Functional Health Patterns

(Adapted from Eisenhauer, L. A. and Murphy, M. A. (1998).

Pharmacotherapeutics and advanced nursing practice. NY: McGraw-Hill.)


Assessment of Functional Health Patterns (FHP)

Gordon's Functional Health Patterns provide a useful framework for assessing the myriad of factors that can influence drug response, and that can impact on compliance and successful outcomes of drug therapy. The FHP discussed below incorporate both subjective and objective data. Through each of these eleven patterns, one can look at how each pattern may affect drug therapy as well as how drug therapy may impact on that pattern.

I. Health Perception-Health Maintenance Pattern:

"client's perceived pattern of health and well-being and how his or her health is managed."

Impact of pattern on drug therapy

Assessment of this pattern can provide a rich data base for planning drug and other therapeutics. It provides insights into the beliefs of the client, current health practices that may affect drug therapy, and resources (or lack of) to enhance health.
Elicitation of beliefs about the nature of health and factors affecting it or the causation of a current illness can provide insights into beliefs about disease causation and how disease should be treated. The use of home remedies is an important area to explore since these may interfere with drug therapy; they also can provides clues to patient's understanding of health, disease, and treatment. Examples include: use of baking soda as antacid; use of Chinese medicines; and the use of herbs. Beliefs about "yin and yang or the "hot and cold" basis of disease and the use of opposite treatments may mean that one particular type of medication may not be acceptable while another would be. Use of homeopathy, health foods and other related preparations, and use of OTC drugs are important to determine in order to prevent interactions with current or future drug therapy.

The history of the patient's current medications and past drug therapy and responses to drug therapy is essential. This can also serve to detect any "allergies" or intolerances to drugs or any familial responses to drug therapy.

The meaning of drug therapy to patients can reveal whether "taking pills" connotes being ill to an extent that either enhances or could interfere with compliance. This information can be useful in determining motivating factors that can help a patient comply to a regimen.

Questions to elicit patterns of compliance are useful in predicting future compliance; it may also elicit any indications of drug-seeking behavior- seeking drug therapy as the answer for any symptom or illness or in the extreme the drug seeking behavior of addiction.. It may be helpful to ask the patient to describe his or her day in relation to taking medications, how they take their medications, eating meals, or other therapeutic interventions, and typical daily activities and events.

Taking a history of immunizations provides specific information about immunization status and also can provide clues about patient's degree of appropriate management of health status.

The use of alcohol, cigarettes, and drugs of abuse are important to determine for possible interaction with drug therapy. Alcohol as a CNS depressant can interact with many other CNS depressants to produce excessive sedation or even death. It also causes gastric irritation which may compound gastric problems with ASA, NSAIDS, and steroids. Alcohol can affect the microsomal enzymes and therefore affect the metabolism of many drugs. The impact of chronic alcohol use on liver function also can affect the biotransformation of many drugs.

Cigarette smoking may affect risk factors for complications of oral contraceptives; may be a contraindication. Nicotine can also affect biotransformation of drugs.(e.g., theophylline)

Health resources available to the patient may affect the choice of drug therapy (unfortunately). Health insurance and managed care today impacts on what drugs can be prescribed. HMO formularies may have only certain drugs that can be prescribed . Medicare, Medicaid, and health insurance plans with coverage for drugs may mandate the use of generic drugs. Most restrict the amount of tablets that can be dispensed at any one time, which may impact on the person's ability to go to the pharmacy or otherwise obtain the medication every 30 days. While this does save money in the event that a medication becomes unnecessary, it does required intricate planning for a patient on multiple medications with differing renewal dates. The cost of medications is a factor in patient compliance with the drug therapy. As a rule of thumb, each prescription medication costs about $50 per month. Therefore an individual on 3 or 4 or more medications can have a considerable financial cost, especially if they do not have insurance.

Assessment of the patient's home and living situation will show if the patient has family members or other caregivers who can help with management of the drug therapy if necessary. This is of particular importance with drug therapy such as insulin in diabetes or adrenocorticosteroids in Addison's disease where daily administration is necessary and where patients can become incapacitated or severely compromised if they do not receive the required doses. The patient's living situation also needs to be assessed in terms of drug storage and disposal. If children (or grandchildren) are present, there is the need to insure appropriate storage and use of childproof caps. Availability of a refrigerator is necessary for storage of certain drugs e.g suppositories, insulin (preferred storage). Medications can be particularly difficult to manage in individuals who are homeless or living in marginal housing situations.

Impact of drug therapy on pattern

The necessity of taking medication for whatever reason on a daily basis may cause the person to believe they are ill and dysfunctional. Certain drug side effects may impact upon the person's perception of their health and well-being. Psychotropic drugs cause many physical side effects (e.g. dystonias, akathesia, Parkinsonism, anticholinergic side effects) that make these individuals feel physically ill when the condition being treated is of a psychological or emotional nature. These side effects can interfere with their agreement to continue with the drug therapy. Many antihypertensive drugs can produce side effects that may interfere with the person's willingness to continue therapy for a condition that often is symptomless. Patients can feel ill from the drug and not from their illness.
Some drugs cause changes in appearance that can affect the person's body image or self image. The steroids cause moon face, and redistribution of fat to the upper torso. Cancer drugs cause loss of hair and changes in facial appearance.

2. Nutrition-metabolic pattern:

" pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply."
Impact of pattern on drug therapy:

Impact of pattern on drug therapy

Assessment of physical parameters related to this pattern also provide valuable data for drug therapy. The patency of the gag reflex and ability to swallow obviously impacts upon the ability to take oral medications.

The person's height and weight and body mass is important for determining drug dosages. Some drugs are prescribed on basis of actual weight while others may be prescribed on the basis of dry weight. Weight loss and weight gain is important to determine in order to evaluate the need for adjustment of drug dosages. The amount of body fat may have implications for the distribution, and therefore dosing, of fat-soluble drugs.

The person's usual dietary pattern and timing of meals will provide data re when drug therapy should be scheduled, e.g., in conjunction with meals or at times away from meals. The use of vitamins or other nutrients or supplements are important to know in terms of usual patterns and also for potential interactions.

Types of foods usually consumed will provide information about potential interactions with foods. e.g. intake of natural licorice and anthypetensive drugs, intake of certain foods with MAO inhibitors, potential interference of certain foods with anticoagulant therapy.

Caffeine intake is important to assess- not only the caffeine in coffee or tea but also in cola and other beverages, as well as chocolate. The possible interference of caffeine with medications such as theophylline, sedatives and also its contribution to gastric irritation are of concern.

The amount and type of fluid intake may influence drug effects. Orally administered drugs will not dissolve as rapidly as expected unless given with an adequate amount of fluid. A general rule at least a half glass of water is preferred. Fluids other than water may cause interactions or alter gastric pH; the outcome depends on the particular drug. Giving an enteric coated drug with milk or an antacid may result in the premature dissolution of the enteric coating in the stomach (rather than the alkaline pH of the small intestines), thus negating the enteric coating and cause the gastric irritation or other side effects intended to be avoided.

Growth factors as occur during adolescence, menopause, and aging may indicate the need for adjustments in dosage of certain medications such as insulin or vitamins.

Impact of drug therapy on pattern

Drugs may affect the nutrition metabolic pattern by altering gastrointestinal function. Drugs, such as those with anticholinergic effects, cause drying of saliva which can affect the ability to swallow tablets or food; these drugs also delay gastric emptying which could increase the rate of absorption of acid drugs and delay the onset of action of alkaline drugs.
Drugs that cause nausea and/or vomiting as a side effect can seriously affect the metabolic pattern. The cancer chemotherapy drugs are a major example; these drugs also cause stomatitis and mucositis that can severely impact on the patient's readiness to ingest food.
Some drugs may interfere with the absorption of nutrients. For example the absorption of tetracyclines will be decreased if given with antacids or iron preparations.
Thyroid drugs may increase or decrease the patient's general metabolic rate. Insulin and oral agents for diabetes mellitus have an intricate relationship with the amount, type, and timing of food intake.
Malnutrition can affect a person's response to a wide variety of drugs. The decrease in serum protein (albumin) can result in highly protein-bound drugs having higher than expected levels of "free" drug. Persons with severe malnutrition usually can not mount an adequate immune response, resulting in possible false negative results with diagnostic tests such as tuberculin testing that rely on an intact immune response. Immunizations may be less effective.

3. Elimination Pattern:

"patterns of excretory function (bowel, bladder, skin)." Excretion of drugs by the lungs may be affected(eg. anesthetics, alcohol)

Impact of pattern on drug therapy:

Assessment of this pattern is important in order to establish the adequacy of function of systems that are responsible for the excretion of drugs. In particular, since most drugs are excreted by the kidneys, renal function is essential to assess in selecting drugs as well as during the ongoing monitoring of drug therapy.

Renal function can be assessed through a variety of methods. Estimates of creatinine clearance estimates are often used to estimate renal function and to serve as a basis for adjusting drug dosages if necessary. A 24-hour urine specimen can be used.

More convenient for general purposes is the estimation of creatinine clearance from the serum creatinine. (The BUN is considered less reliable because it can be affected by a variety of other factors ). In the elderly the serum creatinine is less reliable as an indicator of renal function because of the normal reduction of muscle mass.

The following formula (Cockcroft & Gault, 1976) is often used to estimate creatinine clearance:

Creatinine clearance = (140-age) X Lean Wt(kg)divided by (72 x serum creatinine)

For women: multiply value obtained by 0.85

Lean weight:
For males: 50 kg + 2.3 kg for each inch over 5 feet
For females: 50 kg + 2.3 (?) kg for each inch over 5 feet

Another formula, which does not use weight in the formula, is the Jelliffe Formula (Jelliffe, 1973):
Creatinine clearance = 98 - [(0.8) (Age -20)] divided by the serum creatinine.

Drug elimination via the bowel occurs with some drugs. Elimination of drugs from the lungs occurs with alcohol and paraldehyde. Elimination of drugs through the skin often is not appreciated because it is not usually visible. Alcohol is eliminated from the skin. The antiinfective rifampim provides colorful evidence of its excretion via body secretions by its orange discoloration of tears, perspiration, and urine. (It also can discolor contact lenses)

The patient's usual pattern of urinary and bowel elimination is important to know in planning the scheduling of diuretics and laxatives.

Effects of drug therapy on pattern

Discoloration of the feces can be caused by drugs such as bismuth and iron. Diarrhea may be caused by superinfection of antibiotic therapy, as well as possibly indicating adverse effects of antibiotics such as pseudomembranous colitis. Undiluted liquid KCL or ingestion of large amounts of diet foods containing sorbitol (diet food syndrome) can cause diarrhea by creating hyperosmolarity.

Constipation can be caused by drugs with anticholinergic effects, calcium channels blockers, opioids, calcium or aluminum based antacids, iron.

Urinary output may be increased directly by diuretics and indirectly by digitalis and other cardiotonics as they improve blood circulation to the kidneys. A person's bowel and kidney elimination pattern can be also affected by the timing of administration of these as well as pharmacokinetic variables.

Urine discoloration can be caused by drugs such as phenophthalein, pyridium, rifampin as well as dyes in many vitamin preparations.

4. Activity- Exercise Pattern:

"pattern of exercise, activity, leisure, recreation"

Impact of pattern on drug therapy:

The amount type of physical activity involved in the patient daily life - - either at work, as part of exercise routine - - can influence drug therapy. Assessment of a patient's usual patterns of exercise can provide clues to overall health-related lifestyle as well as detecting any extremes. It could reveal the use of muscle-bulking agents and illicit use of anabolic steroids which could alter drug pharmacokinetics.

Muscular aches and pains from exercise can lead to self-medication with NSAIDs and ASA - which can be basis for gastric irritation and bleeding or renal dysfunction.

The relationship of exercise with insulin and drug and diet therapy is intricately related in diabetes mellitus. The dosing regimen and planning of meals and snacks in relation to exercise is important.

Knowledge of leisure and recreation preference may be useful in motivating patients as well as devising diversional activities as might be desired in the management of chronic pain.

Knowledge of leisure activities such as travel or outdoor camping may indicate need for certain immunizations or preventive drugs( e.g. Hepatitis A and B, tetanus, malarial prophylaxis)

Effects of drug therapy on pattern

Knowledge of the patient's work role and activities can provide information about possible dangers of sedative side effects of drugs. Beta blockers may not be the preferred drug in individuals who participate in rigorous physical activity because of the "braking" effect on cardiac responsiveness.

Drugs may affect the coordination of movement and muscle activity, e.g., antipsychotics producing Parkinson-like changes, dystonias, and akathisias.

5. Sleep-Rest Pattern:

"patterns of sleep, rest, and relaxation."

Impact of pattern on drug therapy:

This pattern is of special significance in determining the effects of Circadian rhythm variations on drug therapy. The emerging fields of chronobiology and chronopharmacology are revealing differences in the effects of drugs given at different times of the day and night. The most well known is that of diurnal variation in blood steroid levels. The peak blood steroid levels in the 24 hour cycle of a person who sleeps at night and is awake during the day occurs in the 4 - 8 AM time period. Administration of exogenous pharmacological (above physiological replacement) doses during early morning has much less suppression of the HPA axis and adrenal cortical function than when doses are given in the evening. The latter results in an additional time period of suppression of ACTH and the adrenal cortex and thus increases the probability of adrenal atrophy. If a person is a night worker, their diurnal variation may differ and a different dosing schedule may be needed in order to prevent adrenal atrophy.

Research on variations in blood pressure throughout the 24 hours had led to recongition that some patients need antihypertensice drug therapy to cover the period of sleep.

The adequacy of sleep is best judged by the client's perception of the adequacy of feeling rested rather than the hours of sleep. If sleep pattern disturbances are detected, careful assessment of environmental factors and of the patient's bedtime routine is necessary before recommending drug therapy. Drugs with CNS stimulating effects need to be given earlier if they are interfering with sleep (e.g. theophylline, ritalin).

Effects of drug therapy on pattern

Several drugs can affect the sleep pattern -many of these have psychotropic effects (e.g. antianxiety, antipsychotic). Antidepressants often improve a disturbed sleep pattern (which is a common sign of depression). Alcohol and other CNS depressants can cause sedation and promote the onset of sleep; often, however, the sleep is not restful and may produce undesirable dreams.

CNS stimulants can affect sleep onset, including caffeine from diet sources as well as from the metabolic breakdown of theophylline. The scheduling of theophylline too close to bedtime should be avoided if it interferes with sleep.

Rebound insomnia and daymares can occur after a person has been using hypnotics. This is believed to result from the hypnotic's decrease in REM sleep; abrupt discontinuance of the hypnotic leads to rebound REM. Hypnotics also can affect this pattern through a hangover effect the next day.

6. Cognitive Perceptual Pattern:

"describes sensory-perceptual and cognitive patterns"

Impact of pattern on drug therapy:

Assessment of mental status, hearing and visual acuity, language and reading skills, as well as learning style preferences provide data useful in judging the person's ability to manage their therapeutic regimen and how they can best be taught.

Short term memory can be important in the patient's ability to remember to take medication and whether or he or she has actually taken a particular dose.

Assessment of sensory pattern will provide data re perception and response to pain- either in past or present.
Effects of Drug Therapy on Pattern:

Many drugs can affect cognitive function in addition to CNS depressants, antidepressants, and psychotropics. Ritalin and amphetamines are drugs that in adults is to enhance cognitive function (and in hyperactive children produce calming effects).

Amnesia can result from many drugs but of note is the amnesia that can occur with hypnotics with short-half lives (e.g. Halcion) and the intended amnesia from drugs administered as part of conscious sedation or monitored anesthesia care. This amnesia can extend backwards to a period of time prior to administration; therefore, patient teaching done just before a procedure may not be recalled by the patient.

Neuropathy ( altered sensations or pain) can result from a variety of drugs such as various .cancer chemotherapy agents or isoniazid (INH).

Ototoxicity can result in both hearing loss and damage to the vestibular branch of the eighth cranial nerve. Ataxia, dizziness, and tinnitus may be early signs. Antibiotics (e.g. aminoglycosides) and loop diuretics (e.g. furosemide, butemide) are commonly used drugs with this potential effect.

Knowledge of a person's impaired hearing might result in the choice of a different drug rather than risk a further loss of hearing. Assessment of hearing prior to the initiation of drugs with potential ototoxic effects can provide a baseline for evaluating hearing level later - during and/or after the course of the drug therapy.

Impaired vision may result from drugs producing mydriasis (e.g., atropine or anticholinergic drugs) or miosis (opiates). Other drugs may produce cataracts, glaucoma or retinopathy.

7. Self Perception Self Concept Pattern:

"Describes self concept pattern and perceptions of self, image, identity, general sense of worth, general emotional pattern."

Impact of pattern on drug therapy:

Persons' perception of themselves as well or ill can depend on their perception of the meaning of drug therapy. Persons with hypertension usually do not experience symptoms and do not see themselves as ill. Being on drug therapy can result in their changing their perception of themselves from being well to being ill; this could result in denial and a subsequent refusal to comply with the prescribed drug therapy.

Some people do not wish to have others know that they have certain conditions and therefore may not want to take any medications that must be taken at work or school. (e.g. persons with epilepsy). This may have implications for the choice of a particular drug or the use of the particular dosing schedule.

Assessment of a person's emotional pattern and their usual ways of responding to life events may indicate the need for psychotropic drug therapy.

Effects of drug therapy on pattern

Physical changes to body appearance
as occurs from steroids, cancer chemotherapy, and Parkinsonian side effects and extrapyramidal effects of antipsychotic drugs can affect a person's body image and sense of self-worth.

Body and head hair can affect a person's image. Alopecia, moon facies, and facial hirsutism can occur with glucocorticosteroids. Local alopecia may occur with the use of birth control pills. Hirsutism/hair growth on head, face, and/or other areas of the body can be an effect of minoxidil; whether this is desirable or not depends on why the minoxidil is used and where the hirsuitism occurs.

Skin color changes also may affect self-image. Birth control pills may produce melasma -the "mask of pregnancy". Quinacrine can cause brown discoloration; yellow skin discoloration may indicate drug-induced jaundice (e.g., INH, tetracycline). Gold injections and bismuth can cause gray or gray-blue discoloration. (Longe & Calvert, 1994, p 4-6)

Mood changes can occur with some drugs; generally any change in hormone levels produce changes in mood and emotional response.

8. Role Relationship Pattern:

Pattern of role engagements and relationships, perceptions of major roles and responsibilities in current life situations

Impact of pattern on drug therapy:

Assessment of the patient's family roles and responsibilities can help to provide an indication of the degree of responsibility taken for his or her own health as well as that of others. Caregiving responsibilities for both children and parents are important to assess in terms of providing expertise in care giving and also as a source of stress to the patient. The latter could result in unintentional noncompliance with therapeutic regimens due to the time and stress involved in caregiving for others. Also important to assess is the availability of caregivers for the patient in the event that he or she becomes unable to manage their therapeutic regimen.

Assessment of family relationships can often provide clues to alcohol or drug abuse in the client and/or family.

Information about work activities can provide data bout potential influence of environmental agents on drug therapy (e.g., contact with insecticides). The location and timingof work activities may have implications for scheduling and administration of medications during work hours. Persons with diabetes and epilepsy as well as others may need to take medication routinely atwork or school and need to work out the best way to do this in their particular setting.

Effects of drug therapy on pattern

Assessment of occupation and work roles can provide important information for planning drug therapy. Especially important to determine are any roles and responsibilities requiring alertness and quick judgment. This is of particular concern when prescribing drugs with sedating effects. Sometimes the sedation produced by many of drugs as side effect usually abates after two or three weeks. Clinicians need to warn patients about this sedation; many occupations require employees to report to their employers whenever they are taking any medications (e.g. bus drivers, pilots, etc.). All patients should be warned not to drive a car or operate any dangerous machinery until these effects have been determined or have abated.

9. Sexuality-Reproductive Pattern:

"patterns of satisfaction or dissatisfaction with sexuality; describes reproductive pattern."

Impact of pattern on drug therapy:

Methods of fertility control used( birth control or drugs to enhance fertilization)are important to assess. Some women may forget to mention oral contraceptives as a medication unless specifically asked about this because they do not necessarily think of these

as a drug or medication.
The current reproductive status and methods of birth control is essential to know, especially in women, in order to determine the risk of any medication to a fetus at the present or in the future while on drug therapy. Also pregnancy status and especially knowledge of breast feeding is important in order to determine potential effects of a drug on a breast feeding infant.

Establishing future reproductive intention in males would be important to determine before initiating chemotherapy or other drug therapy that may affect male sperm production or female egg maturation. Some individuals may wish to arrange to preserve their sperm, ova, or fertilized ova for their future use before initiating certain drug therapies.

Drug use during pregnancy must be carefully chosen, balancing the risk and benefits to both the mother and fetus and in light of what is known about a drug's teratogenicity. (____________ Categories )

Effects of drug therapy on pattern:

A number of drugs can affect sexual function through effects on the libido or on sexual function(e.g. impotence, difficulty in achieving orgasm). Sexual dysfunction is a not uncommon side effects of several types of antihypertensive drugs; patients may be reluctant to discuss this problem or may not realize its possible relationship with the drug therapy.

Other drugs can alter a woman's menstrual cycle.(eg., antipsychotics).Certain drugs may interfere with the effectiveness or oral contraceptives (e.g. antibiotics), necessitating the use of alternate methods of birth control during drug therapy.

Secondary sex characteristics can be altered by adrenocorticosteroids and sex hormones (e.g androgens given to women or estrogens to men)

A prostaglandin analog (misoprostel), used to prevent gastric ulceration in patients on NSAIDs can cause uterine contractions and could precipitate a miscarriage in a pregnant woman.

10. Coping-Stress Tolerance Pattern:

"general coping pattern and effectiveness of the pattern in terms of stress tolerance."

Impact of pattern on drug therapy:

Assessment of the ways in which the patient usually handles stress can provide clues to possible self-medication with alcohol or other drugs of abuse (licit or illicit) to help the person handle stress.

Drug therapy itself should be assessed as a possible stressor- the degree to which it produces stress on the person and the extent to which the person is able to handle this stress. This may provide clues to the need to simplify drug regimens, especially in cases of polypharmacy, especially those in which drugs are added to the regimen to deal with the side effects of another drug-often leading to a multiplicity of often unnecessary drugs.

Effects on drug therapy on pattern

Antianxiety agents and other psychotropics obviously can alter emotion responses and reactions to stress.

Any drug causing sedation can interfere with a person's immediate response to stress and ability to react to it. This can be positive or negative effect, depending upon the situation and intent of the drug therapy.

Adrenergic blockers block the effects of the sympathetic nervous system on target tissues and therefore alter many of the physiological reactions to stress; this is the basis for their use in treating hypertension as well as stage fright.

11. Value-Belief Pattern:

"Patterns of values, goals, or beliefs (including spiritual) that guide choices or decisions."

Impact of pattern on drug therapy:

Careful and sensitive assessment of this pattern can provide insights into patients' beliefs about the meaning of health, suffering, and illness, the causation of illness and what they believe will help or cure the disease or will heal them. This information can help to design an effective regimen that the patient will adhere to.

Certain religious beliefs and practices may affect a person's willingness to take certain medications. a Catholic may be refuse to take oral contraceptives; a Jehovah Witness may refuse drug based on blood products; some strict Jews may declined the use of insulin derived from pork.

The beliefs elicited in this pattern are closely related to the first pattern-health perception-health management- providing a full circle of the patterns and demonstrating their interactive nature.