Individual Client Health History and Examination
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
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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? © 2016. Grand Canyon University. All Rights Reserved. Pattern of Value and Beliefs: • 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): © 2016. Grand Canyon University. All Rights Reserved. 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.
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