Professional Documents
Culture Documents
1. History
c. Most important things you do to keep healthy? Think these things make a difference to health?
(Include family folk remedies when appropriate.) Use of cigarettes, alcohol, drugs? Breast self-
examination?
e. In past, been easy to find ways to follow suggestions from physicians or nurses?
f. When appropriate: what do you think caused this ill- ness? Actions taken when symptoms perceived?
Results of action?
g. When appropriate: things important to you in your health care? How can we be most helpful?
NUTRITIONAL-METABOLIC PATTERN
1. History
d. Appetite?
2. Examination
e. Temperature.
ELIMINATION PATTERN
1. History
d. Body cavity drainage, suction, and so on? (Specify.) 2. Examination—when indicated: examine excreta
or drain- age color and consistency.
ACTIVITY-EXERCISE PATTERN
1. History
COGNITIVE-PERCEPTUAL PATTERN
1. History
2. Examination
a. Orientation.
b. Hears whisper?
c. Reads newsprint?
e. Language spoken.
1. History
a. How describe self? Most of the time, feel good (not so good) about self?
c. Changes in way you feel about self or body (since ill- ness started)?
2. Examination
c. Nervous (5) or relaxed (1); rate from 1 to 5. d. Assertive (5) or passive (1); rate from 1 to 5.
ROLES-RELATIONSHIPS PATTERN
b. Any family problems you have difficulty handling (nu- clear or extended)?
d. When appropriate: How family or others feel about ill- ness or hospitalization?
2. Examination
a. Interaction with family member(s) or others (if present). S
EXUALITY-REPRODUCTIVE PATTERN
1. History
a. When appropriate to age and situations: Sexual relationships satisfying? Changes? Problems?
c. Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida?
2. Examination
a. None unless problem identified or pelvic examination is part of full physical assessment.
1. History
a. Any big changes in your life in the last year or two? Crisis?
d. Use any medicines, drugs, alcohol? e. When (if) have big problems (any problems) in your life, how do
you handle them? f. Most of the time is this (are these) way(s) successful?
2. Examination: None.
VALUES-BELIEFS PATTERN
1. History
a. Generally get things you want from life? Important plans for the future?
b. Religion important in life? When appropriate: Does this help when difficulties arise?
c. When appropriate: Will being here interfere with any religious practices?
2. Examination: None.
3. Other concerns a. Any other things we haven’t talked about that you would like to mention? b. Any
questions?
1.
What do you do to stay healthy? Do you drink alcohol or use tobacco products?c.
Do you have regular check-ups with your physician and/or specialists (Pediatrician,Ob/Gyn,
Cardiologist, etc.)? Do you listen to and follow any suggestions made by yourhealth care
providers?2.
Nutritional-Metabolic Patterna.
Describe your
Family’s
typical daily food intake? Do you consider your family healthyeaters?b.
Describe your
family’s
typical daily fluid intake? Do you drink alcohol?c.
Does anyone consider themself over or under weight? Is there any unexplained weightgain
or loss?3.
Elimination Patterna.
Describe you
r family’s
regular bowel elimination pattern? Frequency? Character?Discomfort? Difficulty?b.
Describe you
r family’s
regular urinary elimination pattern? Frequency? Discomfort?Problems with control?4.
Activity-Exercise Patterna.
What do you like to do in your spare time? What sports do you participate in?5.
Sleep-Rest Patterna.
Do you feel that you are generally well rested and able to perform your daily activities?b.
How well do you fall asleep? Stay asleep? Do you use any aids to help you sleep?c.
Cognitive-Perceptual Patterna.
Does anyone have difficulty seeing? Do you have routine eye exams?c.
How do you learn best? Preference for visual or audio aids? Do you have
difficultylearning?7.
Self-Perception
–
Self-Concept Patterna.
8.
Roles-Relationships Patterna.
Who do you live with? Alone, family, others? What was the structure in which you
grewup?b.
Do you belong to social groups? Do you interact with others outside of work or school?9.
Sexuality-Reproductive Patterna.
Female: Describe menstruation cycle. Problems? Last menstrual period? Para? Gravida?10.
Who is most helpful in talking things over? Are the frequently available to you?c.
Values-Beliefs Patterna.
Describe your plans for the future. Do you generally get what you want from life?