HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN Assignment
Student Name: Laurie Christensen
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Client Profile: My client is a Caucasian 16-YO named Jessica. She is in 11th grade. She
complains of seasonal allergies and uses Benadryl occasionally for that. She is not on any
other medications or drugs. She is here today for a prenatal visit and realizes the importance of
maintaining her health for her current pregnant status.
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Developmental History: Jessica relates how stressful it is to be pregnant. She gets sick and
has to leave class often. She wants to get through school but feels very isolated. She states
that she has no friends at school. She relates that her relationship with the baby’s father is OK.
She lives with her parents and her sister. Jessica should be at Erickson’s stage of identity
versus role confusion. This pregnancy may inhibit her from progressing on to the next stage of
intimacy versus isolation—as she already feels isolated from her peers.
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Health Perception-Management Pattern: She rates her health as a 9 (on a scale of 1-10). 5
years ago she would have rated her health at 10. She is currently 12 weeks pregnant and does
receive financial and emotional support from her parents. She has a little childcare experience
but is not sure she will know how to care for a newborn. She is current on all her immunizations
and has committed to make regular doctor visits while she is pregnant.
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Nutritional-Metabolic Pattern: Jessica has a varying diet—right now it consists of crackers.
She states that she drinks an average of 6 glasses of water a day. She has felt nauseous and
has had some vomiting but has not lost any weight. Her skin, hair, and nails all look healthy.
She is 5’2” and weighs 115#. She makes regular visits to the dentist and orthodontist.
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Elimination Pattern: She states that she is often constipated and “poops out tiny marbles”.
Her last BM was 2 days ago. She states that she “pees all the time”. Urine is clear and causes
no burning sensation.
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Activity-Exercise Pattern: Her normal activity includes getting up and getting ready for school.
She doesn’t talk to anyone and they seem to avoid her due to her pregnancy. Her hobbies
include watching movies and riding horse. She enjoys gym class, which has been specially
modified to keep her healthy during pregnancy. Jessica works at a movie rental store part time.
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Sexuality-Reproduction Pattern: Jessica’s periods have been irregular, and she had been on
birth control to help regulate her cycles. She went off of the pill 4 months ago and used no other
form of contraception, therefore resulting in her pregnancy. She confided that she and her
boyfriend used the “pull and pray” method of birth control. She is comfortable with her sexual
health and stated that now they can “do it” anytime because they are already pregnant. Her
breasts are a little uncomfortable and tender.
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Sleep-Rest Pattern: She states that she sleeps pretty good –an 8 (on a scale of 1-10)
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Sensory-Perceptual Pattern: All senses are good. Biology class makes her nauseous due to
pregnancy. Because all sensory fields appear normal and healthy for her age, no fall
assessment or skin assessment is necessary.
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Cognitive Pattern: Her attention span seems short. She rates it at 6 (on a scale of 1-10).
Jessica’s grades are average or above.
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Role-Relationship Pattern: Her parents are married and her younger sister is still at home as
well. Her Dad didn’t talk to her for a week after finding out about her pregnancy. Mom is more
understanding. The most important person in her life is her boyfriend and her sister. The only
social activities or groups she participates in are 4H with the horse club.
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Self-Perception-Self-Concept Pattern: She states that this “sucks”. She is lonely and feels
stressed. She is nervous and scared about having a baby. She feels “fat” but is still wearing
her normal clothes and is not in any larger or in maternity sizes yet.
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Coping-Stress Tolerance Pattern: Jessica says that because she is only 16, this is the most
stressful thing in her life so far! Her parents will help her financially for now. To relieve stress,
she has smoked, cried, ridden her horse, and punched a hole in the window. She feels she is
coping better now than when she first found out about her pregnancy.
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Value-Belief Pattern: Her most important value is faith. She states that she believes in God
and goes to church on Sundays. It doesn’t seem to be an active part of her daily life..
Summary: What are the priority problem areas identified for this client? This patient
has several things that need to be worked through for healthy functioning.
 She needs to be educated on the importance of not smoking while she is
pregnant.
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She needs guidance on choosing proper nutrition and teaching on healthy
weight gain while pregnant.
 She needs to stay connected with family and friends to address her loneliness.
 She needs realistic reasons to have a positive self-image.
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She needs to address the delayed/interrupted goals that pregnancy and being a
parent will have on her education and future.
She will need to have some preparation classes on caring for a newborn and
parenting skills.
She needs training on healthy and positive ways to reduce stress.