FUNCTIONAL HEALTH PATTERNS ASSESSMENT TOOL (Patient’s Profile)

Student: Jezzabel Kyra G. Badayos Date_April 10.2021_

Patient's Initials__Mrs. Edith__ Male____ Female__/___ Age: 83 years old
Medical Diagnosis __Health Concerns_________________________________________
Reason for seeking health care: For safety precautions about her health
1. HEALTH PERCEPTION-HEALTH MANAGEMENT
Past medical history:
Illnesses :_____N\A________________________________________
Surgery: _____Removal of Seizure Disease in the Dorsal part of the Head________
History of chronic disease: _______N/A_________________________
Immunization History: ( Please check all that applies)
____ Tetanus______ Pneumonia_____ Influenza__/___ MMR______ Polio ______ Hepatitis B

Use of Tobacco:_
_/__ None –Quit (date_____<1ppd____1-2ppd___ >2pks/day ___Packs/yr history__
_____smokeless tobacco) ____ pipe _____cigar

Alcohol: Amount/type __________N/A_________________ Date of last drink _______N/A___________

Frequency of use ______________N/A______________
Other drugs: Amount/Type :__________N/A____________Freq. of Use :______N/A_______________

Medication Dose Frequency of Use Last Dose

(prescription/Nonprescription)
Name

2. NUTRITIONAL-METABOLIC
_/___Not Assessed
____Ht.____ Wt. _______________________Weight fluctuations for the last 6 months

Type of Diet/Restrictions:
_/___ Regular ____Low Salt ____Diabetic__ Other Supplements_______

Appetite
__/__Normal ___Increased ___Decreased ___Decreased taste ___Food intolerance:_____
_____Nausea _____Vomiting Describe:_____________________
_____Swallowing difficulties _____gag reflex _______chewing difficulties

Feeding __/__self ____Assist

Condition of mouth:
___/__pink ______inflammed _____moist ______dry
_______lesions/ulcerations describe__________________ teeth /gums___________________
______ Dentures ____upper (partial/full)_______lower(partial/full)

______Intravenous fluids type/amount ____________N/A__________________________________

Insertion Site:_______________________N/A_____________________________________
_N/A_____NG___N/A_____ Gastrostomy

Skin Condition: __Brownish Skin__color: pallor, ashen, pink, jaundice, cyanotic, ruddy
_Warm___ temperature: warm, cool, hot
__Dry__dry, moist, clammy, diaphoretic
_None___ :edema: pitting/non-pitting
_Poor___ : good, poor, tenting
__none__ :pruritus
__/__intact
__none__bruises/lesions describe: (size, location)___________________________

Body temperature:__36.5C____ tympanic ______oral _____rectal

3. ELIMINATION

____Not Assessed
Bowel Habits Describe:___Yellowish/ Brownish________(consistency, color, amount)
____N/A___#BM's/day_4/10/21_____ Date of last BM
_______ Constipation _____Diarrhea ___/____Incontinence

Bladder Habits Describe:_Transparent/Clear______________(color, clarity, amount)

_/____Frequency ____Dysuria __/__Nocturia ___/__Urgency _______Hematuria
____Retention _____ Burning ______Hesitancy ________Pressure
Incontinency: ___No __/_Yes ______daytime ____/____ nightime
________ occasional __/____difficulty delaying voiding

Assistive Devices: _N/A____ intermittent catheterization ______indwelling catheter

______external catheter____________ incontinent briefs
Ostomy: type: ____none____ ____Appliance ______self-care

Inspect Abdomen:___/__ symmetry_____ flat___/__ rounded_______ obese

Auscultate Abdomen:___/___ normal bowel sounds ______Hypoactive______ Hyperactive

Palpate abdomen:___/__ soft____ firm_____ tender : describe_________________

_____ distention: describe:_____________________________________

4. ACTIVITY-EXERCISE

____/__Not Assessed
A. Musculoskeletal: ______tremors ____atrophy ______swelling

Self-Care Ability:
0 =Independent
1 =Assistive device
2 =Assistance from others
3 =Assistance from person and equipment
4 =Dependent/Unable

SELF CARE ABILITIES 0 1 2 3 4

Eating /
Bathing /
Dressing /
Toileting /
Bed Mobility /
Transferring /
Ambulating /
Stairs /
Shopping /
Cooking /
Home Maintenance /
Assistive Devices:_/__ none____ crutches ______Bedside commode______ Walker
____cane_____ splint/brace _____wheelchair________ other
Gait:__/ ___normal______abnormaI_______________________________(describe)
Range of Motion ___/___normal ______limited_______________________(describe)
Posture: ____/__normal _______Kyphosis _________Lordosis
Deformities _____no __/____yes:_Two toes in her feet are attach to each other________(describe)
Amputation____none____________________Prosthesis________none_________________
Physical Development Assessment :___/__normal _______abnormal
Describe:______________________________________
B. CV
_____Not Assessed
Pulse:70 __/___regular ____irregular ______strong _____weak
_____radial rate _____apical rate
Blood Pressure:______ standing _______lying ___/___sitting
Extremities: Temperature: ___cold ___cool __/__warm _____hot
Capillary Refill: _____brisk __/__sluggish
Color: _Brownish______________(describe)
Homan's Sign :____/__Negative _________Positive
Nails: ___/____Normal________ Thickened _______other: ________(describe)
Hair distribution:__/___normal________abnormal________________(describe)
Pulses:_______Femoral_______Popliteal_________Post-tibial_________Dorsalis
___/___Palpable _______Doppled
Claudication: ______yes _______no

C. Respiratory

______Not Assessed
Inspect chest: _____/___symmetrical ___________asymmetrical
Respirations _N/A__
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: N/A

_______crackles _______ rhonchi ______friction rub _______wheezing
describe:___________________________________________ -
Other : N/A
_______chest tube_______ tracheostomy Describe:________________________
______________________________________________________________________
Oxygen:_______________________________________________________________

5. SLEEP-REST
____/____Not Assessed
Usual Sleep Habits:
___7 hours_ hours per night ______consecutive hours slept per noc
____a.m. nap ___3:00pm_____p.m. nap
feel rested after sleep _/_yes __no awakening during night __yes _/_no
insomnia __yes _/_no
Methods used to promote sleep: __medication:___________________________________
_____/_____warm fluids ___/__rituals: (bathing, reading, tv, music)

6. COGNITIVE-PERCEPTUAL
_______Not Assessed
Level of Consciousness: ____alert___ lethargic _/__drowsy ____stuporous ______comatose
Mood (subjective):_/__ pleasant ___irritable _/__calm ___happy ____euphoric
_____ anxious_____ fearful_____ other:__________________________
Affect (objective):__surprise _/_anger /__sadness __joy ___ disgust ___fear___ flat__ blunted__
full___
Orientation Level:
_/__person _/__place __/__time __/__significant other
Memory:
recent: _/__yes ___no
Remote: _/_yes __no
Pupils: ____size ____Reaction (brisk/sluggish)
Reflexes:
_____normal __/___absent
Grasps:
__strong____ Right: strong/weak __weak____ left: strong/weak
Push/Pulls:
__strong____ right: strong/weak _weak____ left: strong/weak
Other: NONE
_____numbness _____tingling
Pain:__/__Denies
__/__Location: describe: _Lower superior cluneal and right leg
__/__Radiation: describe: _______Numbness_________________
_7___Intensity: (0-10 scale)
_Ocassionally___Timing (how often, events that percipitate)
When did pain begin? ____Last year 2020 but sometimes only
What alleviates pain ?_____when pooping and acids ____________________
What increases pain ?_House Chores and Standing up for a long time____________________
Thought Content:_________________________________________________________________
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_Bisaya_ read _/___clear__/_, articulate_/___

Ability to make decisions __easy __/_moderately easy ___moderately difficult ___difficult

(subjective)

7. SELF-PERCEPTION-SELF-CONCEPT
_______Not Assessed
Appearance:__/__calm____anxious____irritable_____withdrawn_____restless _____appropriate
dress _______hygiene
Level of anxiety: (subjective) Rate on 0-10 scale_____2__________

(objective) face reddened: ___/___no _____yes

voice volume changes ___no _/__yes(loud/soft) voice quality _/__no ___ yes(quavering/hesitation)
muscle tenseness: relaxed fists/teeth clenched
Body language: describe: Calm and cheerful
Eye contact:
Answers questions: _____/____readily __________hesitantly
Usual view of self_____ positive ____/__neutral _______somewhat negative (subjective)
Level of control in this situation____10________(0-10) (subjective)
Usual level of assertiveness_______6________(0-10) (subjective)
Body Image: Is current illness going to result in a change in body structure or function?
__/___no _______unsure _____yes describe: ______________(subjective)

8. ROLE-RELATIONSHIP
____/__Not Assessed
Does patient live alone ____yes ___/_no: with whom: with her youngest daughter and niece
Married_____/_______ Children; Noel Badayos, Miriam Wynn, Maria eden Mazon, Anna Marier
Quito, Soriano Badayos Jr.
Next of Kin_____________________________________________
Occupation:__Teacher___________________________

Employment Status: ___employed ____short-term disability _____long-term disability

__/_retired ______unemployed
Support System: _____spouse ______neighbors/friends ________none __/___family in same
residence -family in separate residence
Family: Interaction: (describe)____Good Communication_________________ __________

Question patient regarding:

Concerns about illness:___________ N/A___________________________________________
_________________________________________________________________________
Will admission cause significant changes in usual role?______________________________
__________________________________________________________________________

Social activities: _______active ____/____limited _______none

Activities participated
in:__________N/A__________________________________________________
Comfort in social situations (subjective)______/__comfortable ___________uncomfortable
**** if patient is dependent on others for care note any evidence of physical or psychosocial abuse

9. SEXUALITY-REPRODUCTIVE
____/____Not Assessed
Female:
______date of LMP ___Para ____Gravida _______Pregnant
Menopause ____no ___/___yes ___1978____year
Contraception ____/__no_____ yes_______Type

Hx. of vaginal bleeding __/___no ____yes (describe)_____________________

Last Pap Smear___________
History of sexually transmitted disease __/__no _____yes:_________________

Male: History of Prostate problems _____yes ______no History of penile discharge, bleeding,
lesions; ______no ______yes describe:_____________________________
Last prostate exam:_______________________
History of sexually transmitted disease ________no _______yes:
Both: Problems with sexual functioning?____________________________________________
Sexual concerns at this time?____________________________________________________

1 0. COPING-STRESS TOLERANCE
____/_____Not Assessed
 Overt signs of stress (crying, wringing of hands, clenched fists)
Describe:________________________________________________________________
Question patient regarding:
Primary way you deal with
stress?______________________________________________________________________
___________________________________________________________________________
Concerns regarding hospitalization /illness: (financial, self-care)_________________________
Major loss within last year ____yes _____no Describe:________________________________
___________________________________________________________________________

11. VALUE-BELIEF
___/____Not Assessed
Religion: _____Protestant ____Catholic ___ Jewish __Muslim ___Buddhist ___None ___other:

Question Patient regarding:

Religious Restrictions:_________________________________________________________
Religious Practices:___________________________________________________________
Concerns related to ability to practice usual spiritual or religious customs?

___________no ___________ yes Describe:_______________________________________