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    Health Perception - Health Management Pattern: Vitals

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    novikane
    This document contains questions for a nurse to ask a patient to assess patterns in their health, including their health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, sexuality, coping ability, and values. The nurse would ask questions in each area, make observations, and identify any problems or nursing diagnoses to address.

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    Health Perception - Health Management Pattern: Vitals

    Uploaded by

    novikane
    68 views5 pages
    This document contains questions for a nurse to ask a patient to assess patterns in their health, including their health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, sexuality, coping ability, and values. The nurse would ask questions in each area, make observations, and identify any problems or nursing diagnoses to address.

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    FHP combined assess

    Original Title

    Nurse Assess New 2

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    This document contains questions for a nurse to ask a patient to assess patterns in their health, including their health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, sexuality, coping ability, and values. The nurse would ask questions in each area, make observations, and identify any problems or nursing diagnoses to address.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    68 views5 pages

    Health Perception - Health Management Pattern: Vitals

    Uploaded by

    novikane
    This document contains questions for a nurse to ask a patient to assess patterns in their health, including their health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, sexuality, coping ability, and values. The nurse would ask questions in each area, make observations, and identify any problems or nursing diagnoses to address.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    Health Perception Health Management Pattern

    Assessment/labs/diagnostic Vitals: Interview Read and Understand questions? How has your general health been? Any colds in the past year? Absences from work? Most important thing you do to keep healthy? Do you think these things make a difference to health? Use of cigarettes, alcohol, drugs? Breast self-exam; testicular exam? Home remedies-folk remedies used? In the past, has it been easy to find ways to follow instructions suggested from the doctors or nurses? If appropriate: what do you think caused this illness? Actions taken when symptoms perceived? Results from this? Priority Notes / Observations

    Nursing Diagnosis/Problem

    Nutritional-Metabolic Pattern
    Assessment/labs/diagnostic Ht.: Wt.: BMI: Integument: Interview Typical daily food intake? Describe with a 24 hour dietary intake? Supplements (vitamins, type of snacks)? Weight loss/gain? (amount) Height loss/gain (amount) Appetite? Food or eating: Discomfort? Swallowing? Diet restrictions? Heal well or poorly? Skin problems: lesions, Notes / Observations

    Nose/throat/mouth:

    Nutritional-Metabolic Pattern
    dryness? Dental problems? Priority

    Nursing Diagnosis/Problem

    Elimination Pattern
    Assessment/labs/diagnostic Abdomen: Interview Bowel elimination pattern (describe) frequency, color, consistency? Character? Discomfort? Problem in control? Laxatives? Ostomies? Urinary elimination pattern (describe) frequency, color, clarity? Problems in control? Discomfort? Ostomies? Excess perspiration? Odor problems? Body cavity drainage, suction, etc? Priority Notes / Observations

    Nursing Diagnosis/Problem

    Activity-Exercise Pattern
    Assessment/labs/diagnostic Musculo-skeletal: CV: Interview Sufficient energy for desired/required activities? Exercise pattern? Type? Regularity? Spare time (leisure) activities? Child play activities? General appearance? Priority Notes / Observations

    Nursing Diagnosis/Problem

    Sleep-Rest Pattern
    Interview Generally rested and ready for daily activities after sleep? Bedtime? Awakens? Sleep onset problems? Aids? Dreams? Early awakenings? Rest-relaxation periods? Nursing Diagnosis/Problem Priority Notes / Observations

    Cognitive-Perceptual Pattern
    Assessment/labs/diagnostic Neuro & Eyes/Ears: Interview Hearing difficulty? Aid? Vision? Wear glasses/contact lenses? Last checked? When changed? Big decision easy/difficult to make? Easiest way for you to learn things? Any difficulty? Any discomfort? Pain? If appropriate: How do you manage it? Level of Consciousness/ Are they alert and oriented to time/person/place? Is the speech slurred/clear? Do they have short-term memory loss/long term memory loss? Priority Notes / Observations

    Nursing Diagnosis/Problem

    Self-Perception / Self-Concept Pattern


    Assessment/labs/diagnostic Eye contact / Attention span Voice and speech pattern. Body posture. Nervous (5) or relaxed (1) 1-5 Interview How do you describe yourself? Most of the time, do you feel good, or not so good about yourself? Changes in body or things you can do? Problem to Notes / Observations

    Self-Perception / Self-Concept Pattern


    Assertive (5) or passive (1) you? Changes in way you feel about self or body (since illness started)? Things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? Not in control? What helps? Ever feel you lost hope? Priority

    Nursing Diagnosis/Problem

    Roles-Relationships Pattern
    Interview Notes / Observations NOTE: Interaction with family member(s) or others (if present) Live alone? Family? Family Structure? Any family problems that you have difficulty handling (nuclear/extended)? Family or others depend on you for things? How managing? If appropriate: How family/others feel about illness? Hospitalization? If appropriate: Problems with children? Difficult handling? Belong to social groups? Close friends? Feel lonely? Things generally go well at work? (school)? Income sufficient for needs? What kind of work do you do? Nursing Diagnosis/Problem Priority

    Sexuality-Reproductive Pattern
    Interview If appropriate to age and situation: Sexual relationships Notes / Observations

    Sexuality-Reproductive Pattern
    satisfying? Changes? Problems? Use of contraceptives? Problems? Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? Nursing Diagnosis/Problem Priority

    Coping-Stress Tolerance Pattern


    Interview Any big changes in your life in the last year or two? Crisis? Whos most helpful in talking things over? Available now? Tense or relaxed most of the time? If tense, what helps? Use any medicines, drugs, alcohol? How do you handle big problems? Is this successful? Nursing Diagnosis/Problem Priority Notes / Observations

    Values-Beliefs Pattern
    Interview Generally get things you want from life? Important plans for the future? Religion important in life? Helpful? Nursing Diagnosis/Problem Priority Notes / Observations

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