COLLEGE OF NURSING LRH

Functional Health Pattern: Assessment Tool

Student Name_______________________________
Patient Name_____________________ Sex ____ Age ______ DOA_________ Marital status_________
Religion_________ Culture_________ Education__________ Occupation____________________ ___
Language _________Bed No._______ Present Medical diagnosis_______________________________
Surgeries____________________ Allergies ________________________________________________
Physician/Surgeon______________________________

1. Health Perception-Health management

Client’s perception regarding health________________________________________________________
_____________________________________________________________________________________
General Appearance____________________________________________________________________
Immunization Status____________________________________________________________________
Medication taking at home (with purpose)__________________________________________________
____________________________________________________________________________________
Knowledge of current disease____________________________________________________________
Healthcare behaviors(Health promotion and prevention activities)_______________________________
____________________________________________________________________________________
Previous illness/Accidents/Surgeries and hospitalization with date_______________________________
Nursing diagnosis______________________________________________________________________
Teaching Needs________________________________________________________________________

2. Nutritional Metabolic Pattern

Weight________ Height_________ Skin condition_________ Lesions____________________________
Temperature____________ Turgor_________ Daily food/fluid intake_____________________________
Favorite food________________________________________ Dislikes___________________________
Dietary supplements_________________ Oral cavity________________ Dentures__________________
Fluid restriction______________________ Weight loss/gain in last 6 months_______________________
I/V fluids (type)__________________ I/V site________ Rate of flow__________ Condition of site______
Electrolytes: Na______________ K_______________ Ca_______________ Cl___________________
Feeding: Oral_________ Enteral_________________ TPN____________ Type____________________
Nursing diagnosis______________________________________________________________________
Teaching Needs________________________________________________________________________

3. Activity Exercise Pattern

Respiratory rate_______ Rhythm________ Use of accessory muscles_________ Chest shape__________
Cyanosis_______ Tactile fremitus___________ Chest Expansion____________ ____________________
Breath sounds_______________________ Cough__________ Sputum_____________ Color__________
Oxygen/Room air____________ Tracheostomy__________ Suction________ Chest tubes____________
Medication____________________________________________________________________________
diagnostic/special/tests__________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

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CIRCULATION
B.P__________ Pulse_________ Rhythm____________ Amplitude_________ Temperature__________
Capillary refill__________ JVP______________ Temperature of extremities_______________________
Edema: No □ Yes □ Site______________________ Chest Pain___________ Heart sounds____________
ECG monitor____________ Pace maker (type)______________I/V line (type)______________________
Medication____________________________________________________________________________
Special tests___________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
ADL
Exercise pattern (type)________________________________________ Frequency_________________
Activity level _____________________ ROM (Full/limited)___________ Stiffness___________________
Contractures____________________ Amputation_____________ Accessory devices________________
Cast/Traction______________ Prosthesis________________________________ Side rails___________
Medications___________________________________________________________________________
Special tests___________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

4. Elimination Pattern
GASTRO-INTESTINAL:
Abdomen: Soft □ Firm □ Tender □ Distended □ Flat □ Protruded □ Abdominal girth (cm)_________
Bowl sounds: Present_______ Absent_______ Hypoactive_____________ Hyperactive______________
Bowl function: Normal________ Constipation____________ Diarrhea_________ Incontinence________
Colostomy_____________________________ Ileostomy_______________________________________
Special tests___________________________________________________________________________
Nursing Diagnosis______________________________________________________________________
Teaching Needs________________________________________________________________________
GENITO-URINARY
Bladder: Soft_____ Distended______ Nocturia ______Incontinence ______ Oliguria/Polyuria________
Daily fluid intake_____________________ Output_________________ Balance(+ve/--ve )____________
Urine: Color__________ Cloudy________ Concentrated_______ Bloody______ Painful______________
Foleys____________________ Condom____________ Bladder Irrigation__________________________
Medication____________________________________________________________________________
Special tests___________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

5. Sleep Rest Pattern

Normal sleep pattern at home________________ Quality____________ Nap______________________
In hospital__________________ Sleep problems_____________________________________________
Sleep aids_____________________________________________________________________________
Medication____________________________________________________________________________
Special tests___________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________
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6. Cognitive Perceptual Pattern
LOC________ Orientation______________ Memory: Recent_____________ Remote________________
Speech/Voice______________ Language barrier_______________ Sensory status__________________
Thought Process_____________________ GCS_____________ Pain Tolerance Scale (0—5) ___________
C=Charateristic________________________________________________________________________
O= Onset_____________________________________________________________________________
L=Location____________________________________________________________________________
D=Duration___________________________________________________________________________
E=Exacerbation________________________________________________________________________
R=Relieving___________________________________________________________________________
A=Associated__________________________________________________________________________
Medication____________________________________________________________________________
Special tests___________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

7. Coping Stress Tolerance Pattern

Affect/Mood___________ Calm____ Angry____ Irritable____ Fearful____ Anxious____ Withdrawal___
Apathetic_____
Stressors/Major life changes______________________________________________________________
Coping mechanism/Problem management__________________________________________________
Use of alcohol/Tobacco/Pan/Cigarette/Drug_________________________________________________
Support system________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

8. Role-Relationship Pattern
Family: Housing situation__________________________ Family system: Nuclear/Extended__________
Communication pattern (decision making)__________________________________________________
Roles and responsibilities in family/Problems________________________________________________
Socialization___________________ Financial situation________________________________________
Satisfaction with family/Work/Relationship__________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

9. Self-Perception/Self Concept Pattern

Feeling about self/Self-esteem____________________ Body Image______________________________
Emotional state/Affect__________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

10. Sexuality/Reproductive Pattern

Menstruation:
Cycle: Regular/Irregular____________ Normal (amount)________________ Pain/Problem___________
Frequency______________________________ Menopause____________________________________

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Number of children (M/F), ages___________________________________________________________
Contraception_________________________________________________________________________
Relationship with couple_________________________________________________________________
Sexual satisfaction______________________________________________________________________
Medication____________________________________________________________________________
Special tests___________________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

11. Value Belief Pattern

Satisfaction with life____________________________________________________________________
Religious practices______________________________________________________________________
Value belief conflicts____________________________________________________________________
Nursing diagnosis_______________________________________________________________________
Teaching Needs________________________________________________________________________

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