Essay Grade

Functional Health Pattern Assessment (FHP)
Pattern of Health Perception and Health Management:
• How does the person describe current health?
• What does the person do to maintain health?
• What does person know about links between lifestyle and health?
• How big a problem is financing health care for this person?
• Can this person report his/her medications and the reason for taking them?
• If this person has allergies, what does he/she do to prevent/manage them?
• What does the person know about medical problems in his/her family?
• Have there been any important illnesses/injuries in this person’s life?
Nutritional-Metabolic Pattern:
• Is this person well-nourished?
• How does this person’s food intake compare with recommended food intake?
• Does this person have any disease that affects nutritional/metabolic function?
Pattern of Elimination:
• Are the person’s excretory functions within normal range?
• Does the person have any disease of the digestive system, urinary system, or skin?
Pattern of Activity and Exercise:
• How does this person describe his/her weekly pattern of:
Activity/Leisure?–Exercise/Recreation?
• Does this person have any disease that affects his/her:
Cardio/Respiratory System?–Musculoskeletal System?
Cognitive/Perceptual Pattern:
• Does this person have any sensory deficits? If yes, are they corrected?
• Can this person express himself/herself clearly and logically?
• What is this person’s level of education?
• Does this person have any disease that affects mental or sensory functions?
• If this person has pain, describe it and its causes.
Pattern of Sleep and Rest:
• Describe this person’s sleep/wake cycle.
• Does this person appear physically rested and relaxed?
Pattern of Self-Perception and Self-Concept:
• Is there anything unusual about this person’s appearance?
• Does this person seem comfortable with his/her appearance?
• Describe this person’s feeling state.
Role-Relationship Pattern:
• How does this person describe his/her various roles in life?
• Has, or does this person presently have positive role models for these roles?
• Which relationships are most important to this person at this time?
• Is this person presently going through any changes in role or relationships? If yes, describe changes.
Sexuality – Reproductive Pattern:
• Is this person satisfied with his/her situation related to sexuality?
• Does this person have any disease/dysfunction of the reproductive system?
• Is this person satisfied with his/her plans regarding children?
Pattern of Coping and Stress Tolerance:
• How does this person cope with difficult situations/problems?
• Do these coping mechanism/actions help or make things worse?
• Has this person had any treatment for emotional distress?
Pattern of Value and Beliefs:
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What principles did this person learn as a child that are still important to him/her?
Does this person identify with any social, religious, ethnic, regional, cultural, or other groups?
What support systems does this person currently have?
© 2016. Grand Canyon University. All Rights Reserved.
Health History and Examination
Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological
System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular
System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and
Genitourinary Systems
Save this form on your computer as a Microsoft Word document. You can expand or shrink each
area as you need to include relevant data for your client.
Student Name:
Date:
Client/Patient Initials:
Occupation of Client/Patient:
Sex:
Age:
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness,
numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on
head/neck, medications):
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering,
tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of
surgery, difficulty hearing, environmental noise exposure, vertigo, medications):
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore
throat, allergies, surgeries, usual dental care, medications):
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or
moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental
hazards/exposures, medications):
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or
© 2016. Grand Canyon University. All Rights Reserved.
injury to breast, mammography, breast self-exam, medications):
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs,
swelling in legs or ankles, swollen glands, medications):
Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family
history of cardiac disease, tire easily, self-history of heart disease, medications):
Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing,
history of lung disease, smoking history, living/working conditions that affect breathing, last
TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications):
Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of
movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to
bones; back pain; difficulty with activity of daily living, medications):
Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not
tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease,
ulcers, medications):
Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria,
oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary
disease, pain in flank, groin, suprapubic region or low back):
Physical Examination
(Comprehensive examination of each system. Record findings.)
Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):
Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes,
palpate the trachea, palpate and auscultate the thyroid gland):
Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye
structures, inspect anterior eyeball structures, inspect ocular fundus):
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Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test
hearing acuity):
Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the
mouth, inspect the throat):
Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and
palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach selfexamination techniques):
Breasts and Axilla (deferred for purpose of class assignment)
Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs,
venous pattern, varicosities, pulses, color, swelling, lumps):
Cardiovascular System (inspect and palpate carotid arteries, jugular venous system,
precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any
extra heart sounds, murmur):
Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate
symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing
sounds):
Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity,
pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity,
pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain,
range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity,
pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain,
range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range
of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and
© 2016. Grand Canyon University. All Rights Reserved.
range of motion):
Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition,
pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all
four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall,
tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness):
Genitourinary System (deferred for purpose of this class)
FHP Assessment
Cognitive-Perceptual Pattern:
Nutritional-Metabolic Pattern:
Sexuality-Reproductive Pattern:
Pattern of Elimination
Pattern of Activity and Exercise:
Pattern of Sleep and Rest:
Pattern of Self-Perception and Self-Concept:
Summarize Your Findings
(Use format that provides logical progression of assessment.)
Situation (reason for seeking care, patient statements):
© 2016. Grand Canyon University. All Rights Reserved.
Background (health and family history, recent observations):
Assessment (assessment of health state or problems, nursing diagnosis):
Recommendation (diagnostic evaluation, follow-up care, patient education teaching including
health promotion education):
© 2016. Grand Canyon University. All Rights Reserved.
SBAR TEMPLATE – to submit issues of concern to NNLC
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication
between members of the health care team. Although this technique was original developed to target a patient-centered
condition, the NNLC will implement this technique to communicate and address critical issues to support immediate
attention and action by the committee. This SBAR tool was developed by Kaiser Permanente.
S
B
A
R
Situation:
What is the situation you are writing about?
• Identity self, health care site, area, title, date, etc.
• Briefly state the problem/issue, what is it, when it happened or started, and how severe.
EXAMPLE:
Author: Sharon Feldstein, Chair-Albuquerque Area Council of Nurse Executives
Date: July 10, 2008
Situation: Public Health Nursing Funded Positions
Background
Pertinent background information related to the situation could include the following:
• The history of problem/issue, the date of the problem/issue.
• List of current situations.
• Most recent occurrences.
• National standards, policy, regulations, standards, requirements.
EXAMPLE:
Background:
At the John P. Morgan Health Center, during FY 2008, the Public Health Nursing (PHN) department
consisted of 5 PHNs. During this time, 3 PHNs were detailed to outpatient on average 40% of their time and
supervised by the Clinical Director, which decreased the PHN Provider Productivity significantly.
The IHS Public Health Nursing scope of Practice is designed to build healthy communities by promoting
healthy behaviors and lifestyles through provision of care based on a primary prevention public health model.
The American Nurses Association Scope of Practice Model describes the practice of the PHN as placing
emphasis on primary prevention in all health promotion & health protection strategies with the focus on
population level outcome.
The GPRA objective related to the Health Promotion & Disease Prevention correlates directly with the PHN
program funding & is most effective with the PHN planning, developing, & supporting systems in the
community setting.
PHN visits are done primarily in the home, PHN specialty clinics, PHN office settings, school & community
sites with primary prevention as the focus for meeting the IHS mission.
PHN core services are divided into direct & indirect care activities listed in the RRM document with do not
cover services defined in the clinic settings supervised by another discipline.
The standard PHN position description, which is held at a minimum educational level of BSN, describes PHN
supervision directly under the DPHN & with the scope of community focused primary prevention.
Assessment
What is your assessment of the situation?
EXAMPLE:
Assessment: A lack of adherence to the defined standards identified in the PHN PD. Poor use of PHN
services in addressing public health issues. Disregard for IHS line-item funded PHN position.
Recommendation
What is your recommendation or what do you want (say what you want done)?
EXAMPLE:
Recommendation: NNLC will support the following recommendations1) The PHN funded positions must follow PHN job description duties with education qualifications
adhered to & functions with primary prevention focus under the direction of the DPHN; therefore, the
utilization of the PHN staff in their highest potential capability.
2) PHN funded positions will no longer be detailed for non PHN-duties.
NNLC reviewed on: _______________________________(date)
Recommendations were made on: ___________________ (date)
Was this forwarded to the Chief Nurse? ____ Yes; ____ No. If so, on what date: _____________________.
enchmark – Individual Client Health History and Examination
2
1
3
Less than
Unsatisfactory
Satisfactory
Satisfactory
0.00%
79.00%
75.00%
4
Good
89.00%
80.0 %Content
40.0 %Uses
With or
Uses SBAR Uses SBAR Uses SBAR
SBAR Format without SBAR format to
format to
format to
to Include All format,
provide all
provide all provide all
Components of provides
components of components components of
the Health
incomplete
the health
of the health the health
History
medical history history based history
history
(Biographical, with or without upon the
(biographical, (biographical,
Past Heath,
use of
information past health, past health,
Family,
appropriate
collected in the family,
family,
Symptoms)
medical
health history. symptoms) symptoms)
Using
acronyms and Appropriate using
using
Appropriate abbreviations. medical
appropriate appropriate
Medical
acronyms and medical
medical
Acronyms and
abbreviations acronyms and acronyms and
Abbreviations
are absent or abbreviations. abbreviations,
inconsistent.
and relates
information to
the diagnoses.
40.0
Health
%Benchmark screening and
D5: Holistic
diagnosis do
Patient Care not
Competency demonstrate
5.1:
understand of
Understand the the human
human
experience
experience
across the
across the
health-illness
health-illness continuum.
continuum
10.0
%Organization
Health
screening and
diagnosis
suggest
minimal
understanding
of the human
experience
across the
health-illness
continuum.
Health
Health
screening and screening and
diagnosis
diagnosis are
demonstrate integrated in
understanding an
of the human understanding
experience of the human
across the
experience
health-illness across the
continuum. health-illness
continuum.
5
Excellent
100.00%
Uses SBAR
format to
provide all
components of
the health
history
(biographical,
past health,
family,
symptoms)
using
appropriate
medical
acronyms and
abbreviations,
and relates
information to
the diagnoses
and integrates
into treatment
plan.
Health
screening and
diagnosis are
integrated in
an
understanding
of the human
experience
across the
health-illness
continuum
and provide
specific
suggestions
for treatment
across this
continuum.
and
Effectiveness
10.0
Surface errors Frequent and Some
%Mechanics of pervasive
repetitive
mechanical
Writing
enough that
mechanical
errors/typos
(Includes
they impede errors distract are present,
spelling,
communication the reader.
but are not
punctuation, of meaning.
Inconsistencies overly
grammar, and Inappropriate in language
distracting to
language use) word choice choice
the reader.
and/or
(register),
Correct
sentence
sentence
sentence
construction structure,
structure and
used.
and/or word audiencechoice are
appropriate
present.
language are
used.
10.0 %Format
10.0
No reference Reference
Reference
%Research
page is
page is
page is
Citations (In- included. No present.
included and
text citations citations are Citations are lists sources
for
used.
inconsistently used in the
paraphrasing
used.
paper.
and direct
Sources are
quotes, and
appropriately
reference page
documented,
listing and
although
formatting, as
some errors
appropriate to
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present.
100 %Total
Weightage
Prose is largely Writer is
free of
clearly in
mechanical
command of
errors,
standard,
although a few written,
may be
academic
present. A
English.
variety of
sentence
structures and
effective
figures of
speech are
used.
Reference
In-text
page is present citations and a
and fully
reference page
inclusive of all are complete.
cited sources. The
Documentation documentation
is appropriate of cited
and style is
sources is free
usually
of error.
correct.

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