Name: ____________________________________ Nationality: _______________________________ Civil Status: _______________________________ Chief Complaint (s): ________________________ Address: __________________________________ Date and Time of Admission: _________________ Sex: _____________________________________ Diagnosis: ________________________________ Educational Attainment: _____________________ General Impression of Client (appearance upon first Religion: __________________________________ contact): Occupation: _______________________________ __________________________________________ Room and Bed No. __________________________ __________________________________________ Doctor/s in charge: __________________________ __________________________________________
Part 2. FUNCTIONAL HEALTH PATTERN ASSESSMENT
USUAL INITIAL 1. Health Perception- Health Management Pattern Usual: o How general health has been? o Any colds in the past year? o Previous hospitalizations and management/ treatment done o Check-up (regular?) o Most important things done to keep healthy (folk remedies, breast self-exam) o Use of cigarettes, alcohol, drugs o Easy to find ways to follow things nurses or doctors suggest? Initial: o What do you think caused this illness? o Actions taken when symptoms perceived? Results of actions? o Things important to you while you are here? How can we be most helpful? o Vital Signs o Medications o Labs: Hematology 2. Nutritional- metabolic pattern Usual: o Daily food intake (describe/categorized) Food taken? Consumes whole share? Supplements? o Daily fluid intake (in cc/ml) (describe) o Weight gain/ weight loss o Appetite o Discomforts in eating o Diet restrictions o Heal well/ poorly o Skin problems o Dental Problems Initial: o Daily food intake (describe/ categorized) Food taken? Consumes whole share? Supplements? o Measurement of intake: Ex: D5LR x 33 gtts/min- 500cc H2O- 300 cc Orange juice- 240 cc Soup 100 cc = 1.140 cc o Weight loss/ gain o Appetite o Diet restrictions o P.A integument, mouth, abdomen, capillary refill, Labs/ diagnostics: RBS, FBS, ultrasound of abdomen, liver, spleen. 3. Elimination pattern Usual: o Bowel elimination (describe) frequency? o Character? Discomfort? o Urinary Elimination (describe) frequency? o Amount in cc/ml, character? o Discomfort? Problem in control? o Excess perspiration? Odor Problems Initial: o Bowel elimination (describe) frequency? o Character? Discomfort? o Urinary Elimination (describe) frequency? o Amount in cc/ml, character? o Discomfort? Problem in control? o Excess perspiration? Odor Problems 4. Activity- Exercise Pattern Usual: o Routine daily activities o Sufficient energy for completing desired/required activities o Exercise pattern? Type? Regularity? o Spare time? Leisure activities? Initial: o Activities in the hospital? o Level of Consciousness? o Difficulty in breathing? Restless? o Level codes for the different activities o Sufficient energy to complete activities? o P.A: cardio, respiratory, extremities o Vital signs o Diagnostics: chest x-ray, ECG 5. Sleep-rest pattern Usual: o Sleep onset? Waking time? o Generally rested or ready for daily activities after sleep? o Sleep-onset problems? Aids? (like meds, with lights on, pillows, etc.) Nightmares? o Early awakening o Nap time Initial: o Sleep onset? Waking time? o Generally rested or ready for daily activities after sleep? o Sleep-onset problems? Aids? (like meds, with lights on, pillows, etc.) Nightmares? o Early awakening o Nap time o P.A: Appearance 6. Cognitive-perceptual pattern Usual: o Hearing difficulty? o Vision? Wear glasses? Last checked? o Any change in memory? o Easiest way to learn things? Any difficulty learning? Initial: o Hearing difficulty? o Vision? Wear glasses? Last checked? o Any change in memory? o Easiest way to learn things? Any difficulty learning? o Coherence in speech/ appropriate? o Pain? How do you manage it? o Pain medications o P.A: eyes, ears, nose, neurologic system 7. Self-perception- Self-concept pattern Usual: o How would you describe yourself most of the time? (feels good, not so good) o Things that make you angry? Annoyed? o Fearful? Anxious? Depressed? What helps? Initial: o How would you describe yourself now? o Changes in your body or the things you can do? Is this a problem to you? o Changes in the way you feel about yourself or your body (since illness started) o Things that make you angry? Annoyed, fearful? Anxious? Depressed? In the hospital. What helps? 8. Role- relationship Usual: o Live alone? Family? Family structure? o Problems you have difficulty handling? o How does family usually handle problems? o Family depends on you for things? If appropriate: how managing? o Problems with children? Difficulty handling? o Income sufficient for needs? o Feel part of neighborhood? o Belong to social groups? Friendly? Lonely? Initial: o How does family feel about your illness/ hospitalization? o Presence of family members in the hospital/ support system? o How does illness hospitalization affect family roles? 9. Sexuality-Reproductive Usual o Use of contraceptives? Problems? o History of any operations involving the reproductive system? o Female: when menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? Initial o Observation: gestures of intimacy between partners? o If appropriate: any change or problems in sexual relation o PA: breast, genitals (as appropriate according to patients condition) 10. Coping stress tolerance Usual o Tense all the time? What helps? Use any medicines, drugs, alcohol? o Who’s most helpful in talking things over? o Big changes in your life, how do you handle them? Most of the time, are these ways successful? Initial o Tense all the time? What helps? Use any medicines, drugs, alcohol? o Who’s most helpful in talking things over? o How does family cope with your hospitalization? o How do you cope with hospital routines and treatment procedures? With hospital personnel/ health team? 11. Value-belief Usual o Generally, get things you want out of life? Most important things? o Religion important in your life? Does this help when difficulty arises? Initial o What is of value during hospitalization? o Spiritual practices in the hospital? o Will being here interfere with any religious practices? 12. Questions (other things not mentioned)
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