Functional health assessment

Functional HealthAssessment

Functional Health Pattern

Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base.

These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

Health Perception and Health Management. Data collection is focused on

the person's perceived level of health and well-being, and on practices for maintaining health.

Habits evaluated includes smoking and alcohol or drug use.

Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.

Client’s general health? Any colds in past year? If appropriate: any absences from work/school? Most important things you do to keep healthy? Use of cigarettes, alcohol, drugs? Perform self exams, i.e. Breast/testicular self-examination? Accidents at home, work, school, driving? In past, has it been easy to find ways to carry out doctor’s or nurse’s suggestions? (If appropriate) What do you think caused current illness? What actions have you taken since symptoms started?Have your actions helped? (If appropriate) What things are most important to your health? How can we be most helpful? How often do you exercise?

Nutrition and Metabolism Assessment is focused on

the pattern of food and fluid consumption relative to metabolic need.

The adequacy of local nutrient supplies is evaluated.

Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

History (subjective data):Typical daily food intake? (Describe) Use of supplements, vitamins, types of snacks?Typical daily fluid intake? (Describe)Weight loss/gain? Height loss/gain?Appetite? Breastfeeding? Infant feeding?Food or eating: Discomfort, swallowing difficulties, diet restrictions, able to follow?Healing – any problems?Skin problems: lesions? Dryness?Dental problems?

Examination (examples of objective data):Skin assessment, oral mucous membranes, teeth, actual weight/height, temperature.Abdominal assessment.

Elimination.Data collection is

focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.

History (subjective data):Bowel elimination pattern (describe) Frequency, character, discomfort, problem with bowel control, use of laxatives (i.e. type, frequency), etc.? Urinary elimination pattern (describe) Frequency, problem with bladder control? Excess perspiration? Odour problems? Body cavity drainage, suction, etc.?

Examination (examples of objective data):If indicated, examine excretions or drainage for characteristics, colour, and consistency. Abdominal assessment.

Activity and Exercise. Assessment is focused on

the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.

History (subjective data):Sufficient energy for desired and/or required activities? Exercise pattern? Type? regularity? Spare time (leisure) activities? Child-play activities? Perceived ability for feeding, grooming, bathing, general mobility, toileting, home maintenance, bed mobility, dressing and shopping?

Examination (examples of objective data):Demonstrate ability for above criteria. Gait. Posture. Absent body part. Range of motion (ROM) joints. Hand grip - can pick up pencil? Respiration. Blood pressure. General appearance. Musculoskeletal, cardiac and respiratory assessments.

Cognition and Perception. Assessment is focused on

the ability to comprehend and use information and on the sensory functions.

Data pertaining to neurologic functions are collected to aid this process.

Sensory experiences such as pain and altered sensory input may be identified and further evaluated.

History (subjective data):Hearing difficulty? Hearing aid? Vision? Wears glasses? Last checked? When last changed?Any change in memory? Concentration? Important decisions easy/difficult to make? Easiest way for you to learn things? Any difficulty? Any discomfort? Pain? If appropriate – PQRST questions PQRST P – Palliative, Provocative Q - Quality or quantity R – Region or radiation S - Severity or scale T - Timing (Morton, 1977) COLDSPA C - Character O - Onset L - Location D - Duration S – Severity P - Pattern A - Associated factors (Weber, 2003)

Examination (examples of objective data):Orientation. Hears whispers? Reads newsprint? Grasps ideas and questions (abstract, concrete)? Language spoken. Vocabulary level. Attention span.

Sleep and Rest. Assessment is focused on

the person's sleep, rest, and relaxation practices.

Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.

History (subjective data):Generally rested and ready for activity after sleep? Sleep onset problems? Aids?Dreams (nightmares), early awakening? Rest / relaxation periods? Sleep routine? Sleep apnea symptoms?

Examination (examples of objective data):Observe sleep pattern and rest pattern.

Self-Perception and Self-Concept. Assessment is

focused on the person's attitudes toward self, including identity, body image, and sense of self-worth.

The person's level of self-esteem and response to threats to his or her self-concept may be identified.

History (subjective data):How do you describe yourself? Most of the time, feel good (or not so good) about self? Changes in body or things you can do? Problems for you? Changes in the way you feel about self or body (generally or since illness started)? Things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? Not able to control things? What helps? Ever feel you lose hope?

Examination (examples of objective data):Eye contact. Attention span (distraction?). Voice and speech pattern. Body posture. Client nervous (5) or relaxed (1) (rate scale 1-5) Client assertive (5) or passive (1) (rate scale 1-5)

Roles and Relationships. Assessment is focused on

the person's roles in the world and relationships with others.

Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.

History (subjective data):Live alone? Family? Family structure? Any family problems you have difficulty handling (nuclear/extended family)? Family or others depend on you for things? How well are you managing? If appropriate – How families/others feel about your illness? Problems with children? Belong to social groups? Close friends? Feel lonely? (Frequency) Things generally go well at work / school? If appropriate – income sufficient for needs? Feel part of (or isolated in) your neighbourhood?

Examination (examples of objective data):Interaction with family members or others if present.

Sexuality and Reproduction. Assessment is focused

on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions.

Concerns with sexuality may he identified.

History (subjective data):If appropriate to age and situation – Sexual relationships satisfying? Changes? Problems? If appropriate – Use of contraceptives? Problems? Female – when did menstruation begin? Last menstrual period (LMP)? Any menstrual problems? (Gravida/Para if appropriate)

Examination (examples of objective data):None unless a problem is identified or a pelvic examination is warranted as part of full physical assessment (advanced nursing skill).

Coping and Stress Tolerance. Assessment is focused on

the person's perception of stress and on his or her coping strategies

Support systems are evaluated, and symptoms of stress are noted.

The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated.

History (subjective data):Any big changes in your life in last year or two? Crisis? Who is most helpful in talking things over? Available to you now? Tense or relaxed most of the time? When tense, what helps? Use any medications, drugs, alcohol to relax? When (if) there are big problems in your life, how do you handle them? Most of the time, are these ways successful?

Values and Belief. Assessment is focused

on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions.

History (subjective data):Generally get things you want from life? Important plans for future? Religion important to you? If appropriate - Does this help when difficulties arise? If appropriate – will being here interfere with any religious practices?

Sample.pptx

FUNCTIONAL

ASSESSMENT TESTS

ASSESSMENT OF NEWBORN

APGAR SCOREThe test is generally

done at one and five minutes after birth, and may be repeated later if the score is and remains low. Scores 7 and above are generally normal, 4 to 6 fairly low, and 3 and below are generally regarded as critically low.

Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), andRespiration

NEWBORNAPGAR SCORING TEST

Newborn Screening

Republic Act 9288 Newborn screening (NBS) is a public health program aimed at the early identification of infants who are affected by certain genetic/metabolic/ infectious conditions. Early identification and timely intervention can lead to significant reduction of morbidity, mortality, and associated disabilities in affected infants. NBS in the Philippines started in June 1996 and was integrated into the public health delivery system with the enactment of the Newborn Screening Act of 2004 (Republic Act 9288). From 1996 to December 2010, the program has saved 45 283 patients.   Five conditions are currently screened: Congenital Hypothyroidism, Congenital Adrenal Hyperplasia, Phenylketonuria, Galactosemia, and Glucose-6-Phosphate Dehydrogenase Deficiency.  

ASSESSMENT OFINFANT AND CHILDREN

Height and Length

Growth is not only a result of nutrition but also a result of inherited factors. Ethnicity can influence a child’s growth patterns, and so some countries have their own growth charts. 

How to Measure

How to take measurementsTypical measurements taken for

children 0-24 months include:Head circumferenceLengthWeight

Measurements should be taken at regular intervals in order to observe reliable trends. Recommendations for measurement intervals include:

Infants (0-12 months): every 2 months

Young Children: at 15, 18, 24 and 30 months

Ages 3+: every year

Growth Charts Module_Branded

Measurement Schedule handout.pdf

Head CircumferenceHead circumference is a

measurement taken around the largest part of a child’s head. This measurement is typically taken with children ages 0-3 years old.

The measurement should be taken with a measuring tape that cannot be stretched. This is typically a flexible, metal measuring tape. To measure, securely wrap the tape around the widest possible circumference of the head. Typically, this is from 1-2 finger-widths above the eyebrow on the forehead to the most prominent part of the back of the head. Take the measurement three times and select the

largest measurement to the nearest 0.1cm.

cht_hcfa_boys_z_0_2.pdf

cht_hcfa_girls_z_0_2.pdf

Height- it is good determination of health and

normal nutrition as weight-male infant is an average of 2-3cm

longer than of female at birth -During first year of the life the infant

HT should increase by 25-30 cm- by age 2 yrs , the child will be an

average of 12.5 cm taller -most toddlers have reached approximately 1\2 of their adult height.

-AT birth: 46-56cm , average( 50cm)

LengthLength is the linear measurement for

infants up to 24 months. Length measurements (instead of height) are also taken for children 24 to 36 months who cannot stand without assistance.

Length

Length is measured when children are in a recumbent (lying down) position. The most accurate way to measure length is by using a calibrated length board. Length boards should have a fixed headpiece and a moveable foot piece perpendicular to the surface of the board.

To measure, lay the child on the board with their head against the fixed headpiece. Make sure the child is not wearing shoes or a hairpiece. An assistant may be helpful to hold the child still and centered on the board. Straighten the child’s legs and adjust the moveable foot piece so the soles of the feet are against the foot piece. Record the length to the nearest 0.1 cm.

cht_lfa_boys_z_0_2.pdf

cht_lfa_girls_z_0_2.pdf

WeightWeight is a measurement taken

throughout the lifespan to help determine trends and current nutritional status.

WeightInfant weight can be accurately measured

using one of several different pieces of equipment. If available, a pan-type pediatric scale allows a child to be weighed while lying down. These pediatric scales are either electronic or beam scales with non-detachable weights, and are accurate to the nearest 10 gram. Another option is a hanging scale. A hanging scale needs to be attached to a sturdy structure (e.g. building rafter, door frame) and the child is suspended from the scale in weighing pants.

WeightTo measure, make sure the child is

wearing as little clothing as possible and that no one is touching the child. Read the scale at eye-level and record weight to the nearest 10 gram. Repeat the measurement three times, exclude values that appear skewed, and find the average.

Weight

In the event a baby scale is unavailable, an adult standing scale can be used to measure infant weight. Weigh an adult first, and then weigh the same adult while holding a child. Find the difference between the two weights – this is the infant’s weight.

Weight-for-age is an important indicator of a child’s nutritional status over time, such as trends in underweight.

Weight:Average newborn boy

weight=3400g, and girl= 3200g- infant lose 5-10% of birth weight

at age 3-4 days to gain it back in 2 weeks with a steady growth rate.

infant double birth Wight by 6 month

they triple the body weight by 12 month= 10 kg.

Chest, and abdominal circumference.

Whaley and Wong

Abdominal Girth

Abdominal girth should be measured over the umbilicusWhenever possible.

head circumference and chest circumference :

 Measure at birth and routinely until age 3

yrs.HC measures directly skeletal growth

(skull), and indirectly cerebral growth.Measurement at birth = 33-35 cmChest circumference : CC = 31-33 cm at

birthRatio of head to chest circumference: birth : HC is larger than CC2 cm1 yrs-18 month : HC=CC2-3 yrs HC slightly smaller than CC > 3 yrs :HC is smaller than CC by 5-7 cm

Metro Manila Development Screening Test (MMDST)

Developed for health professionals (MDs, RNs, etc)

It is not an intelligence testIt is a screening instrument to

determine if child’s development is within normal

Children 6 ½ years and below

Purposes Measures developmental delaysEvaluates 4 aspects of development

Metro Manila Development Screening Test (MMDST)

4 sectors of developmentPersonal-Social – tasks which

indicate the child’s ability to get along with people and to take care of himself

Fine-Motor Adaptive – tasks which indicate the child’s ability to see and use his hands to pick up objects and to draw

Language – tasks which indicate the child’s ability to hear, follow directions and to speak

Gross-Motor – tasks which indicate the child’s ability to sit, walk and jump

MMDST KIT.  Preparation for test administration involves the nurse

ensuring the completeness of the test materials contained in the MMDST Kit.  These materials should be followed as specified:

MMDST manualtest Formbright red yarn pom-pomrattle with narrow handleeight  1-inch colored wooden blocks (red, yellow, blue

green)small clear glass/bottle with 5/8 inch openingsmall bell with 2 ½ inch-diameter mouthrubber ball 12 ½ inches in circumferencecheese curlspencil

EXPLAINING THE PROCEDURE.AGE & THE AGE LINE. TEST ITEMS.SCORING.

What is the Barthel Index?The Barthel Index consists of 10 items

that measure a person's daily functioning specifically the activities of daily living and mobility. The items include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing, continence of bowels and bladder.

How is the Barthel Index used?

The assessment can be used to determine a baseline level of functioning and can be used to monitor improvement in activities of daily living over time. The items are weighted according to a scheme developed by the authors. The person receives a score based on whether they have received help while doing the task. The scores for each of the items are summed to create a total score. The higher the score the more "independent" the person. Independence means that the person needs no assistance at any part of the task.   If a persons does about 50% independently then the "middle" score would apply.

KATZ INDEXWHY: Normal aging changes and health

problems frequently show themselves as declines in the functional status of older adults. Decline may place the older adult on a spiral of iatrogenesis leading to further health problems. One of the best ways to evaluate the health status of older adults is through functional assessment which provides objective data that may indicate future decline or improvement in health status, allowing the nurse to plan and intervene appropriately.

BEST TOOL: The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is the most appropriate instrument to assess functional status as a measurement of the client’s ability to perform activities of daily living independently. Clinicians typically use the tool to detect problems in performing activities of daily living and to plan care accordingly. The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Clients are scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.

BMIYour BMI is based on your height and

weight. It's one way to see if you're at a healthy weight.

Underweight: Your BMI is less than 18Healthy weight: Your BMI is 18.5 to

24.9Overweight: Your BMI is 25 to 29.9Obese: Your BMI is 30 or higher

HOW TO CALCULATE YOUR BODY MASS INDEX OR BMI

BMI is your weight (in kilograms) over your height squared (in centimeters). Let’s calculate, however, using pounds and inches.

For instance, the BMI of a person who is 5’3" and weighs 125 lbs is calculated as follows:

1. Multiply the weight in pounds by 0.45 (the metric conversion factor)

125 X 0.45 = 56.25 kg

2. Multiply the height in inches by 0.025 (the metric conversion factor)

63 X 0.025 = 1.575 m

3. Square the answer from step 21.575 X 1.575 = 2.480625

4.Divide the answer from step 1 by the answer from step 3

56.25 : 2.480625 = 22.7

3. Square the answer from step 2•1.575 X 1.575 = 2.480625

The BMI for a person who is 5’3" and weighs 125 lbs is 22.7 or practically, 23

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