Developmental Teaching Plan

HEALTH PATTERNS ASSESSMENT

Meeting Date: _______________ Time:____________________

Participants: ______________________________

______________________________

NOTES:

Illness

Description per ______Nurse _____ Patient

1. Present Illness or Diagnosis: __________________________________

For how long: _____________________________________________

Describe: ________________________________________________________________

2. How has it affected you:__________________________________________

Your S.O.:______________________________________________________

Your Family: ___________________________________________________

Describe: _________________________________________________________________

3. Interventions: None Medications Lifestyle None Other

Describe: _________________________________________________________________

NOTES:

Reproductive

Male

Sexual Dysfunction:

Describe:

NOTES:

Female

LMP_____ Last Pap Smear________ Pain with: Pregnant

Para_____ Itching Breast Lumps Menstruation Yes

Gravida____ Abnormal Bleeding PMS Intercourse No

Contraception Discharge Other

Role Relationship

1. Home Environment: Lives with Spouse Lives Alone Lives with family

Living with friend

2. Who do you rely on for emotional support? Spouse Family Friend Self Other

Describe: ________________________________________________________________

3. How does your illness/hospitalization affect your family significant others?

Describe: _______________________________________________________________

NOTES:

Coping/ Stress

1. Have you had any recent changes in your life (job, move, divorce, death, major surgeries, recent abuse, new illness)

Yes No Describe: _________________________________________________________

2. Do you feel you are dealing successfully with stresses associated with this change?

Describe: ________________________________________________________________

Sleep/ Rest

1. Sleep: No problem Difficulty falling asleep Difficulty staying asleep

Does not feel rested after sleep

Other: ___________________________________________________________________

2. What helps you sleep?

NOTES:

Self-Perception

1. What concerns you most about your illness/ hospitalization?

Describe: ________________________________________________________________

2. Does your illness and/ or hospitalization affect your sexuality/ body image?

Yes No

NOTES:

Values Beliefs

1. Is religion important in your life? Yes No

Religion/ Faith___________________________

Describe: _____________________________________________________________

NOTES:

Safety

1. All areas with ** should be considered for FPP

2. FPP should automatically be instituted for pts. who have/ are

A) fallen previously

B) Confused disoriented or combative

C) Chemical or physical restraints required

NOTES: