ASSESSMENT — Functional Health Patterns BIOLOGIC @ ‘58 yr. old female lying in bed awake. TV infusing DS %NS in right wrist. Emests basin, apple, and cup of ice water on bedside table. ‘Sandals beside bed on floor, Cognition/Perception (LOC, orientation, memory, pertinent eranial nerves (vision, hearing, smell) sensory discrimination, spinal reflexes) ‘Alert and oriented x3. Memory intact- able to state name, date of birth, and years of surgeries. CNI intact- able to distinguish smell of alcohol swab. CNII intact able to read nametag at 12 inches, CNHI intact- both eyes PERRLA, CNIV and CNVI intact. able to follow Penlight with eyes, CNVIIl- able to hear normal spoken voice and finger rub in both ears, AbIC to discriminate different pressures and sensations in feet, no tingling or numbness of extremities reported. Reflexes deferred. Activity/Exercise (Respiratory, cardiac, peripheral vascular, musculoskeletal including gait, ROM, strength, coordination, ability to perform ADL) Lunas cle bieeve lly Respiratory rate 16 breaths per minute, unlabored and regula. Radial pulse is 62 bpm, strong and regular. Apical pulse is 60 bpm, strong and regular. Pulse deficit is 2. Blood pressure is 120/69. Carotid pulse is strong and regular. Radial and pedal pulses equal bilateral Copillary refills brisk in fingers and toes. No edema in extremities. Full ROM, Gaiteven and balance steady with no assistance. Positive Romberg. Hand grasp is equal bilaterally. Muscle strength equal bilaterally in all extremities. Able to perform all ADL’ with Nutrition/Metabolism (Hut, body temperature, color sclerae, color conjunctivae, hair, mouth and throat, intake, skin wounds, turgor) ® Hight in chart is 64 inches. Weight in chart is 94 kg. Temperature is 97.0 orally. Sclera white and conjunctivae pink and moist. Hair ‘equally distributed, gray, and clean. Mucus membranes pink and moist with no lesions. Uvula midline. Teeth white, but | tooth misting ‘on bottom front and | missing on top back right. Skin is pink, warm and dry. Good skin targor. Client on carb consistent det due to diabetes. Fluid intake before discharge orally was approx. 50 m.. TV fluids DC"d at 0700. Hep-lock DC'd at 0925, Elimination (Abdomen, urinary and bowel elimination) Abdomen soft, nontender, and rounded. Bowel sounds hyperactive all 4 quadrants. Client states no problems voiding. No longer having any pain during urination. Client states bowels are diarthea and frequent. ‘CDIFF tet reformed but no results at discharge, Client states -diarthea started on 4/22/09, ‘Sleep / Rest (Frequent yawning, decreased attention span, dark circles under eyes, frequent naps) Client repors feeling well rested. No circles under eyes, no observance of any yawning. Did not observe client napping during shift ‘Attention span normal and alert and oriented. PSYCHOSOCIAL ‘Sele-Perception / SelicConcept (Eye contact, personal grooming, posture, mood, emotions) Maintained eye contact with student nurse during assessment. Hair is clean and groomed. Client had already performed oral hygiene. Client is wearing clean gown. Posture erect. Client smiles often and laughs with roommate and husband, Curtain between roommates i pulled back so they can talk to each other. ® SAMPLE a4oles / Relationships (Interactions with others [verbal and nonverbal) ing discharge, lab results, and what she can do at home for diarrhea. lent is a mother of 3 grown boys and la married, Talks ut sone and husband often, os with student nurse, nurse, PCA, roommate and family. Smiles often during conversation. Asks a lt of questions about Coping / Stress Tolerance ({IFin acute tess), pallor, diaphoresis, heart rate rate and depth of respirations [No apparent distress skin pink, no diaphoresis, Heart Rate 71 bpm. Respiations 16, unlabored and regular, ‘Sexuality / Reproduction (Breast exam, genitalia) [may be biologie and/or psychosoctal] Breasts equal to inspection. Client states she docs breast self exams Ix month at home. Clint states she cannot remember dtc of last ‘sexual Intercourse. Tubal ligetion preformed in 1989, lues/Betiefs (Bible, cross, rosary, prayer book, visits by clergy, pictures) [psychosecil and / oF spiritual No bible or religious material noticed in room. Client declined regarding religion. Clint did mention that hospital clergy came to visit her yesterday. No flowers or pictures in room. (Health promotion activities) ‘Observed client ambulating with no assistance. Client on carb consistent dict and client states trying to follow healthy diet at home because of her diabetes. Client states she checks blood sugar 2x daily at home, @ 345;