ADULT ASSESSMENT

Nursing History
1. HEALTH-PERCEPTION-HEALTH-MANAGEMENT PATTERN
 What is your opinion about health?
 Are you immunized about seven target diseases?
 Last immunization?
 Do you have any allergy? If yes then type of allergy.
 Any surgery in past? What type of surgery?
 Last physical examination & for what purpose.
 Are you using any medicine recently?
 Do you know about these medicines?
2. NUTRITIONAL-METABOLIC PATTERN
• Ask about their skin, scalp and nails?
• What is your diet menu?
• Any food restriction regarding disease point of view?
• Any food restriction regarding religious point of view?
• Any food like or dislike?
• Any food allergy?
3. ELIMINATION PATTERN
Urine:
• Color of urine, amount, frequency, odor and any discharge.
• Any urinary problem, dysurea, Anurea, Oligourea, , polyuria.
Defecation:
• Are you using any laxative? If yes which?
• Any problem during passing defecation?
4. ACTIVITY-EXERCISE PATTERN
 Do you any breathing problem?
 In which apnea, hypoxia, hypoxemia, hypercapnia.
 Do you have cough? (Productive or non productive)
 Any changes in heart beat during exercise?
 Do you feel pale during exercise?
 What type of exercise you do or any problem during exercise?
 Sufficient energy for desired/required activities?
 Spare time (leisure) activities? Child’s play activities?
 Perceived ability for the following (code level according to Functional Levels Code below)

Functional Levels Code

Level 0: Full self-care
Level I: Requires use of equipment or device
Level II: Requires assistance or supervision of another person
Level III: Requires assistance or supervision of another person and equipment or device
Level IV: Is dependent and does not participate
5. SLEEP-REST PATTERN
• Sleeping hour?
• Are you using nap (evening type sleeping).
• What do you feel after waking? (Fresh, headache, drowsy).
• Are you using any medication for sleeping?
• Do you have any exercise or walking at night?
• Sleep-onset problems? Aids? Dreams (nightmares)? Early awakening?
6. COGNITIVE-PERCEPTUAL PATTERN
 Hearing difficulty? Aid?
 Vision? Wear glasses? Last checked?
 Any change in memory lately?
 Easy/difficult to make decisions?
 Easiest way for you to learn things? Any difficulty learning?
 Any discomfort? Pain? How do you manage it?
 Orientation about time place and person.
• Any difficulty in sentence making?
• Loss of memory.
7. SELF-PERCEPTION-SELF-CONCEPT PATTERN
• How would you describe yourself? Most of the time, do you feel good (not so good) about yourself?
• Changes in your body or the things you can do? Are these problematic for you?
• Changes in way you feel about yourself or your body (since illness started)?
• Find things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? What helps?
• Ever feel you lose hope? Not able to control things in life? What helps?
• Do you like grooming?
8. ROLE-RELATIONSHIP PATTERN
• Live alone? Family? Family structure? Draw diagram.
• Any family problems you have difficulty handling (nuclear/extended)?
• How does the family usually handle problems?
• Family depend on you for things? How are you managing?
• If appropriate, how do family/others feel about your illness/hospitalization?
• If appropriate, problems with children? Difficulty handling?
• Belong to social groups? Close friends? Feel lonely (frequency)?
• Things generally go well for you at work? School? If appropriate, income sufficient for needs?
• Feel part of (or isolated in) neighborhood where living?
• What is your role in family?
• If you are in hospital then who will perform your responsibilities?
• All the family members are cooperative with you?
• Who is decision maker in your family?
9. SEXUALITY-REPRODUCTIVE PATTERN
• If appropriate to age/situation, sexual relationships satisfying? Changes? Problems?
• If appropriate, use of contraceptives? Problems?
• For females, when menstruation started? Last menstrual period? Menstrual problems? Para? Gravida?
• When you first notice changes in your menarche (first menses is called menarche)
• Do you have any sexual problem? (loss of libido)
o Active sex (direct sex with male and female)
o Passive sex (sex without male and female partner)
o Digital sex (Artificial dimy etc)
• Reproductive: Infertility
10. COPING-STRESS-TOLERANCE PATTERN
• Any big changes in your life in the last year or two? Crisis?
• Who’s most helpful in talking things over? Available to you now?
• Tense a lot of the time? What helps? Use any medicines, drugs, alcohol?
• When (if) problems occur in your life, how do you handle them?
• Most of the time, is this way(s) successful?
11. VALUE-BELIEF PATTERN
• Generally get things you want out of life? Important plans for the future?
• Religion important in your life? If appropriate, does this help when difficulties arise?
• If appropriate, will being here interfere with any religious practices?
• What is your religion?
• Do you offer prayer?