The patient Is complaining that they feel weak, their urine is dark, nausea, pain in…
Adult Functional Health Assessment
How does the person describe current health? This is a 64 year old male with a history of hypertension, high cholesterol, and GERI. PC reports he is in good health and recently lost 20 pounds to help reduce is blood pressure and “get in better shape. ” He walks an average of 2-3 miles, 5 days a week for exercise and plays gold 3 times a week. He feels he is in better health than he has been In the last ten years.
PC reports, he has had 2 basal cell carcinomas moved and now always uses sun screen and wear shirts when outside to reduce sun exposure. What does the person do to maintain health? PC walks 2-3 miles, 5 days a week. PC reports he has been increasing his walking distance. He has lost 20 pounds over the last 6 months by increasing daily activity and eating a low fat and low cholesterol diet. PC reports he also plays gold “as much as he can,” which is usually 3-4 times a week when he is not traveling. What does person know about links between lifestyle and health?
Patient was not overly concerned about his health until ten years ago, when his father died of a heart attack. He was also diagnosed with high blood pressure and high cholesterol close to that time. PC reports he wants to maintain a healthy lifestyle and reduce his current blood pressure and cholesterol. How big a problem is financing health care for this person? PC retired 3 years ago after being in the education system in Oregon. He currently has Medicare and states he has good Insurance coverage. Can this person report his/her medications and the reason for taking them? PC does know his medication and their doses.
He also can tell you what interacts with his medications ND what they are used for. Patient currently takes illusionist MGM once a day and Lipton MGM, which was recently reduced from MGM. PC states he also uses a ETC Primrose to help with heart burn. If this person has allergies, what does he/she do to prevent/manage them? PC states he is allergic to sulfa. He has not taken any sulfa based medication In years, but what he remembers Is breaking out In hives after a dose he received. What does the person know about medical problems In his/her family? PC is very aware about his families medical past.
Father died 10 years ago Have there been any important illnesses/in]Aries 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: Actively/Leisure? Exercise/Recreation? Cardiac/Respiratory System? –Musculoskeletal System? Cognitive/Perceptual Pattern: Does this person have 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 eave 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? 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?