Nursing Health

Assessments
Chapter (4)
Functional Health Pattern
(NANDA)

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 Functional Health Pattern
(NANDA)
Health Perception-Health management pattern
Nutritional-Metabolic Pattern
Elimination Pattern
Activity-Exercise Pattern
Sexuality-Reproduction Pattern
Sleep-Rest Pattern
Sensory-Perceptual Pattern

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 NANDA. Cont…

Cognitive Pattern
Role-Relationship Pattern
Self-Perception-Self- Concept
Pattern
Coping-Stress Tolerance Pattern
Value-Belief Pattern
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Health Perception-Health
Management Pattern

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Purpose:
The purpose of assessing the client's health
Perception health maintenance pattern is
to determine how the client perceives and
manage his/her current and past nursing
and, medical recommendations.
The client's ability to perceive the
relationship between activities of daily
living and health is also determined
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 Subjective Data:
Guideline Questions
Client perception of health
Describe your health.
How would you rate your health on a scale of 1 to 10 (10 is
excellent) now, 5 years ago, and 5 years ahead?
Client perception of illness.
Describe your illness or current health problem.
How has this affected your normal daily activities?
How do you feel your current daily activities have affected
your Health What do you feel caused your illness?
What course do you predict your illness will take?
How do you feel your illness should be treated?
Do you have or anticipate any difficulties in caring for
Yourself or other sat home? If yes, explain.
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 Guideline Questions. Cont..

Health management and habits

Tell me what you do when you have a health problem.
When do you seek nursing or medical advice?
How often do you go for professional exams (dental, Pap
Smears, breast, BP)?
What activities do you feel keep you healthy? Contribute to
illness?
Do you perform self-exams (blood pressure, breast,
testicular)?
When were your last immunizations? Are they up to date?
Do you use alcohol, tobacco, drugs? Describe the amount and
Length of time used Are you exposed to pollutants or toxins?
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 Compliance With Prescribed
Medications and Treatments
Have you been able to take your
prescribed medications? If not, what
caused your inability to do so?
Have you been able to follow through
with your prescribed nursing and medical
treatment (e.g., diet, exercise)? It not,
what caused your inability to do so?

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 Objective Data: Refer to General Physical Survey.
Associated Nursing Diagnoses Categories to
Consider
Health Seeking Behaviors
Effective Management of Therapeutic
Regimen
Risk for Injury
Risk for diagnoses
Risk for Suffocation
Risk for Poisoning
Risk for Trauma
Risk for Peri-operative Positioning Injury 9
 Actual Diagnoses

Energy Field Disturbance.

Altered Growth and Development.
Altered Health Maintenance.
Ineffective Management of Therapeutic
Regimen: Individual.
Ineffective Management of Therapeutic
Regimen: Family.
Ineffective Management of Therapeutic
Regime: Community Non compliance.
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Nutritional-Metabolic Pattern

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Purpose:
The purpose of assessing the client's
nutritional- metabolic pattern is to
determine the client dietary habits
and metabolic needs.
The conditions of hair, skin, nails,
teeth and mucous membranes are
assessed.
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 Subjective Data:
Guideline Questions
Dietary and Fluid Intake
Describe the type and amount of food you eat at
breakfast, lunch, and supper on an average day
Do follow any certain type of diet? Explain.
What time do you usually eat your meals?
Do you find it difficult to eat meals on time? Explain.
What types of snacks do you eat? How often?
Do you take any vitamin supplements? Describe.
Do you consider your diet high in fat? Sugar? Salt?

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 Subjective Data. Cont..

Do you find it difficult to tolerate certain foods? Specify.

What kind of fluids do you usually drink? How much per
day?
Do you have difficulty chewing or swallowing food?
When was your last dental exam? What were the result?
Do you ever experience sore throat, sore tongue, sore
gums? Describe
Do you ever experience nausea and vomiting?
Prescribe
Do you ever experience abdominal pains? Describe.
Do you use antacids? How often? What kind?

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 Condition of Skin

Describe the condition of your skin.

How well and how quickly does your
skin heal?
Do you have any skin lesions?
Describe-
Do you have excessive oily or dry skin?
Do you have any itching? What do you
do for relief?
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 Condition of Hair, Nails
Describe the condition of your hair, nails
Do you have excessively oily or dry hair?
Have you had difficulty with scalp itching or
sores?
Do you use any special hair or scalp care
products?
Have you noticed any changes in your
nails? Color
Cracking? Shape? Lines?
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 Metabolism
What would you consider to be your "ideal weight"?
Have you had any recent weight gains or losses?
Have you used any measures to gain or lose weight?
Describe.
Do you have any intolerance to heat or cold?
Have you noted any changes in your eating or
drinking habits? Explain.
Have you noticed any voice changes?
Have you had difficulty with nervousness?

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 Objective Data
Assess the client's temperature, pulse, respirations, and
height and weight.
Wellness Diagnoses

Opportunity to enhance nutritional

metabolic pattern
Opportunity to enhance effective
breast feeding
Opportunity to enhance skin
integrity
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 Actual Diagnoses
Decreased Adaptive Capacity: Intracranial.
Ineffective Thermo regulation.
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body requirements
Altered Nutrition: More than body requirements
Ineffective Breastfeeding
Interrupted Breastfeeding
Ineffective Infant Feeding Pattern Impaired Swallowing
Altered Protection
Impaired Tissue Integrity
Altered Oral Mucous Membrane
Impaired Skin Integrity.
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Elimination Pattern

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 Purpose:

The purpose of assessing the client's

elimination pattern is to determine the
adequacy of function of the client's bowel
and bladder for elimination. The client's
bowel and urinary routines and habits are
assessed .In addition, any bowel or
urinary problems and use of urinary or
bowel elimination devices are examined.
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 Subjective Data

Guidelines Questions
Bowel Habits
Describe your bowel pattern. Have there been any recent
changes?
How frequent are your bowel movements?
What is the color and consistency of your stools?
Do you use laxatives? What kind and how often do you use
them?
Do you use enemas? How often and what kind?
Do you use suppositories? How often and what kind?
Do you have any discomfort with your bowel movements?
Describe.
Have you ever had bowel surgery? What type? Ileostomy?
Colostomy?
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 Bladder Habits
Describe your urinary habits.
How frequently do you urinate?
What is the amount and color of your urine?
Do you have any of the following problems with
urinating:.
Pain? Blood in urine? Difficulty starting a stream?
Incontinence? Voiding frequently at night? Voiding
frequently during day? Bladder infections?
Have you ever had bladder surgery? Describe.
Have you ever had a urinary catheter? Describe.
When? How long?
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 Objective Data:

Refer to Abdominal
Assessment and the rectal
assessment.
Associated nursing-Diagnoses
Categories to Consider
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 Wellness Diagnoses

Opportunity to enhance
adequate bowel elimination
pattern
Opportunity to enhance
adequate urinary elimination
pattern
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 Risk Diagnoses

Risk for constipation

Risk for altered
urinary elimination

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 Actual Diagnoses
Altered Bowel Elimination Constipation
Colonic constipation
Perceived constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary
Retention
Total Incontinence
Functional Incontinence
Reflex Incontinence
Urge Incontinence
Stress Incontinence
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Activity- Exercise Pattern

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 Purpose
The purpose of assessing the client's activity-
exercise- pattern is to determine the client's
activities of daily living, including routines of
exercise, leisure, and recreation. This includes
activities necessary for personal hygiene, cooking,
shopping eating, maintaining the home, and
working. An assessment is made of any factors
that affect or interfere with the client's routine
activities of daily living. Activities are evaluated
in reference to the client's perception of their
significance in his or her life. 29
 Subjective Data
Guideline Questions
Activities of Daily Lining
Describe your activities on a normal day. (Including
hygiene, activities, cooking activities, shopping
activities, eating activities, house and yard activities,
other self-care activities.)
How satisfied are you with these activities?
Do you have difficulty with any of these self-care
activities? Explain.
Does anyone help you with these activities? How?
Do you use any special devices to help you with your
activities?
Does your current physical health affect any of these
activities e.g. dyspnea, shortness of breath,
palpations, chest pain. stiffness, weakness)? Explain. 30
 Leisure Activities
Describe the leisure activities you enjoy.
Has your health affected your ability to enjoy
your leisure? Explain.
Do you have time for leisure activities?
Describe any hobbies you have.
Exercise Routine:
Describe those activities that you feel give you
exercise.
How often are you able to do this type of
exercise?
Has your health interfered with your exercise
routine? 31
 Occupational Activities

Describe what you do to make a

living.
How satisfied are you with this job?
Do you feel it has affected your
health?
How has your health affected your
ability to work?
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Objective Data Refer to
Thoracic and Lung
Assessment; Cardiac
Assessment; Peripheral
Vascular Assessment; and
Musculoskeletal Assessment
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Associated Nursing Diagnoses
Categories to Consider

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 Wellness Diagnoses

Potential for enhance organized infant behavior

Opportunity to enhance effective cardiac output
Opportunity to enhance effective diversional activity
pattern
Opportunity to enhance effective activity-exercise
pattern
Opportunity to enhance effective home maintenance
management
Opportunity to enhance effective self-care activities
Opportunity to enhance adequate tissue perfusion
Opportunity to enhance effective breathing pattern
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 Risk Diagnoses

Risk for Disorganized Infant

Behavior
Risk for Peripheral Neurovascular
Dysfunction
Risk for altered respiratory
function
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 Actual Diagnoses
Activity Intolerance
Impaired Gas Exchange in effective Airway Clearance
Ineffective Breathing Pattern
Decreased Adaptive Intracranial Capacity
Decreased Cardiac Output
Disuse syndrome
Diversional Activity Deficit
Impaired Home Maintenance Management
Impaired Physical Mobility
Dysfunctional Ventilatory Weaning Response
Inability to Sustain Spontaneous Ventilation
Self-Care Deficit: (Feeding, Bathing/Hygiene,
Dressing/Grooming,
Toileting)
Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral,
and Cardiopulmonary. Renal, Gastrointestinal, Peripheral)
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Disorganized Infant Behavior
Sexuality-Reproduction
Pattern

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Purpose:
The purpose of assessing the client's sexuality
reproductive pattern is to determine the client’s
fulfillment of sexual needs and perceived level
of satisfaction. The reproductive pattern and
developmental level of the client is
determined, and perceived problems related to
sexual activities, relationships, or self-concept
are elicited. The physical and psychological
effects of the client's current health status, on
his or her sexuality or sexual expression are
examined.
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 Subjective Data
Guideline Questions
Female.
A. Menstrual history:
How old were you when you began menstruating? On
what date did your last cycle begin? How many days
dose your cycle normally last? How many days elapse
from the beginning of one cycle until the beginning of
another?
Have you noticed any change in your menstrual cycle?
Have you noticed any bleeding between your menstrual
cycles? Do you experience episodes of flushing; chilling,
or intolerance to temperature change? Describe any
mood changes or discomfort before, during, or after
your cycle. 40
B. Obstetric history:
How many times have you been pregnant? Describe
the outcome of each pregnancies if you have
children? What are the ages and sex of each?
Describe your feelings with each pregnancy. Explain
any health problems or concerns you had with each
pregnancy. If pregnant now,
Was this a planned or unexpected pregnancy?
Describe your feelings about this pregnancy.
What changes in your life-style do you anticipate
with this Pregnancy?
Describe any difficulties or discomfort you have had
with this Pregnancy.
How can I help you meet your needs during this
pregnancy? 41
2. Male/female
A. Contraception
What do you or your partner do to
prevent pregnancy? How acceptable is
this method to both of you? Do this
means of birth control affect your
enjoyment of sexual relations?
Describe any discomfort or undesirable
effects this method produces.
Have you had any difficulty with
fertility? Explain. Has infertility
affected your relationship with your
partner? Explain.
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B. Perception of sexual activities
Describe you sexual feelings.
How comfortable are you with your feelings of
femininity/masculinity?
Describe your level of satisfaction from your sexual
relationship (s) on scale of 1 to 10(with 10 being very
satisfying).
Explain any changes in your sexual relationship (s)
that you Would like to make.
Describe any pain or discomfort you have during
intercourse
Have you (has your partner) experienced any
difficulty achieving an orgasm or maintaining an
erection? If so, bow has this – affected your
relationship? 43
C. Concerns related to illness
How has your illness affected your sexual
relationships)? How comfortable are you discussing
sexual problems with your partner? Who would you
seek help from for sexual concerns?
D. Special problems
Do you have or have you ever had a sexually
transmitted disease? Describe.
What method do you use to prevent contracting a
sexually transmitted disease? Describe any pain,
burning, or discomfort you have while voiding.
Describe any discharge or unusual odor you have
from your penis/vagina. What is the date of your last
Pap smear?
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E. History of sexual abuse
Describe the time and place the incident
occurred.
Explain the type of sexual contact that
occurred.
Describe the person who assaulted you.
Identify any witnesses present.
Describe your feelings about this incident.
Have you had any difficulty sleeping, eating,
or working since the incident occurred?
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 Objective Data
Refer to Breast Assessment, Abdominal
Assessment, and urinary-Reproductive
Assessment
Associated nursing Diagnoses Categories to Consider
Wellness Diagnoses opportunity to enhance sexuality
patterns
Risk- Diagnoses
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
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Sleep-Rest Pattern

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Purpose:
The purpose of assessing the
client's sleep-rest pattern is to
determine the client perception of
the quality of his or her relaxation
and energy levels Methods used
to promote relaxation and sleep
is also assessed.
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 Subjective Data
Guideline Questions
Sleep Habits

Describe your usual sleeping time at home.

How would you rate the quality of your sleep?
Special Problems
Do you ever experience difficulty with falling asleep?
Remaining a sleep? Do you ever feel fatigued after a
sleep period?
Has your current health altered your normal sleep
habits? Explain.
Do you feel your sleep habits have contributed to
your current Illness? Explain.
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Sleeping Aids
What helps you to fall asleep?
Medications? Reading?
Relaxation technique?
Watching TV?
Listening to music?
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 Objective Data
1-Observe appearance
Pale
Puffy eyes with dark circles
2-Observe behavior
Awning.
Dozing during day
Irritability
Short attention span
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Associated nursing Diagnoses Category to Consider
Wellness Diagnoses
Opportunity to enhance sleep
Risk Diagnoses
Risk for sleep pattern disturbance
Actual Diagnosis:
sleeps Pattern Disturbance.

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Sensory-Perceptual
Pattern

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Purpose
The purpose of assessing the client's
sensory-perceptual pattern is to
determine the functioning status of five
senses: vision, hearing, smelling, taste
and touch, (including pain perception)
Devices and methods used to assist the
client with deficits in any of these five
senses are assessed

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 Subjective Data
Guideline Questions
Perception of Senses, describe your
ability to see, hear, feel, taste, and
smell.
Describe any difficulty you have with
your vision, hearing, and ability to feel
(e.g., touch, pain, heat, cold), taste
(salty, sweet, bitter, sour), or smell.
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 Pain Assessment
Describe any pain you have now.
What brings it on? What relieves it?
When does it occur? How often? How long
does it last?
What else do you feel when you have this
pain?
Show me where on this drawing [of a figure]
you have pain.
Rate your pain on a scale of 1 to 10, with 10
being the most severe Pain.
How has your pain affected your activities of
daily living?
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Special Aids
What devices (e.g., glasses, contact
lenses, hearing aids) or methods do
you use to help you with any of the
above problems?
Describe any medications you take
to help you with these problems.

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 Objective Data
Refer to the section on Nose, Sinus, Eye, and
Ear Assessment.
Associated Nursing Diagnoses Categories to
Consider
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses
Risk for pain, Risk for Aspiration
Actual Diagnoses
Pain, Chronic Pain and Dysreflexia.
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Cognitive Pattern

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Purpose
The purpose of assessing the
client's cognitive pattern is to
determine the client’s ability to
understand, communicate,
remember, and make decision.

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 Subjective Data
Guideline Questions
Ability to Understand
Explain what your doctor has told you about your
health: Do you feel you understand your illness and
prescribed care? What is the best way for you to learn
something new (read, watch TV, etc.)?
Ability to Communicate:
Can you tell me how you feel about your current state
of health? Are you able to ask questions about your
treatments, medications, and so forth? Do you ever
have difficulty expressing yourself or explaining
things to others?
Ability to Remember: Are you able to remember
recent event and events of long years ago? Explain.
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Ability to Make Decisions

Describe how you feel when faced with a

decision.
What assists you in making decisions?
Do you find decision making difficult,
fairly easy, or variable?

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 Objective Data
Refer to the Mental Status Assessment
Associated nursing Diagnoses Categories
to Consider
Wellness Diagnosis:
Opportunity to enhance cognition
Risk Diagnoses:
Risk for altered thought processes
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 Actual Diagnoses

Acute confusion
Chronic Confusion
Decisional Conflict
Impaired Environmental Interpretation
Syndrome
Knowledge Deficit (Specify)
Altered Thought Processes
Impaired Memory
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Role-Relationship Pattern

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 Purpose
The purpose of assessing the client's role-
relationship pattern is to determine the
client’s perceptions of responsibilities and
roles in the family, at work, and in social
life.
The client's level of satisfaction with these
is assessed. In addition, any difficulties in
the client's relationships and interactions
with others are examined.
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 Subjective Data
Guideline Questions
Perception of Major Roles and Responsibilities in Family
Describe your family.
Do you live with your family? alone?
How does your family get along?
Who makes the major decisions in your family?
Who is the main financial supporter of your family?
How do you feel about your family?
What is your role in your family? Is this an important role?
What is your major responsibility in your family? How do you
feel about this responsibility?
How does your family deal with problems?
Are there any major problems now?
Who is the person you feel closest to in your family? Explain.67
 Subjective Data. Cont…
How is your family coping with your current state of health?
Perception of Major Roles and Responsibilities at Work
Describe your occupation.
What is your major responsibility at work? How do you feel
about those you work with?
What would you change if you could about your work?
Are there any major problems you have at work?
Perception of Major Social Roles and Responsibilities
Who is the most important person in your life? Explain.
Describe your neighborhood and the community in which you
live.
How do you feel about the people in your community?
Do you participate in any social groups or neighborhood
activities?
What do you see as your contribution to society?
What about your community would you change if you could? 68
 Objective Data

Outline a family genogram for your client.

Observe your client's family members.
How do they communicate with each
other?
How do they respond to the client?
Do they visit, and how long do they stay
with the client?
69
Associated Nursing Diagnoses Categories to
Consider
Wellness Diagnoses
Opportunity to enhance effective relationships
Opportunity to enhance effective parenting
Opportunity to enhance effective role
performance
Opportunity to enhance effective
communication
Opportunity to enhance effective social
interaction.
Opportunity to enhance effective caregiver role
Opportunity to enhance effective grieving
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Risk Diagnoses
Risk for dysfunctional grieving, High risk for
Loneliness.
Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses
Impaired Verbal Communication
Altered Family Processes: Alcoholism
Anticipatory Grieving
Dysfunctional Grieving?
Altered Parenting
Parental Role Conflict
Altered Role Performance
Impaired Social Interaction: Social Isolation
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Self-Perception-Self-Concept
Pattern

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Purpose
The purpose of assessing the client's
self-perception-self- concept pattern
is to determine the client’s perception
of his or her identity, abilities, body
image, and self worth. The client's
behavior attitude, and emotional
patterns are also assessed

73
 Subjective Data
Guideline Questions
Perception of Identity:
Describe yourself.
Has your illness affected how you describe
yourself?
Perception of Abilities and Self-Worth:
What do you consider to be your strengths?
Weaknesses? How do you feel about
yourself?
How does your family feel about you and
your illness?
74
Body Image
How do you feel about your
appearance?
Has this changed since your illness?
Explain.
How would you change your
appearance if you could?
How do you feel about other people
with disabilities? 75
 Objective Data

Refer to the procedures for observing

appearance, mood under the Mental Status
assessment.
Associated Nursing Diagnoses Categories to
Consider
Wellness Diagnoses
Opportunity to enhance self-perception
Opportunity to enhance self-concept
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Risk Diagnoses
Risk for hopelessness
Risk for body image disturbance
Risk for low self esteem
Actual Diagnoses
Anxiety fatigue - Fear - Hopelessness-
Powerlessness- Personal Identity.
Disturbance - Body Image
Disturbance- self Esteem
Disturbance.
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Coping-Stress Tolerance Pattern

78
Purpose:
The purpose of assessing client’s coping –
stress tolerance pattern is to determine the
areas and amount of stress in a client’s
life and the effectiveness if coping
methods used to deal with it Availability
and use of support systems such as
family, friends, and religious believes are
assessed.
79
 Subjective Data

Guideline Questions
Perception of Stress and Problems in Life
Describe what you believe to be the most
stressful situation in your life. How has your
illness affected the stress you feel? Or how
do you feel stress has affected your illness?
Has there been a personal loss or major
change in your life over the last year?
Explain. What has helped you to cope with
this change or loss? 80
 Subjective Data. Cont…
Coping Methods and Support Systems
What do you usually do first when faced
with a problem? What helps you to
relieve stress and tension? To whom do
you usually turn when you have a
problem or feel under pressure? How do
you usually deal with problems? Do you
use medication, drugs, or alcohol to help
relieve stress? Explain.
81
 Objective Data
Refer to the Mental Status Assessment.
Associated nursing Diagnoses Categories to
Consider
Wellness Diagnoses
Opportunity to enhance effective
individual coping.
Opportunity to enhance family coping
Potential for Enhanced Spiritual Well
Being.
Potential for Enhanced Community
coping. 82
 Objective Data. Cont…
Risk Diagnoses
Risk for ineffective coping (individual,
family, or community)
Risk for self-harm
Risk for self- abuse.
Risk for Self-Mutilation
Risk for suicide
Risk for Violence; Self- directed or
directed at others 83
 Objective Data. Cont…

Actual Diagnoses
Impaired Adjustment
Ineffective Individual Coping
Ineffective Family Coping: Disabling
Ineffective Family Coping: Compromised
Ineffective Community Coping: Post-Trauma
Response,
Rape-Trauma Syndrome Relocation and Stress
Syndrome.
84
Value-Belief Pattern

85
Purpose
The purpose of assessing the client's value-
belief pattern is to determine the client’s
life values and goals, philosophical,
religious beliefs, and spiritual beliefs that
influence his or her choices and
decisions. Conflicts between these
values, goals, beliefs, and expectations
that are related to health are assessed
86
 Subjective Data
Guideline Questions
Values Goals? And Philosophical beliefs
What is most important to you in Life?
What do you hope to accomplish in your life?
What is the major influencing factor that helps you make decisions?
What is your major source of hope and strength in life?
Religious and Spiritual Beliefs:
Do you have a religious affiliation? Is this important to you? *
Are there certain health practices or restrictions that are important for you
to follow while you are ill or hospitalized? Explain.
Is there a significant person (e.g., minister, priest) from your religious
denomination whom you want to be contacted?
Would you like the hospital chaplain to visit?
Are there certain practices (e.g., prayer, reading scripture) that are important
to you?
Is a relationship with God an important part of your life? Explain.
Do you have another source of strength that is important to you?
How can I help you continue with this source of spiritual strength while you
are ill in the hospital?
87
 Objective Data
1-Observe religious practices
Presence of religious articles in room (e.g., Bible, cards,
medals, Statues)
Visits from clergy
Religious actions of client: prayer, visit to chapel, request for
clergy, watching of religious TV programs or listening to
religious radio stations
2-Observe client's behavior for signs of spiritual distress.
Anxiety
Anger
Depression
Doubt
Hopelessness
Powerlessness
88
Associated Nursing Diagnoses Category
to Consider
Wellness Diagnosis
Potential for Enhanced Spiritual Well-
Being
Risk diagnosis
Risk for spiritual distress
Actual Diagnosis
Spiritual disturbance (distress of the human
spirit). 89
 THE END
THANK YOU

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