HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN Assignment Guide · Use this form to help guide interview questions and take notes during your client interview. - AcademixHelp

HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN

Assignment Guide

· Use this form to help guide interview questions and take notes during your client interview. This sheet will be turned into the assignment folder in D2L.

· Make sure to include both subjective and objective data. Subjective data is the information the client directly tells you. Objective data is information that you observe as a nurse. Objective data is in bold below.

· Utilize information from this sheet to then neatly and succinctly type and summarize information on the FHP template; students are REQUIRED to use template for final submission.

Client
Profile:

Bio graphics- ethnic origin, level
of education, reason for seeking care, current treatments & medications,
summary of significant past medical history, and allergies.

Developmental
History:

History of growth & development, any developmental
handicaps, their stated goals in life, effect of current health/illness on goals. Does the individual function at the
expected developmental stage? (State stage according to Erikson &
evidence of positive or negative resolution)
What issues might be impacting the developmental stage? If the client does not function at expected
stage, state stage they are functioning and support with cues.

Health
Perception-Management Pattern:

Describe your
health- how would you rate it on scale of 1-10, now, 5 yrs ago, & 5 yrs
ahead? Describe your illness (health problem). What do you believe caused your illness?
How will you care for yourself (or others) at home? What do you do when you have a health
problem? Are you able to state the names of current medications
you take and their purpose?

If this person reports having allergies, what does she/he do to
prevent them? Have there been any
important illnesses or injuries in this person’s life?

Discuss dates & history of routine health exams. What do you do to maintain your health? Flu shot,
Pneumonia or shingles immunizations?
Do use any substances (drugs, caffeine, tobacco, etc.)? History of
exposure to toxins? How well do they
comply with treatment plans?

General
appearance (describe the individual objectively). Vital Signs: RR, HR, BP, T., & O2sats.

Nutritional-Metabolic
Pattern:

Assess dietary & fluid intake:
what do you typically eat/drink in a day?
When was last dental exam? Any difficulty eating/drinking? Any changes in eating or drinking? Assess for N-V, indigestion, use of
antacids. What is current
weight? Any recent weight gains or
losses?

List height,
weight, and BMI. Include assessment of skin, hair, nails as condition can
reflect nutritional status. List any feeding precautions or if the
client receives, TPN or tube feedings, or uses supplemental beverages. List use of probiotics, prebiotics,
vitamins etc. Blood sugar
pattern. Note if client experiences
adrenal insufficiency, takes corticosteroids, or has any other endocrine
problems. Labs reflecting nutritional status:
glucose, electrolytes, lipid panel, protein/albumin, & BUN.

Elimination
Pattern:

Describe typical bowel pattern. Have there been recent changes? Quality of stool? Do you do or take anything to facilitate
BM? Any history of GI surgery? When was the last BM?

Describe usual urinary habits. Any recent changes? Quality of urine? Problems with urination
(nocturia, incontinence, frequency, dysuria)?
History of bladder surgery?

Provide
I & O data if relevant. Bowel sounds/abdominal assessment. If surgical client, describe surgical
site. Dietary intake, nausea,
vomiting. Objective assessment of the
urine & stool by the nurse?

Activity-Exercise
Pattern:

Describe a normal
day. Assess ability to complete ADLs-
are they independent or do they require support? Who helps?
Is there anything they would
like to do at home that they are unable to do? What do they do
for fun? Hobbies? Exercise routine? What do they do for a living? What is the relationship between work and
health?

Include data from
Respiratory, Cardiovascular, and Musculoskeletal assessment. List presence of respiratory or cardiac
interventions (Chest tubes, ventilator, CPAP, oxygen) Also hematology abnormalities?

Sexuality-Reproduction
Pattern:

Gather data relevant to gender &
age: Females-menstrual history,
obstetric history, menopause, BSE; males-erectile dysfunction, prostate
problems, testicular changes, TSE.
Discuss: contraceptive use, perception of sexual activities, impact of
health on sexuality, STDs, & any history of sexual abuse. Has this person had any past negative
experiences that could affect sexual health?

If the
client is OB or post-partum, assess perineum, lochia, uterus (fundus), &
breasts.

Sleep-Rest
Pattern:

Describe usual sleeping time & habits. Do you use anything to help you sleep? How would you rate the quality of your
sleep? Do you have difficulty
sleeping? Have you noticed a change in
sleeping pattern?

Include objective
cues that indicate fatigue.

Sensory-Perceptual
Pattern:

Describe your ability to see, hear, feel, taste, smell. Share
any difficulties you have in these areas.
List any assistive devices utilized (glasses, hearing aids).

Include pain and
neurological assessment.

Cognitive
Pattern:

What is the highest
level of education achieved? What is the
client’s preferred learning method/style?
How do they make decisions? As
you interview, you can gather information below based on their ability to respond:

Level of
consciousness and orientation to person, place, time. Describe their ability to understand,
communicate, and recall information.
Assess their decision-making ability.
What is their attention span?
Perform a mental status assessment if appropriate.

Role-Relationship
Pattern:

Describe your family. Assess roles within the family. Explore extended family and relationships
within family of origin (siblings, parents, grandparents). Identify the
person(s) most important in life- best friends, work friends, etc. How is your family coping with your current
state of health? How would you
describe communication between family members? Discuss distribution of roles in
family. Describe current or past
occupation. How do you feel about your
work? Who is the most important person
in your life? What social groups or
community activities do you participate in?

Does
the client have visitors? Is there evidence of caring (cards, flowers,
balloons, phone calls)? Post-partum client: note evidence of bonding. If
partner present, assess interactions/family roles.

Self-Perception-Self-Concept
Pattern:

Describe yourself. Has illness affected this? What are your strengths &
weaknesses? How do you feel about
yourself? How do you feel about your
appearance? Has this changed since
your illness? If client is
post-partum, how does she feel about role as parent (also assess partner if
present)?

Note
client’s interest & participation in personal hygiene, wearing own
robe, slippers, etc.

Coping-Stress
Tolerance Pattern:

Describe the most stressful situation in your life. How has illness affected stress and Stress
affected illness? How big a problem is financing health
care? Have you experienced any personal loss or major life change last
year? How do you typically cope with
problems? What relieves
stress/tension? Who do you turn to
when you have problems or pressure? Do
you use any substances to help relieve stress?

Value-Belief
Pattern:

What is most important to you in life? What do you hope to accomplish? What is your major source of hope &
strength? Do you have a religious
affiliation? How important is this to
you? Any special requests? Would you
like contact with minister, chaplain, priest, shaman, etc.). Are there health practices or restrictions
important for you to follow while hospitalized?

Observe any
artifacts or talismans (prayer books, tobacco, prayer rug, medicine bag,
rosaries, etc.) at bedside that provide clues to spiritual beliefs. Listen for themes in communication that
indicate values & beliefs important to client.

Summary: Bullet point out the significant health concerns, opportunities for health improvement, and client strengths/weaknesses. Summary should address psychosocial as well as physical concerns. The summary should make a case for your chosen diagnosis based on the data above.

When you have completed the assessment, identify problem areas. This may be areas where the client expressed dissatisfaction or a desire for improvement, it may be areas where there is a deviation from the client’s normal level of functioning (e.g. typically has BM daily, but has not had one in 3 days; typically eats 3 well-balanced meals with snacks, but recently has lost appetite; is typically independent in all areas of daily living (meal preparation, eating, bathing, dressing, ambulation), but currently requires assistance with ambulation and bathing; describes difficulty managing current levels of stress, etc.). It is important to look at the client’s “normal”, or desired level of health, and compare it to current status based on subjective and objective data collected. Summary should include holistic data, identifying significant physical, developmental, psychological, and social issues. Then summarize the strengths/weaknesses you identified in your data that can be an asset or detriment to the client in achieving their health goals.

HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN Assignment Guide · Use this form to help guide interview questions and take notes during your client interview.