Barthel

APPENDIX A

A.BETTY NEUMAN SYSTEM MODEL

Note:This is an interview guide based on the system model by Betty Neuman .This tool was
constructed for comprehensiveevaluation of the client’s overall health condition.
A.Intake Summary
1.Name:
Age:
Sex:
Marital Status

B.Stressors as Perceived by the Client

(If client is incapacitated,secure data from family or other resources.)
1.What do you consider your major stress are or areas of health concerns?
2.How do you present circumstance differ from your usual pattern of living
3.Have you experienced a similar problem?If so,what was the problem and how did you
handle it?Were you successful?
4.What do you anticipate for yourself in the future as a consequence of your present
situation?
5.What are you doing and what you can do to help yourself?
6.What do you expect caregivers,family,friends,or others do for you.
C.Stressors as Perceived By caregiver

1.What do you consider your major stress area or areas of health concern?
2.How do you present circumstances differ from the client’s usual pattern of living?
3.Has the client ever experienced a similar problem?If so ,how would you evaluate .
What the client did?How successful do you think it was?
4.What do you anticipate for the future as a consequence of the clients present
situation?
5.What can the client do to himself?
6.What do you think the client expects from caregivers,family,friend or other resources?
Summary of Impressions
Note:Any discrepancies or distortions between the client’s perception and of that caregiver
related to the situation.
D.Intrapersonal Factors
1.Physical (Degree of mobility,range of Body Function)
2.Psyco-sociocultural(attitudes,values,expecattions,behavior,patterns and natural
coping patterns
B.GORDON’S FUNCTIONAL HEALTH PATTERN

:
(1) Health Perception and Health Management Pattern:
Data collection is focused on the person's perceived level of health and well-being, and
on practices for maintaining health.
• What is your opinion about health?
• Are you immunized about seven target diseases?
• Last immunization?
• Do you have any allergy? If yes then type of allergy.
• Any surgery in past? What type of surgery?
• Last physical examination & for what purpose.
• Are you using any medicine recently? • Do you know about these medicines?
(2) Nutrition and Metabolism Pattern:

Assessment is focused on the pattern of food and fluid consumption relative to
metabolic need.
• Ask about their skin, scalp and nails?
• What is your diet menu?
• Any food restriction regarding disease point of view?
• Any food restriction regarding religious point of view?
• Any food like or dislike?
• Any food allergy?
(3) Elimination Pattern:

Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory
problems such as incontinence, constipation, diarrhea, and urinary retention.
Urine:
• Color of urine, amount, frequency, odor and any discharge. Any urinary problem,
dysurea, Anurea, Oligourea, , polyuria.
Defecation:
• Are you using any laxative? If yes which?
• Any problem during passing defecation?
(4) Activity and Exercise Pattern:

Assessment is focused on the activities of daily living requiring energy expenditure,
including self-care activities, exercise, leisure activities respiratory and cardiac system
. • Do you any breathing problem? In which apnea, hypoxia, hypoxemia, hypercapnia.
• Do you have cough? (Productive or non productive)
• Any changes in heart beat during exercise?
• Do you feel pale during exercise? • What type of exercise you do or any problem
during exercise?
(5) Cognition and Perception Pattern:

Assessment is focused on the ability to thinking, decision making, and problem solving.
• Orientation about time place and person.
• Any difficulty in sentence making?
• Loss of memory.
(6) Sleep and Rest Pattern:
Assessment is focused on the person's sleep, rest, and relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be
identified.
• Sleeping hour?
• Are you using nap (evening type sleeping).
• What do you feel after waking? (Fresh, headache, drowsy).
• Are you using any medication for sleeping? • Do you have any exercise or walking at
night?
(7) Self-Perception and Self-Concept Pattern:

Assessment is focused on the person's attitudes toward self, including identity, body
image, and sense of self-worth.
• What is your self perception about yourself?
• Are you satisfied with your self body image?
• Do you like grooming?
(8) Roles and Relationships Pattern: Assessment

is focused on the person's roles in the family and relationships with others.
• What is your role in family?
• If you are in hospital then who will perform your responsibilities?
• All the family members are cooperative with you?
• Who is decision maker in your family?
(9) Sexuality and Reproduction Pattern:

Assessment is focused on the person's satisfaction or dissatisfaction with sexuality
patterns and reproductive functions.
• When you first notice changes in your menarche (first menses is called menarche) •
Do you have any sexual problem? (loss of libido)
• Active sex (direct sex with male and female) Passive sex (sex without male and female
partner) Digital sex (Artificial dimy etc)
• Reproductive: Infertility
(10) Coping and Stress Tolerance Pattern: Assessment is focused on the person's
perception of stress and on his or her coping strategies Support systems are evaluated,
and symptoms of stress are noted.
• If you have stress then what is your coping mechanism towards stress? Crying, angry,
violence, (what is your opinion regarding that)
(11) Values and Belief Pattern: Assessment is focused on the person's values and beliefs
(including spiritual beliefs).
• What is your religion?
• Do you offer prayer?
C.BARTHEL INDEX OF ACTIVITIES OF DAILY LIVING
THE Patient Name: ___________________________

BARTHEL Rater Name: ___________________________
INDEX Date: ___________________________
Activity Score
FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent ______
BATHING
0 = dependent
5 = independent (or in shower) ______
GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided) ______
DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.) ______
BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent ______
BLADDER
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent ______
TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping) ______
TRANSFERS (BED TO CHAIR AND BACK)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
MOBILITY (ON LEVEL SURFACES)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards ______
STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
TOTAL (0–100): ______
Provided by the Internet Stroke Center — www.strokecenter.org
The Barthel ADL Index: Guidelines
1. The index should be used as a record of what a patient does, not as a record of what a
patient could do.
2. The main aim is to establish degree of independence from any help, physical or verbal,
however minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient's performance should be established using the best available evidence. Asking
the patient, friends/relatives and nurses are the usual sources, but direct observation and
common sense are also important. However direct testing is not needed.
5. Usually the patient's performance over the preceding 24-48 hours is important, but
occasionally longer periods will be relevant.
6. Middle categories imply that the patient supplies over 50 per cent of the effort.
7. Use of aids to be independent is allowed.
8. Provided by the Internet Stroke Center — www.strokecenter.org

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APPENDIX A

A.BETTY NEUMAN SYSTEM MODEL

B.Stressors as Perceived by the Client

C.Stressors as Perceived By caregiver

B.GORDON’S FUNCTIONAL HEALTH PATTERN

(2) Nutrition and Metabolism Pattern:

(3) Elimination Pattern:

(4) Activity and Exercise Pattern:

(5) Cognition and Perception Pattern:

(7) Self-Perception and Self-Concept Pattern:

(8) Roles and Relationships Pattern: Assessment

(9) Sexuality and Reproduction Pattern:

C.BARTHEL INDEX OF ACTIVITIES OF DAILY LIVING

THE Patient Name: ___________________________

Provided by the Internet Stroke Center — www.strokecenter.org

The Barthel ADL Index: Guidelines

8. Provided by the Internet Stroke Center — www.strokecenter.org

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