Nursing Health Assessments

1. Nursing Health Assessments Chapter (4) Functional Health Pattern(NANDA)

2. Functional Health Pattern(NANDA) • Health Perception-Health management pattern • Nutritional-Metabolic Pattern • Elimination Pattern • Activity-Exercise Pattern • Sexuality-Reproduction Pattern • Sleep-Rest Pattern • Sensory-Perceptual Pattern

3. NANDA. Cont… • Cognitive Pattern • Role-Relationship Pattern • Self-Perception-Self- Concept Pattern • Coping-Stress Tolerance Pattern • Value-Belief Pattern

4. Health Perception-Health Management Pattern

5. Purpose: The purpose of assessing the client's health Perception health maintenance pattern is to determine how the client perceives and manage his/her current and past nursing and, medical recommendations. The client's ability to perceive the relationship between activities of daily living and health is also determined

6. Subjective Data: Guideline Questions Client perception of health • Describe your health. • How would you rate your health on a scale of 1 to 10 (10 is excellent) now, 5 years ago, and 5 years ahead? • Client perception of illness. • Describe your illness or current health problem. • How has this affected your normal daily activities? • How do you feel your current daily activities have affected your Health What do you feel caused your illness? • What course do you predict your illness will take? • How do you feel your illness should be treated? • Do you have or anticipate any difficulties in caring for Yourself or other sat home? If yes, explain.

7. Guideline Questions. Cont.. • Health management and habits • Tell me what you do when you have a health problem. • When do you seek nursing or medical advice? • How often do you go for professional exams (dental, Pap • Smears, breast, BP)? • What activities do you feel keep you healthy? Contribute to illness? • Do you perform self-exams (blood pressure, breast, testicular)? • When were your last immunizations? Are they up to date? • Do you use alcohol, tobacco, drugs? Describe the amount and Length of time used Are you exposed to pollutants or toxins?

8. Compliance With Prescribed Medications and Treatments • Have you been able to take your prescribed medications? If not, what caused your inability to do so? • Have you been able to follow through with your prescribed nursing and medical treatment (e.g., diet, exercise)? It not, what caused your inability to do so?

9. Objective Data: Refer to General Physical Survey. Associated Nursing Diagnoses Categories to Consider • Health Seeking Behaviors • Effective Management of Therapeutic Regimen • Risk for Injury • Risk for diagnoses • Risk for Suffocation • Risk for Poisoning • Risk for Trauma • Risk for Peri-operative Positioning Injury

10. Actual Diagnoses • Energy Field Disturbance. • Altered Growth and Development. • Altered Health Maintenance. • Ineffective Management of Therapeutic Regimen: Individual. • Ineffective Management of Therapeutic Regimen: Family. • Ineffective Management of Therapeutic Regime: Community Non compliance.

11. Nutritional-Metabolic Pattern

12. Purpose: • The purpose of assessing the client's nutritional- metabolic pattern is to determine the client dietary habits and metabolic needs. • The conditions of hair, skin, nails, teeth and mucous membranes are assessed.

13. Subjective Data: Guideline Questions Dietary and Fluid Intake • Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day • Do follow any certain type of diet? Explain. • What time do you usually eat your meals? • Do you find it difficult to eat meals on time? Explain. • What types of snacks do you eat? How often? • Do you take any vitamin supplements? Describe. • Do you consider your diet high in fat? Sugar? Salt?

14. Subjective Data. Cont.. • Do you find it difficult to tolerate certain foods? Specify. What kind of fluids do you usually drink? How much per day? • Do you have difficulty chewing or swallowing food? • When was your last dental exam? What were the result? • Do you ever experience sore throat, sore tongue, sore gums? Describe • Do you ever experience nausea and vomiting? Prescribe • Do you ever experience abdominal pains? Describe. • Do you use antacids? How often? What kind?

15. Condition of Skin • Describe the condition of your skin. • How well and how quickly does your skin heal? • Do you have any skin lesions? Describe- • Do you have excessive oily or dry skin? • Do you have any itching? What do you do for relief?

16. Condition of Hair, Nails • Describe the condition of your hair, nails • Do you have excessively oily or dry hair? • Have you had difficulty with scalp itching or sores? • Do you use any special hair or scalp care products? • Have you noticed any changes in your nails? Color • Cracking? Shape? Lines?

17. Metabolism • What would you consider to be your "ideal weight"? • Have you had any recent weight gains or losses? • Have you used any measures to gain or lose weight? Describe. • Do you have any intolerance to heat or cold? • Have you noted any changes in your eating or drinking habits? Explain. • Have you noticed any voice changes? • Have you had difficulty with nervousness?

18. Objective Data Assess the client's temperature, pulse, respirations, and height and weight. Wellness Diagnoses • Opportunity to enhance nutritional metabolic pattern • Opportunity to enhance effective breast feeding • Opportunity to enhance skin integrity

19. Actual Diagnoses • Decreased Adaptive Capacity: Intracranial. • Ineffective Thermo regulation. • Fluid Volume Deficit • Fluid Volume Excess • Altered Nutrition: Less than body requirements • Altered Nutrition: More than body requirements • Ineffective Breastfeeding • Interrupted Breastfeeding • Ineffective Infant Feeding Pattern Impaired Swallowing • Altered Protection • Impaired Tissue Integrity • Altered Oral Mucous Membrane • Impaired Skin Integrity.

20. Elimination Pattern

21. Purpose: The purpose of assessing the client's elimination pattern is to determine the adequacy of function of the client's bowel and bladder for elimination. The client's bowel and urinary routines and habits are assessed .In addition, any bowel or urinary problems and use of urinary or bowel elimination devices are examined.

22. Subjective Data Guidelines Questions • Bowel Habits • Describe your bowel pattern. Have there been any recent changes? • How frequent are your bowel movements? • What is the color and consistency of your stools? • Do you use laxatives? What kind and how often do you use them? • Do you use enemas? How often and what kind? • Do you use suppositories? How often and what kind? • Do you have any discomfort with your bowel movements? Describe. • Have you ever had bowel surgery? What type? Ileostomy? Colostomy?

23. Bladder Habits • Describe your urinary habits. • How frequently do you urinate? • What is the amount and color of your urine? • Do you have any of the following problems with urinating:. • Pain? Blood in urine? Difficulty starting a stream? Incontinence? Voiding frequently at night? Voiding frequently during day? Bladder infections? • Have you ever had bladder surgery? Describe. • Have you ever had a urinary catheter? Describe. When? How long?

24. Objective Data: • Refer to Abdominal Assessment and the rectal assessment. • Associated nursing-Diagnoses Categories to Consider

25. Wellness Diagnoses • Opportunity to enhance adequate bowel elimination pattern • Opportunity to enhance adequate urinary elimination pattern

26. Risk Diagnoses • Risk for constipation • Risk for altered urinary elimination

27. Actual Diagnoses • Altered Bowel Elimination Constipation • Colonic constipation • Perceived constipation • Diarrhea • Bowel Incontinence • Altered Urinary Elimination Patterns of Urinary Retention • Total Incontinence • Functional Incontinence • Reflex Incontinence • Urge Incontinence • Stress Incontinence

28. Activity- Exercise Pattern

29. Purpose The purpose of assessing the client's activity- exercise- pattern is to determine the client's activities of daily living, including routines of exercise, leisure, and recreation. This includes activities necessary for personal hygiene, cooking, shopping eating, maintaining the home, and working. An assessment is made of any factors that affect or interfere with the client's routine activities of daily living. Activities are evaluated in reference to the client's perception of their significance in his or her life.

30. Subjective Data Guideline Questions Activities of Daily Lining • Describe your activities on a normal day. (Including hygiene, activities, cooking activities, shopping activities, eating activities, house and yard activities, other self-care activities.) • How satisfied are you with these activities? • Do you have difficulty with any of these self-care activities? Explain. • Does anyone help you with these activities? How? • Do you use any special devices to help you with your activities? • Does your current physical health affect any of these activities e.g. dyspnea, shortness of breath, palpations, chest pain. stiffness, weakness)? Explain.

31. Leisure Activities • Describe the leisure activities you enjoy. • Has your health affected your ability to enjoy your leisure? Explain. • Do you have time for leisure activities? • Describe any hobbies you have. Exercise Routine: • Describe those activities that you feel give you exercise. • How often are you able to do this type of exercise? • Has your health interfered with your exercise routine?

32. Occupational Activities • Describe what you do to make a living. • How satisfied are you with this job? • Do you feel it has affected your health? • How has your health affected your ability to work?

33. Objective Data Refer to Thoracic and Lung Assessment; Cardiac Assessment; Peripheral Vascular Assessment; and Musculoskeletal Assessment

34. Associated Nursing Diagnoses Categories to Consider

35. Wellness Diagnoses • Potential for enhance organized infant behavior • Opportunity to enhance effective cardiac output • Opportunity to enhance effective diversional activity pattern • Opportunity to enhance effective activity-exercise pattern • Opportunity to enhance effective home maintenance management • Opportunity to enhance effective self-care activities • Opportunity to enhance adequate tissue perfusion • Opportunity to enhance effective breathing pattern

36. Risk Diagnoses • Risk for Disorganized Infant Behavior • Risk for Peripheral Neurovascular Dysfunction • Risk for altered respiratory function

37. Actual Diagnoses • Activity Intolerance • Impaired Gas Exchange in effective Airway Clearance • Ineffective Breathing Pattern • Decreased Adaptive Intracranial Capacity • Decreased Cardiac Output • Disuse syndrome • Diversional Activity Deficit • Impaired Home Maintenance Management • Impaired Physical Mobility • Dysfunctional Ventilatory Weaning Response • Inability to Sustain Spontaneous Ventilation • Self-Care Deficit: (Feeding, Bathing/Hygiene, Dressing/Grooming, • Toileting) • Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral, and Cardiopulmonary. Renal, Gastrointestinal, Peripheral) • Disorganized Infant Behavior

38. Sexuality-Reproduction Pattern

39. Purpose: The purpose of assessing the client's sexuality reproductive pattern is to determine the client’s fulfillment of sexual needs and perceived level of satisfaction. The reproductive pattern and developmental level of the client is determined, and perceived problems related to sexual activities, relationships, or self-concept are elicited. The physical and psychological effects of the client's current health status, on his or her sexuality or sexual expression are examined.

40. Subjective Data Guideline Questions Female. A. Menstrual history: • How old were you when you began menstruating? On what date did your last cycle begin? How many days dose your cycle normally last? How many days elapse from the beginning of one cycle until the beginning of another? • Have you noticed any change in your menstrual cycle? Have you noticed any bleeding between your menstrual cycles? Do you experience episodes of flushing; chilling, or intolerance to temperature change? Describe any mood changes or discomfort before, during, or after your cycle.

41. B. Obstetric history: • How many times have you been pregnant? Describe the outcome of each pregnancies if you have children? What are the ages and sex of each? Describe your feelings with each pregnancy. Explain any health problems or concerns you had with each pregnancy. If pregnant now, • Was this a planned or unexpected pregnancy? • Describe your feelings about this pregnancy. • What changes in your life-style do you anticipate with this Pregnancy? • Describe any difficulties or discomfort you have had with this Pregnancy. • How can I help you meet your needs during this pregnancy?

42. 2. Male/female • Contraception • What do you or your partner do to prevent pregnancy? How acceptable is this method to both of you? Do this means of birth control affect your enjoyment of sexual relations? • Describe any discomfort or undesirable effects this method produces. • Have you had any difficulty with fertility? Explain. Has infertility affected your relationship with your partner? Explain.

43. B. Perception of sexual activities • Describe you sexual feelings. • How comfortable are you with your feelings of femininity/masculinity? • Describe your level of satisfaction from your sexual relationship (s) on scale of 1 to 10(with 10 being very satisfying). • Explain any changes in your sexual relationship (s) that you Would like to make. • Describe any pain or discomfort you have during intercourse • Have you (has your partner) experienced any difficulty achieving an orgasm or maintaining an erection? If so, bow has this – affected your relationship?

44. C. Concerns related to illness How has your illness affected your sexual relationships)? How comfortable are you discussing sexual problems with your partner? Who would you seek help from for sexual concerns? D. Special problems • Do you have or have you ever had a sexually transmitted disease? Describe. • What method do you use to prevent contracting a sexually transmitted disease? Describe any pain, burning, or discomfort you have while voiding. • Describe any discharge or unusual odor you have from your penis/vagina. What is the date of your last Pap smear?

45. E. History of sexual abuse • Describe the time and place the incident occurred. • Explain the type of sexual contact that occurred. • Describe the person who assaulted you. • Identify any witnesses present. • Describe your feelings about this incident. • Have you had any difficulty sleeping, eating, or working since the incident occurred?

46. Objective Data • Refer to Breast Assessment, Abdominal • Assessment, and urinary-Reproductive • Assessment • Associated nursing Diagnoses Categories to Consider • Wellness Diagnoses opportunity to enhance sexuality patterns Risk- Diagnoses Risk for altered sexuality pattern Actual Diagnoses Sexual Dysfunction, Altered Sexuality Patterns

47. Sleep-Rest Pattern

48. Purpose: The purpose of assessing the client's sleep-rest pattern is to determine the client perception of the quality of his or her relaxation and energy levels Methods used to promote relaxation and sleep is also assessed.

49. Subjective Data Guideline Questions Sleep Habits • Describe your usual sleeping time at home. • How would you rate the quality of your sleep? Special Problems • Do you ever experience difficulty with falling asleep? Remaining a sleep? Do you ever feel fatigued after a sleep period? • Has your current health altered your normal sleep habits? Explain. • Do you feel your sleep habits have contributed to your current Illness? Explain.

50. Sleeping Aids • What helps you to fall asleep? • Medications? Reading? • Relaxation technique? • Watching TV? • Listening to music?