This guide may be used to assist in the collection of client data and may be used for the assessment of clients in subsequent clinical courses.
** Not all questions will be applicable to every client.
Health Perception – Health Management Pattern
The objective in assessing this pattern is to obtain data about the individual’s general perception of his/her health status and its relevance to current activities and future planning. Data is collected about general health management and preventative health measures, and cues to potential health hazards in the client’s practices should be noted and explored. Questions to elicit data: 1. How would you usually describe your health? Excellent _____ Good _____ Fair _____ Poor _____ 2. How would you describe your health at this time? 3. What do you do routinely to maintain good health? e.g.: adequate nutrition exercise program weight control regular examinations 4. Do you wait for certain signs and symptoms to appear before seeking health care? 5. Question regarding previous hospitalizations. 6. Do you smoke? How much? For how long? Have you tried to quit? 7. Do you use drugs prescribed by a doctor? 8. Do you use nonprescription drugs or vitamins? 9. Did you bring any drugs to hospital? 10. Do you have any allergies to drugs, food, etc? 11. Has being sick made any difference to your usual life style? 12. How do you expect to get along after you leave hospital? 13. Will your illness affect your family? In what way? 14. Do you consume alcohol? How much? For how long? 15. Do you use any alternative health therapies? Nutritional-Metabolic Pattern
The objective in assessing this pattern is to assess the food and fluid consumption relative to metabolic needs. (Growth states such as healing, childhood and pregnancy should be considered). Data is collected about the typical pattern of food and fluid consumption and any problems perceived by the client in nutrient supplements and food preferences.
Data may be collected by using the 24 hour recall and the basic four food groups. The nurse makes a list of the client’s intake of food and fluids for 24 hours and then compares the client’s diet to the basic four food groups and notes any discrepancy.
Questions to elicit data:
1. What is your typical daily food intake (24 hr. recall)?
2. What is your typical daily fluid intake (24 hr. recall)? 3. Have you had any recent weight loss or weight gain? 4. Do you have a good appetite? 5. Do you experience any discomforts associated with eating? 6. Do you follow any diet restrictions? 7. What are your food likes and dislikes? 8. Do you usually eat alone or with others? 9. Are foods readily accessible and available to you? 10. Do you have any difficulty chewing or swallowing? 11. What are your usual mealtimes? 12. Do you snack between meals?
Elimination Pattern
The objective in assessing this pattern is to collect data about regularity and control of excretory patterns (bladder, bowel and skin), subjective descriptions of perceived problems, remedial actions taken and the perceived effects of these actions are the data of concern.
Questions to elicit data:
1. Do you have any problems with voiding?
a) dysuria d) retention g) nocturia b) polyuria e) burning c) dribbling f) incontinence 2. How often do you have a bowel movement? 3. What is the consistency and color of your stool? 4. Do you take laxatives, how often? 5. Do you experience any discomfort when having a bowel movement? 6. Do you experience excess perspiration? 7. Do you have problems with constipation? 8. Do you experience bowel incontinence?
2 Activity – Exercise Pattern
The objective in assessing this pattern is to determine the client’s ability to carry out activities of daily living. The type, quality and frequency of a planned exercise regimen and the types of activities that promote rest and relaxation further help to describe the exercise-activity patterns. Factors (problems) that interfere with the desired or expected pattern for the individual (such as neuromuscular deficits, dyspnea) should be assessed. Use of leisure time should be included as part of the client’s activity pattern.
Questions to elicit data:
1. What is your usual pattern of activity during the day?
2. Do you have a special exercise program? What is it? 3. What do you feel are the benefits of physical exercise? 4. How do you feel after exercise? 5. What do you do in your leisure time? 6. Do you have restrictions placed on your activities because of health problems? e.g: Ambulating Toileting Bathing Shopping Dressing Home maintenance Feeding 7. Have you had any recent falls or injuries?
Sleep-Rest Pattern
The objective in this pattern is to identify any problems perceived by the client in relation to sleep. If problems are perceived by client, explanations, previous actions taken and their effects are elicited. Rest and relaxation comprise a second component to be assessed in this pattern.
Questions to elicit data:
1. How many hours sleep do you feel you require in order to feel rested? 2. What is your usual sleep pattern? 3. Do you have any problems with a) falling asleep? b) remaining asleep? c) not feeling rested after sleep? 4. Do you take anything to help you sleep? 5. What do you find is the most comfortable position for sleep? 6. Do you sleep with a night light on? 7. Do you nap during the day?
3 Cognitive & Perceptual Pattern
The objective in assessing this pattern is to explore the client’s sensory perceptions (including vision, hearing, taste, smell & touch) and cognitive abilities, based on education and intelligence. Use of prosthetics (e.g. eyeglasses, hearing aids) should be noted and the regularity of their use described. Also, the client should be asked to describe pain perception and pain tolerance and any measures used to relieve the pain.
Cues to sensory deficits, sensory deprivation or overload and pain management problems must not be overlooked. Impaired reasoning, knowledge deficits related to health practices and memory deficits are additional problems that may exist and may even be the basis for other dysfunctional patterns.
Note the characteristics of the client’s speech, gestures, movements and activities during the interview.
Questions to elicit data:
1. Any deficits in sensory perception? (Vision, hearing, taste, smell, touch)
e.g: How would you describe your vision? Do you wear glasses / contact lenses? Do you see as well as you did 5 years ago? Do you experience any problems with your eyes: pain, itching, headaches? When did you have your last eye examination? 2. What grade did you complete at school? 3. Do you experience pain? How often? Describe what measures you take to relieve pain? 4. Do you have any problems with your memory? Any recent change? 5. Do you have any difficulty hearing? 6. Do you use a hearing aid? 7. Have you noticed any change with sense of smell, taste and touch, temperature and pain?
4 Self-Perception-Self Concept Pattern
The objective in assessing this pattern is to describe the client’s pattern of beliefs and evaluations regarding general self-worth and feeling states. The nurse examines the client’s self-knowledge and attitudes and includes a description of the client’s self image in relation to personal appearance and competence (cognitive affective and psychomotor). Data collected should reflect a person’s personal sense of worth as well as personal goals and opportunities for achievement. Assessment of self-perception and self-concept is not effective unless the nurse has already established an empathic and non-judgmental atmosphere. Patterns of body movement, posture and eye contact can reveal nonverbal cues about self-concept and self-perception.
Questions to elicit data:
1. Do you feel good about yourself?
2. Do you feel comfortable with the way you look and feel? 3. What would you describe as your strengths and weaknesses? 4. Are there things you would like to change about yourself? Describe. 5. Are you pleased with your accomplishments so far? 6. Do you have future goals you would like to achieve? 7. Is there anything about your illness/hospitalization that makes you feel anxious or frightened? 8. Have you experienced a health problem which has affected or altered your lifestyle?
Role-Relationship Pattern
In assessing this pattern the objective is to explore the client’s role (e.g.: father, mother, provider) and the responsibilities of the particular role. Note the client’s occupational history including occupational hazards, satisfaction and productivity in his/her job, and job related stressors. Also, assess family relationships-are they supportive or restrictive? Questions should not be probing, but should be straightforward. Is it an extended or nuclear family? The nurse should explore financial concerns, unemployment and other issues related to work. Where applicable, any problems related to being a student should be examined.
(Loss, change or threat produce the major problems in the role relationship pattern.)
Questions to elicit data:
1. What do you consider your role (s) within your family? 2. Have there been any major changes in your roles and/or responsibilities recently? Explain. 3. Do you anticipate that your illness will affect (a) your ability to work? (b) your role within the family?
5 4. Do you and your family do leisure activities together? 5. Do you consider your family income adequate? 6. Are you employed? 7. Are you happy with your occupation and position? 8. Do you gain personal satisfaction from your work situation? 9. Does your work cause stress? How does this affect you? 10. Are you a member of any committees or organizations? (work, church, school) 11. Do you get paid sick leave from work? 12. With whom do you live? Are they supportive? 13. Who are the most important people in your life? 14. Describe the relationship you have with friends and/or neighbors. Sexuality-Reproductive Pattern In assessing this pattern, the objective is to focus on developmental patterns and perceived satisfactions or dissatisfactions. If problems exist, the nurse should explore them. Assessment of the reproductive patterns involves collecting information about the client’s stage of reproductive development in relationship to developmental milestones such as menarche or menopause. Note any information in your data which indicates that the client is in a high risk category for S.T.I. It should be noted that not all of the questions listed below are applicable to every client, therefore, the student should use tact and discretion. Because assessment related to sexuality and reproduction can be threatening to some clients, it is important that the nurse approach the topic with sensitivity. This part of the assessment may be deferred depending on the client’s circumstances. Questions to elicit data: 1. Do you have a significant partner in your life? 2. Is it a satisfying relationship? 3. Obstetrical History-when applicable-pregnancies, deliveries, abortions etc. 4. Do you examine your breasts regularly? Testes? 5. Do you have any vaginal/penile discharge which you are concerned about? 6. When did you have your last Pap Smear? 7. Do you have any sexual problems you would like to discuss? 8. Has being sick interfered with your sexual life? In what way? 9. Do you think your illness could change your normal pattern of sexual functioning? How? 10. Have you ever had a partner who had a STI? 11. How would you describe your sexual orientation? 12. Are you involved with multiple sexual partners? 13. What method of birth control do you use? 14. What measures do you use to prevent the exchange of body fluids during sexual activity?
6 Coping-Stress Tolerance Pattern
The objective in assessing this pattern is to describe the stress tolerance and coping pattern of the client. It should reflect personality, ability to handle daily stresses and life crises. Assessment should include the client’s perception of actual or potential stresses within his/her environment. When assessing stress, it is important to collect data for use in the prevention of potential health problems.
Questions to elicit data:
1. How would you define stress in yourself?
2. Identify situations that have caused you stress? 3. How do you respond to stressful situations? 4. Does stress interfere with your family relationship or your work? How? 5. Do you have someone special who helps you deal with stress in your daily life? 6. What do you do to relax? 7. Has there been a significant loss in your life? Do you feel you have resolved this loss? 8. Do you feel you are coping well with your life at this point? 9. Have there been any changes in your family during the past two years? e.g. death, child leaving home, divorce, other? 10. Has there been any unusual stress in your family during the past year?
Value-Belief Pattern
The objective in assessing this pattern is to understand the basis for health-related decisions and actions. As human beings develop, they construct a system of beliefs and values. This system may or may not be tied to religious beliefs. Values provide guidelines for important decisions. Beliefs and values may directly affect both treatment and compliance with health care regimes.
Questions to elicit data:
1. Would you consider yourself to be a religious person?
2. Would you like a visit from the clergy? 3. To what extent does religion play a part in your life? 4. What do you value most in life? Do you have any beliefs that you’d like to share? e.g. about blood transfusions, food patterns etc. 5. Have you thought about having a living will? (Advance Health Care Directives)
