FUNCTIONAL HEALTH PATTERN USUAL INITIAL

1. Health Perception-health
Management Pattern
 How would you usually
describe your health?
(Excellent, Good, Fair, Poor)
 How would you describe
your health at this time?
 What do you do to keep
healthy and to prevent
disorders in yourself? In your
children?
 Adequate Nutrition
 Ability to eat
 Food/fluid
consumption
 Exercise program
 Self-exam (breast, testicular)
 Reason for and
expectation of
hospitalization and
previous hospital
experience)
 Describe your illness
(cause, onset)
 What treatment or practices
have been prescribed? (diet,
weight loss, medications,
surgery, cessation of
smoking, exercise)
 Have you been able to follow
the prescribed instructions? If
not, what has prevented you?
 Have you experienced or do
you anticipate a problem with
caring for yourself (your
children, your home)?
mobility problems, sensory
deficits (vision, hearing),
financial concerns, structural
barriers (stairs, narrow
doorways)
2. Nutritional-Metabolic Pattern
 What is the usual daily intake
(meals, snacks)?
 What is the usual fluid intake
(type, amount)?
 How is your appetite?
(indigestion, nausea,
vomiting, sore mouth)
 What are your food
restrictions or preferences?
 Any supplements (vitamins,
feeding)?
 Has your weight changed in
the last 6 months? If yes,
why?
 Any problem with ability to
eat? (swallow liquid, swallow
solids, chew, feed self)

3. Elimination Pattern
Bladder
 Are there any problems or
complaints with the usual
pattern of urinating?
(oliguria, polyuria, dysuria,
dribbling, retention, burning,
incontinence)
 Are assistive device used?
(intermittent catheterization,
catheter (Foley, external),
incontinent briefs
Bowel
 What is the usual time,
frequency, color, consistency
pattern?
 Assistive device (type,
frequency)? (Ileostomy,
colostomy, enemas,
cathartics, laxatives,
suppositories)
Skin
What is the skin condition? (color,
temperature, turgor, edema (type and
location), lesion (type, description,
location)
4. Activity-Exercise Pattern
 Describe usual daily/weekly
activities of daily living.
(occupation, leisure activities,
exercise pattern (type,
frequency)
 Are there any limitations in
ability? Ambulating (gait,
weight-bearing, balance),
bathing self (shower, tub),
toileting (commode, toilet,
bedpan)
 Are there complaints of
dyspnea or fatigue?

5. Sleep-Rest Pattern
 What is the usual sleep
pattern? (bedtime, hours
slept, sleep aids (medication,
food), sleep routine)
 Any problems? (difficulty
falling asleep, difficulty
remaining asleep, not feeling
rested after sleep)

6. Cognitive-Perceptual Pattern
 Any deficits in sensory
perception (hearing, sight,
touch)? Glasses, hearing aid
 Any complaints? Vertigo,
insensitivity to superficial
pain, insensitivity to cold or
heat
 Able to read and write?

7. Self-Perception Pattern
 What are you most
concerned about?
 What are your present health
goals?
 How would you describe
yourself?
 Has being ill made you feel
differently about yourself?
 To what do you attribute the
following? (becoming ill,
getting better, maintaining
health)
8. Role-Relationship Pattern
Communication
 What language is spoken?
 Is speech clear? Relevant?
 Assess ability to express self
and understand others
(verbally, in writing, with
gestures)
Relationships
 Do you live alone? If not,
with whom?
 Who do you turn to for help
in time of need?
 Assess family life (members,
educational level,
occupations). Cultural
background, activities (lone
or group), roles discipline,
decision-making
communication patterns,
finances
 Any complaints? Parenting
difficulties, difficulties with
relative (in-laws, parents),
marital difficulties, abuse
(physical, verbal, substances

9. Sexuality-Sexual Functioning
 Has there been or do you
anticipate a change in your
sexual relations because of
your condition? Fertility,
Libido, Erections,
Menstruation, Pregnancy,
Contraceptive, History
 Assess knowledge of sexual
functioning.

10. Coping-Stress Management

Pattern
 How do you make decision
(alone, with assistance, who)?
 Has there been a loss in your
life in the past year (or
changes-moves, job, health)?
 What do you like about
yourself?
 What would you like to
change in your life?
 What is preventing you?
 What do you do when you are
tense or under stress
(problem-solve, eat, sleep,
take medication, seek help)?
 What can the nurse do to
provide you with more
comfort and security during
your hospitalization?

11. Value-Belief System

 With what (whom) do you
find a source of strength or
meaning
 Is religion of God important
to you?
 What are your religious
practices (type, frequency)
 Have your values or moral
beliefs been challenged
recently? Describe?
Is there a religious person or practice
(diet, book, ritual) that you would
desire during hospitalization
(institutionalization)?
Baptism?
AREA SYSTEM FINDINGS
General:
Usual weight, recent weight change, any clothes that fit
more tightly or loosely than before. Weakness, fatigue, or
fever.

Skin:
Rashes, lumps, sores, itching, dryness, changes in color;
changes in hair or nails; changes in size or color of moles
Head, Eyes, Ears, Nose, Throat (HEENT):
 Head: Headache, head injury, dizziness,
lightheadedness.
 Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing,
double or blurred vision, spots, specks, flashing
lights, glaucoma, cataracts.
 Ears: Hearing, tinnitus, vertigo, earaches,
infection, discharge. If hearing is decreased, use
or nonuse of hearing aids.
 Nose and sinuses: Frequent colds; nasal
stuffiness, discharge, or itching; hay fever;
nosebleeds; sinus trouble.
 Throat (or mouth and pharynx): Condition of
teeth and gums; bleeding gums; dentures, if any,
and how they fit; last dental examination; sore
tongue; dry mouth; frequent sore throats;
hoarseness.

Neck:
“Swollen glands”; goiter; lumps, pain, or stiffness in the
neck.

Breasts:
Lumps, pain, or discomfort; nipple discharge; self-
examination practices; last mammogram.

Respiratory:
Cough, sputum (color, quantity), hemoptysis, dyspnea,
wheezing, pleurisy, last chest x-ray. You may include
asthma, bronchitis, emphysema, pneumonia, and
tuberculosis.

Cardiovascular:
Heart trouble, high blood pressure, rheumatic fever, heart
murmurs; chest pain or discomfort; palpitations, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, edema; results
of past electrocardiograms or other cardiovascular tests.

Gastrointestinal:
Trouble swallowing, heartburn, appetite, nausea. Bowel
movements, stool color and size, change in bowel habits,
pain with defecation, rectal bleeding, black or tarry stools,
hemorrhoids, constipation, diarrhea. Abdominal pain, food
intolerance, excessive belching or passing of gas.
Jaundice, liver, or gallbladder trouble; hepatitis

Peripheral vascular:
Intermittent claudication; leg cramps; varicose veins; past
clots in the veins; swelling in calves, legs, or feet; color
change in fingertips or toes during cold weather; swelling
with redness or tenderness.

Urinary:
Frequency of urination, polyuria, nocturia, urgency,
burning or pain during urination, hematuria, urinary
infections, kidney or flank pain, kidney stones, ureteral
colic, suprapubic pain, incontinence; in males, reduced
caliber or force of the urinary stream, hesitancy, dribbling.

Female Reproductive:
 Age at menarche; regularity, frequency, and
duration of periods; amount of bleeding; bleeding
between periods or after intercourse; date of last
menstrual period; dysmenorrhea; premenstrual
tension. Age at menopause, menopausal
symptoms, postmenopausal bleeding.
 Vaginal discharge, itching, sores, lumps, sexually
transmitted diseases and treatments. Number of
pregnancies, number and type of deliveries,
number of abortions (spontaneous and induced),
complications of pregnancy, birth control
methods. Sexual preference, interest, function,
satisfaction, any problems, including dyspareunia.
Concerns about HIV infection. Human
papillomavirus infection or vaccine (HPV).

Musculoskeletal
Muscle or joint pain, stiffness, arthritis, gout, backache. If
present, describe location of affected joints or muscles,
any swelling, redness, pain, tenderness, stiffness,
weakness, or limitation of motion or activity; include
timing of symptoms (e.g., morning or evening), duration,
and any history of trauma. Neck or low back pain. Joint
pain with systemic features such as fever, chills, rash,
anorexia, weight loss, or weakness.

Psychiatric:
Nervousness; tension; mood, including depression,
memory change, suicide attempts.

Neurologic:
Headache, dizziness, vertigo; fainting, blackouts, seizures,
weakness, paralysis, numbness or loss of sensation,
tingling or “pins and needles,” tremors or other
involuntary movements; seizures. Changes in mood,
attention, or speech; changes in orientation, memory,
insight, or judgment.

Hematologic:
Anemia, easy bruising or bleeding, past transfusions,
transfusion reactions.

Endocrine:
Thyroid issues, heat or cold intolerance, excessive
sweating, excessive thirst or hunger, polyuria, change in
glove or shoe size.
Health History

DEMOGRAPHIC PROFILE
Name:
Address:
Age:
Contact number:
Contact person:
Date of Birth:
Place of Birth:
Sex:
Nationality:
Religion:
Marital Status:
G/P:
Educational Level:
Occupation:
Health Insurance:
Source and Reliability:

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

1. Onset.
When did (does) it start? Setting in which it occurs,
including environmental factors, personal activities,
emotional reactions, or other circumstances that may have
contributed to the illness.

2. Location.
Where is it? Does it radiate?

3. Duration.
How long does it last?

4. Characteristic Symptoms.
What is it like? How severe is it? (For pain, ask a rating
on a scale of 1 to 10.)

5. Associated Manifestations.
Have you noticed anything else that accompanies it?

6. Relieving/Exacerbating Factors.
Is there anything that makes it better or worse?
7. Treatment.
What have you done to treat this? Was it effective?

Past Health History

Allergies
 Allergies, including specific reactions to each
medication, such as rash or nausea, must be
recorded. Allergies to foods, insects, or
environmental factors along with the patient’s
reaction should also be noted.
Medications
 Medications, including name, dose/route, and
frequency of use, are included. Also list home
remedies, nonprescription drugs vitamins, mineral
or herbal supplements, oral contraceptives, and
medicines borrowed from family members or
friends. If the patient is unsure, ask him or her to
bring in all medications to see exactly what is
taken
Childhood illnesses
Childhood illnesses, such as measles, rubella, mumps,
whooping cough, chickenpox, rheumatic fever, scarlet
fever, and polio, are
Adult Illnesses
 Medical: Illnesses such as diabetes, hypertension,
hepatitis, asthma, or HIV; hospitalizations
 Surgical: Dates, reasons for surgery, and types of
operations or treatments
 Accidents: type, dates, treatment and residual
disability of major accidents
 Psychiatric: Illness and time frame,
hospitalizations, and treatments

Health Maintenance
 Immunizations: Ask whether the patient has
received vaccines for tetanus, pertussis,
diphtheria, polio, measles, mumps influenza,
varicella, hepatitis B, Haemophilus influenzae
type B, Neisseria meningitides meningitis, and
pneumococci. Include the dates of original and
booster immunizations.
 Screening Tests: Such as tuberculin tests,
cholesterol tests, stool for occult blood, Pap
smears, and mammograms. Include the results and
the dates the tests were performed. Alternatively,
screening tests may be asked about during and
documented in the Review of Systems.
 Safety Measures: Seat belts in cars, smoke/carbon
monoxide detectors, sports helmets or padding,
etc.
 Risk Factors: Tobacco: Do you use or have you
ever used tobacco? At what age did you start?
How many packs per day (ppd) do you smoke?
How many ppd in the past?
 Environmental Hazards: In home or
work environment?
 Substance Abuse: Do you use or have
you ever used marijuana, cocaine, heroin,
or other recreational drugs?
 Alcohol: How much alcohol do you drink
per sitting and per week?
Travel History
Childhood Illness:

Hospitalization and surgeries:

Serious Injuries:

Serious or Chronic Illness:

Immunization:

Allergies:

Medication:

Travel:
CEPHALOCAUDAL ASSESSMENT
AREA FINDINGS
GENERAL SURVEY

VITAL SIGNS

SKIN

NAILS

HEAD HAIR FACE

EYES

EYELIDS

EARS

NOSE AND SINUSES

MOUTH
Lips
Gums and muscosa
Teeth
Hard Palate
Tongue
Pharynx

Neck

Trachea and thyroid

Chest

Heart

Axilla

Abdomen
Breast