/family’s general health status?


2. NUTRITIONAL-METABOLIC PATTERN

Parent’s report of the infant/child’s



  • Breast/bottle feeding? Intake (estimated)? Sucking strength?



  • Appetite? Feeding discomfort?


  • 24-hour intake of nutrients? Supplements?


  • Eating behavior? Food preferences? Conflicts over food?


  • Birth weight? Current weight?


  • Skin problems: rashes, lesions, other?

Parents (self)



  • Parents’/family’s nutritional status? Problems?


3. ELIMINATION PATTERN

Parent’s report of the infant/child’s



  • Bowel elimination pattern? Describe. Frequency? Character? Discomfort?


  • Diaper changes? Describe routine.


  • Urinary elimination pattern? Describe. Number of wet diapers per day? Estimate amount. Stream (strong, dribble)?


  • Excess perspiration? Odor?

Parents (self)



  • Elimination pattern? Problems?


4. ACTIVITY-EXERCISE PATTERN

Parent’s report of

Jun 12, 2016 | Posted by in NURSING | Comments Off on Functional Health Patterns Assessment Guidelines
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