Republic of the Philippines UNIVERSITY OF EASTERN PHILIPPINES University Town, Northem Samar ‘Web: hitp://uep.edu. ph Email: vepnsofficial@amail com COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES A heath History that Integrates the Assessment of Functional Health Patterns Functional Health _ Patterns 1. Health perception- health management Assessment = Quality of usual and current health rated on a scale of 1 to 10 ~ Self-rating of the importance of health, on a scale of 1 to 10 ~ perceived ability to control and manage health = Resources used in health management including primary health care provider ~ Self-care measures to maintain or prevent disruption of health status = Health habits (e.g. seat belt use, diet, alcohol consumption, tobacco use) - Complete description of present health problem (i.e. chief complaint) - Expectation for outcome of current health problem ~ Expectations for care givers ~ Previous illnesses or hospitalizations, reactions to these events, and their outcomes - Developmental theory, including childhood illnesses and immunizations ~ Ability to manage and comply with recommended treatment of health problems ~ Current medications, including over the counter and recreational (street) drugs allergies ~ Environmental factors affecting health (e.g. occupation, home, leisure) = Socioeconomic factors affecting health (e.g. financial concems, health care insurance, living conditions) - Knowledge and use of community resources to manage health -_ Family history ‘2. Nutritional Metabolic ~ Recall of usual food and fluid intake for the 24 hours - Comparison of a 24-hour recall diet to typical pattern of the diet intake ~ Quality of appetite - Dietary restrictions (medical order) - Food preferences and dislikes - Use of food supplements (e.g. vitamins) - Knowledge level of dietary recommendations (e.g food guide pyramid, recommended dietary allowances, special dietary guidelines) - Past alterations in dietary habits (e.g. bulimia nervosa, anorexia nervosa) - Usual weight = Minimum and maximum weight range - Recent weight gain or loss (how much? Time span? Intentional?) = social significance of food ~ Whops shops for food items? - Who usually prepares meals? - Religious or cultural; beliefs affecting diet or meal preparation - Ability to swallow and chewle 3. Elimination Bowel - Are there any feeding problem? __ _ ~ Usual bowel habits, including frequency, time of day, color, Consistency, assistive devices used (e.g, laxatives, suppositories, enemas) constipation, diarrhea | habits, describe 4. Bladder ~ Usual freq , amount, color of voiding ~ Assistive devices used, (e.g. self-catheterization) ~ Problems with frequency, urgency, burning, retention, incontinence, dribbling, dysuria polyuria, nocturia —| 5. Skin ~ Condition, color, temperature, turgor, lesions, edema, pruritus —t 6. Activity exercise ~ Description of usual daily activities ~ Weekend schedule, if different from daily ~ Occupation-related activities ~ Leisure activities including hobbies - Description of exercises regimen ~ Limitation in ambulation, bathing, dressing, toileting and feeding - Dyspnea with exertion - fatigue 7. Sleep-rest 8. Cognitive- perceptual = Usual sleep habits including bedtime, hours of sleep obtained, wake- up time - Problems falling asleep or staying asleep - Sleep side used, including medications, food beverages and sexual intercourse = Rating of quality of sleep obtained (does client feel rested?) - Periods of decreased wakefulness during the day - Educational level obtained - Seff-rating of intelligence level - Ability to communicate with others = Ability to make decisions and the relative ease or difficulty experienced with decision-making - Ability to see, hear, feel, taste smell - Compensations made for sensory deficits and their effectiveness - Problems with vertigo, heat or cold intolerance - Pain (including a symptom analysis) - Desire to leam 9. Seif:perception-self concept, = Description of self, including strengths and weaknesses - Major concern - Health goals - Body image and feelings about setf - Level of satisfaction with current age - Perceived developmental level - Emotional status - Effect of illness on self-perception - Personal factors contributing to illness, recovery, health maintenance 10. Role relationship ~ Language, quality of speech and relevancy - Ability to express self - Family life, including family members and their relationship to client - Roles client and family members fill - Interpersonal relationship within family - Support systems within family, including person client feels closet to - Family-related problems including living arrangements, parenting, marital problems, abuse - Occupation and job-related role expectations"|= Problems at work - Societal relationship beyond family or work - Most important person to client ~ Type of neighborhood or community in which client lives = Participation in societal groups (e.g. church, synagogue, clubs) - Perceived contributions to society 11. Sexuality. reproductive - Level of satisfaction with role as male or female - Anticipated changes related to heath problem (e.g. fertility, libido, impotence, pregnancy, contraception's, menstruation) = Sexual activity, including how long client has been sexually active, number of partners, use of contraceptives - Known exposure to venereal diseases, including human immunodeficiency virus infection - Level of satisfaction with intercourse - Problems with intercourse (e.g. premature ejaculation, impotence, pain bleeding) = Menstrual history including age at menarche, description of typical cycle, last menstrual period, age at menopause, or manifestation of menopause - Obstetric history including number of pregnancies, number of births, problems during pregnancy or labor and delivery | - Practice of breast self-examination, knowledge of technique, | compliance ~ Last Pap test and resus, frequency of pelvic examinations and Pap | Tests 13. Male = Circumcision - Age at climacteric and description of manifestations experienced | - Practice of testicular self-examination, knowledge of technique, | ‘compliance - Prostate examination, prostate-specific antigen tests and results 14. Coping-stress tolerance = Coping strategies used and their effectiveness - Personal loss or major changes in past year - Comfort and security needs - Most stressful event in life and reaction to it - Use of stress management techniques and their effectiveness (e.g. eating, sleeping, self-medication, counseling, exercise, biofeedback) - Effect of stress on lifestyle and ability to functions, including decision- making 15. — Value-belief ~ Most important value to clent - Sources of strength and hope - Importance of religion, type, and frequency of worship - Life goals - Values influencing decision-making and ability to resolve moral questions. - Recent changes in values or beliefs ~ Conflict in values or beliefs with those of significant others ~ Spirituality needs, particularly during time of illness or hospitalization