FUNCTIONAL HEALTH PATTERNS

ASSESSMENT TOOL

Nursing Practicum____ Student: Ma. Christine Rose T. Orbase

Date: 9-12-12

Patient's Initials: M.I.R Male: / Female: Age: 64 y/o

Medical Diagnosis: Acute Coronary Syndrome
Reason for seeking health care: dizziness and chest pain

1. HEALTH PERCEPTION-HEALTH MANAGEMENT

Past medical history:

Illnesses: known hypertensive
Surgery: none
History of chronic disease: none
Immunization History: / Tetanus __ Pneumonia / Influenza __ MMR
/ Polio / Hepatitis B

Use of Tobacco:____ None -Quit(date / <1ppd____1-2ppd___ >2pks/day ___

Pks/yr history__
_____smokeless tobacco)____pipe / cigar
Alcohol: Amount/type: Malt beer Date of last drink: 8 - 1- 12

Other drugs:
Amount/Type: none Freq. Of Use :________________________

Medication (prescription/Nonprescription)

Name Dose Frequency of Use Last Dose

Atorvastatin 80mg/tab once a day 9-11-12

Lactulose 30 cc once a day 9-11-12
Losartan 50mg/tab once a day 9-11-12
Amlodipine 5mg/tab once a day 9-11-12
Clopidrogrel 75mg/tab once a day 9-11-12

Allergies: NKA
Perception of health: / good ___ fair ___poor
Health Management Habits:
Exercise on a regular basis? __ Yes / No
Follow prescribed regimen? ___Yes / No
Safety: ____Special Equipment ___precautions / Side rails ___Restraints
Question for following: use of seat belt, car seats for kids, breasts/testicular self examination,
safe working conditions: safe working conditions
Home Health in last semester safe environment in home i.e.: smoke detectors, access to home
(stairs), throw rugs/carpets, cleanliness, health issues observed: Good with stairs at home

2. NUTRITIONAL-METABOLIC
____Not Assessed
180 cm Ht. 80 kg Wt. ___Weight fluctuations 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 __ inflamed __moist ___dry ___lesions/ulcerations
describe__________________ teeth/gums___________________ ______
Dentures: / upper (partial/full)_______lower(partial/full) ______
Intravenous fluids type/amt: Heplock
Insertion Site: Right arm

Skin Condition: ____color: pallor, ashen, pink, jaundice, cyanotic, ruddy

__/__temperature: warm, cool, hot
__/__dry, moist, clammy, diaphoretic
____edema: pitting/non-pitting
__/__turgor: good, poor, tenting
____pruriitis
____intact
____bruises/lesions describe: (size, location)______________

Body temperature: 3.8 thru axillary

3. ELIMINATION
____Not Assessed
Bowel Habits Describe: brown in color, moderate amount
(consistency, color, amount)
twice a day #BM's/day 9-11-12 Date of last BM
_n/a_ Constipation _n/a_ Diarrhea _n/a_Incontinence

Bladder Habits Describe: yellow in color, minimal amount

(color, clarity, amount)
4-5 times Frequency _n/a_ Dysuria _n/a_ Nocturia _n/a_ Urgency _n/a_ Hematuria
_n/a_ Retention _n/a_ Burning _n/a_ Hesitancy _n/a_ Pressure
Incontinency: _/ _No ___Yes __n/a__ daytime _n/a__ nightime
_n/a_ occasional _n/a__difficulty delaying voiding

Assistive Devices: _n/a_intermittent catheterization _n/a_ indwelling cath

_n/a_external catheter _n/a_ incontinent briefs
Ostomy: type: _n/a_ Appliance _n/a_ self-care
Inspect Abdomen: _/_ symmetry_____ flat_____ rounded_______ obese
Auscultate Abdomen:_/_ normal bowel sounds ______Hypoactive______ Hyperactive
Palpate abdomen:_/_ soft____ firm non tender : describe________
No distention: describe:______________________

4. ACTIVITY-EXERCISE
______Not Assessed

A.Musculoskeletal: _n/a_ tremors _n/a_ atrophy _n/a_swelling

Self-Care Ability: 0=Independent 1=Assistive device 2=Assistance from others

3=Assistance from person and equipment 4=Dependent/Unable

0 1 2 3 4

Eating 0 1 2 3 4
Bathing 0 1 2 3 4
Dressing 0 1 2 3 4
Toileting 0 1 2 3 4
Bed Mobility 0 1 2 3 4
Transferring 0 1 2 3 4
Ambulating 0 1 2 3 4
Stairs 0 1 2 3 4
Shopping 0 1 2 3 4
Cooking 0 1 2 3 4
Home Maint 0 1 2 3 4

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___n/a__ Prosthesis__n/a____
Physical Development Assessment: _/_normal __abnormal
describe:__________________________

B. CV
_____Not Assessed

Pulse: _/_regular ____irregular _/_strong _____weak

_/_radial rate of 90 bpm
___apical rate
Blood Pressure:___ standing _/_lying with BP of 150/80 mmhg ____sitting
Extremities: Temperature: ___cold ___cool _/_warm ___hot
Capillary Refill: _/_ brisk ____sluggish
Color: < 3 sec. capillary refill (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 _/_rate of 20 _/_depth (shallow, deep, abdominal, diaphragmatic)
_/_regular ___irregular none periods of apnea
_n/a_ dyspnea at rest _n/a_ orthopnea _n/a__ dyspnea on exertion
__/__Cough: dry/productive
Sputum: whitish phlegm
Auscultate chest: _/_ crackles _no_ rhonchi _no_ friction rub _/_wheezing
describe:___________________________________________
Other: ___chest tube ____ tracheostomy Describe:________________________
Oxygen: oxygen inhalation at 2-3 l via nasal cannula as needed

5. SLEEP-REST
________Not Assessed
Usual Sleep Habits: _5_hours per night _________consecutive hours slept per noc
__11__a.m. nap _3__p.m. nap
feel rested after sleep: _/_ yes __no
awakening during night __yes _/_no
insomnia __yes _/_no
Methods used to promote sleep: _/_ medication: Benadryl 25mg/tab
warm fluids: _n/a_ 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: _/_ person _/_ place _/_time _/_significant other
Memory: recent: _/_yes ___no Remote: __yes _/_no
Pupils: 2-3 size _/_Reaction (brisk/sluggish)
Reflexes: _/_normal _____absent
Grasps: _/_Right: strong/weak _/_left: strong/weak
Push/Pulls: _/_right: strong/weak _/_left: strong/weak
Other: _n/a_numbness _n/a_tingling

Pain: ____Denies
__substernal__Location: describe: __stubbing__
Radiation: describe: neck
Intensity: (0-10 scale) 3/10 Timing (how often, events that percipitate)
When did pain begin? when I get mad at work
What alleviates pain? Anger and stress
What increases pain? _______n/a____________
Thought Content: work place and load
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 _n/a_ tingling _n/a__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__1___
(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: ___n/a_______
Eye contact: Answers questions: _/_readily ____hesitantly
Usual view of self_/_ positive ______neutral _______somewhat negative (subjective)
Level of control in this situation: __10___ (0-10) (subjective)
Usual level of assertiveness: __10_ (0-10) (subjective)
Body Image: Is current illness going to result in a change in body structure or function? _/_no
_______unsure _____yes describe: _____________________(subjective)

8. ROLE-RELATIONSHIP
______Not Assessed
Does patient live alone __yes _/__no: with whom: family
Married_/_ Children_4__
Next of Kin: __n/a___
Occupation: Businessman
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) good family interaction

Question patient regarding:

Concerns about illness: if surgery is needed
Will admission cause significant changes in usual role? Yes I will know more about my health
Social activities: __/__active ____limited ____none
Activities participated in: Occasions and business
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: __n/a__ date of LMP
_n/a_Para _n/a__ Gravida _n/a_Pregnant
_n/a_Menopause __n/a__ no __n/a__ yes _______year
Contraception __n/a___ no ____ yes _______Type:
Hx. of vaginal bleeding _____no ____yes
(describe)______n/a_______
Last Pap Smear____n/a_______
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:____unrecalled____
History of sexually transmitted disease __/__no _______yes: Both:
Problems with sexual functioning?_____none_____________
Sexual concerns at this time?_______none_____________

1 0. COPING-STRESS TOLERANCE
_________Not Assessed
Overt signs of stress (crying, wringing of hands, clenched fists) Describe:
_______anxious_______________
Question patient regarding:
Primary way you deal with stress? Talk to family members and friends
Concerns regarding hospitalizaton/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:_______none______________
Religious Practices: hear mass with family every Sunday, and having pilgrimage
Concerns related to ability to practice usual spiritual or religious customs?
__/__no ___ yes Describe:_______________________________________
Subjective/ Objective Cues:

S: “ Sumasakit ung dibdib ko pati leeg ko, tas para akong nasusuka at nahihilo, kung over 10 mga 3 - 4/10, di
naman ako ganun kahirap” as verbalized.

O:
(+) known smoker and alcoholic drinker before
Heart rate of 90 bpm
Blood pressure of 150/80 mmhg
Episodes of chest pain radiating to neck
Feeling of nauseated

Diagnostics:

Trop I – positive
CXR