FUNCTIONAL HEALTH PATTERNS ASSESSMENT TOOL (Patient’s Profile)

Student____Angelo Gabriel Regalado Date____10/28/20____

Patient's Initials_______Mr KJ____________ Male__/__ Female_____ Age__21____
Medical Diagnosis__Community Acquired Pneumonia, High Risk , Anaphylactic Reaction__________
Reason for seeking health care____Sleeplessness due to Shortness of Breath_______________

1. HEALTH PERCEPTION-HEALTH MANAGEMENT

Past medical history:
Illnesses :__None__________________________
Surgery: ______Appnedoctomy ________________________________________
History of chronic disease: ______None__________________________
Immunization History: ( Please check all that applies)
__/__ Tetanus___/___ Pneumonia___/__ Influenza___/__ MMR___/___ Polio ___/___ Hepatitis B

Use of Tobacco:_
__/_ None –Quit (date___x__<1ppd__x__1-2ppd__x_ >2pks/day _x__Packs/yr history__
__x___smokeless tobacco) __x__ pipe __x___cigar
Alcohol: Amount/type______beer _______ Date of last drink____not mentioned____
Frequency of use __________2 per night__________________
Other drugs: Amount/Type: __________none____________Freq. of Use :____x___

Medication Dose Frequency of Use Last Dose

(prescription/Nonprescription)
Name

Salbutamol +ipratropium 1 neb in 3 Every 15 mins. -

doses

Paracetamol 300 mg After Sulbutamol + -

ipratropium

Ceftriaxone
1 gm
Started through ANST -

2. NUTRITIONAL-METABOLIC
____Not Assessed
____Ht.__72 kg__ Wt. _______None________________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
_None______lesions/ulcerations describe__________________ teeth /gums___________________
__None____ Dentures ____upper (partial/full)_______lower(partial/full)
___Yes___Intravenous fluids type/amount_______d5 plain NSS__1 liter_________________
Insertion Site:____________________________________________________________
__None____NG___None_____ Gastrostomy
Skin Condition: __normal__color: pallor, ashen, pink, jaundice, cyanotic, ruddy
__hot__ temperature: warm, cool, hot
__moist__dry, moist, clammy, diaphoretic
__non-pitting__edema: pitting/non-pitting
__NONE__turgor: good, poor, tenting
__NONE__pruritus
__NONE__intact
__NONE__bruises/lesions describe: (size, location)___________________________

Body temperature:___/___ tympanic ______oral _____rectal

3. ELIMINATION
__/__Not Assessed
Bowel Habits Describe:___________-________________________(consistency, color, amount)
___-____#BM's/day___-___ Date of last BM
___-____ Constipation ___-__Diarrhea ____-___Incontinence

Bladder Habits Describe:_______LIGHT YELLOW____________________(color, clarity, amount)

___-__Frequency __-__Dysuria __-__Nocturia __-___Urgency __-_____Hematuria
__-__Retention ___-__ Burning ___-___Hesitancy ____-____Pressure
Incontinency: __/_No ___Yes ___-___daytime _____-___ nightime
___-_____ occasional ___-___difficulty delaying voiding

Assistive Devices: __-___intermittent catheterization ___-___indwelling catheter

___-___external catheter________-____ incontinent briefs
Ostomy: type: ______-__ ____Appliance ___-___self-care
Inspect Abdomen:_____ symmetry_____ flat___/__ rounded_______ obese
Auscultate Abdomen:____/__ normal bowel sounds ______Hypoactive______ Hyperactive
Palpate abdomen:___/__ soft__/__ firm__Non Tender_ tender : describe_________________
__NO DISTENTION___ distention: describe:_____________________________________

4. ACTIVITY-EXERCISE
___/___Not Assessed
4. 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:__________________________________(describe)
Amputation__________-______________Prosthesis______-___________________
Physical Development Assessment :__/___normal _______abnormal
Describe:_________________-_____________________
B. CV
_____Not Assessed
Pulse: ___/__regular __-__irregular ___-___strong __-___weak
___112__radial rate ___-__apical rate
Blood Pressure:___-___ standing ____-___lying ___130/75___sitting
Extremities: Temperature: _-__cold _-__cool __-__warm __/___hot
Capillary Refill: ___/__brisk __-__sluggish
Color:________-_____________(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 __24_rate _shallow__depth (shallow, deep, abdominal, diaphragmatic)
___regular __/_irregular ___periods of apnea
____ dyspnea at rest ____orthopnea ____ dyspnea on exertion
___productive____Cough:dry/productive describe______has sputum_ _________
___/____Sputum: describe____________yellowish_____________

Auscultate chest: ____/___crackles _______ rhonchi ______friction rub _______wheezing

describe:____________Bilateral_______________________________ -
Other :____-___chest tube___-____ tracheostomy Describe:________-________________
______________________________________________________________________
Oxygen:____________5L/MIN ___________________________________________________

5. SLEEP-REST
____/____Not Assessed
Usual Sleep Habits: ___-__hours per night ___-___consecutive hours slept per noc
_-___a.m. nap ____-____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: _ok__person _ok__place __ok__time _ok___significant other
Memory: recent: __/_yes ___no Remote: _/_yes __no
Pupils: _normal___size __brisk__Reaction (brisk/sluggish)
Reflexes: __/___normal _____absent
Grasps: ___strong___Right: strong/weak ___strong___left: strong/weak
Push/Pulls: __strong____right: strong/weak __strong___left: strong/weak
Other: __none___numbness ___none__tingling
Pain :__-__Denies
__-__Location: describe: ________________________
__-__Radiation: describe:________________________
__-__Intensity: (0-10 scale)
__-__Timing (how often, events that percipitate)
When did pain begin?_____________-___________________________
What alleviates pain?______________-__________________________
What increases pain?_____________-___________________________
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__/____ 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____-___________

(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____-____________________________________________________
Eye contact:
Answers questions: ____/_____readily __________hesitantly
Usual view of self_____ positive ____/__neutral _______somewhat negative (subjective)
Level of control in this situation_____9_______(0-10) (subjective)
Usual level of assertiveness_______9________(0-10) (subjective)
Body Image: Is current illness going to result in a change in body structure or function?
_____no _______unsure ___/__yes describe: _____pale and weak_________(subjective)

8. ROLE-RELATIONSHIP
______Not Assessed
Does patient live alone __/__yes ____no: with whom_________________________
Married_____Divorce_______ Children_______3 children___________________
Next of Kin_________________-____________________________
Occupation:_______________furniture dealer______________________________

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)_________kinda good__________________________ __________

Question patient regarding:

Concerns about illness:________________none______________________________________
_________________________________________________________________________
Will admission cause significant changes in usual role?___________probably and it depends on
the recovery___________________
__________________________________________________________________________

Social activities: _______active _____/___limited _______none

Activities participated in:______________-______________________________________________
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 ____-___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:__________-_____________________________