JHELUM COLLEGE OF NURSING & HEALTH SCIENCES
Post RN BScN Year I & Year II
Assessment tool: Gordon’s Functional Health Pattern
Patient Name: ___________ MR No: ______________ Unit/ward: _______________
Date of admission: ____________ Age: ___________ Sex: ____________________
Occupation/ Profession: _________ Language :( 1) ___________ (2) ________________ Education:
_______________ Marital status: ______________
Children: __________ M______ F_______
Medical diagnose: ______________________________________
Past medical history: (1) Hospitalization_______________________________________
(2) Surgery_____________________________________________
(3) Medications at home __________________________________
Chief complaints: _________________________________________________________
________________________________________________________________________
Present surgeries: __________________ Immunization status: _____________________
Vital signs: B.P: _______________ Pulse: ________________ RR: _________________
Temp: ____________
1. Health Perception Health Management Pattern:
Patient’s views about his/her health, and how he/ she manages his/ her health:
________________________________________________________________________
___________________________________________________________________
Patient’s views about his illness, and how he/ she manage his/ her illness:
___________________________________________________________________
Patient’s knowledge about his/her disease:
Patient’s knowledge about disease prevention:
_________________________________________
List of current medications
Over the counter drugs: ___________________________________________________ Allergies: Food
__________ Drugs _______________ Others ________________
Nursing diagnosis: ________________________________________________________
_______________________________________________________________________
2. Nutrition Pattern
Number of meals per day: Breakfast __________ Lunch_________ Dinner________
Snacks _____________
Food Preferences: 1.Likes_________________2)Dislikes_________________________
Amount of fluid per day____________ Route (I/V) ________ Oral ______________
Tube feeding (explain) _____________ Any dietary restriction__________________
Any fluid restriction ________________________
Skin: turgor_____________Color___________Texture___________edema_____________
Hair: Texture________________Distribution__________________
Oral mucous membrane ________Gums____________ No of teeth___________ Alignment ________
Dentures _________ Height ___________ Weight __________
Labs: Hb ___________ Hct ___________ WBC ___________ ESR _________
RBC _____________ Platelets ____________ PT_________ APTT _____________
INR__________ Albumin ____________ Na__________ K ________ Ca_________
Mg________ Others__________________
Nursing Diagnosis: _____________________________________________________
____________________________________________________________________
3. Elimination Pattern
Urine: Frequency /24 hours ____________ Voidingself/catheterized______________
Color____________ Amount/24hrs__________________ Any pain/discomfort during
urination___________________
any problem with bladder Control: Retention/Incontinence______________________
Stool/ 24 hours__________ Color _________ Odor___________
Characteristic _________ Amount_____________ Any laxatives used ______________________
Any problem with bowel control: Constipation/Incontinence___________________
NursingDiagnosis:_____________________________________________________________________
______________________________________________________
4. Activity Exercise Pattern
Life style (active, sedentary) ____________Breathlessness during activity or at rest__________ Cough
(dry, productive) ___________if productive ____________
Color_________Odor________Characteristic_____________Amount______SOB__________O2/min
_______ via _____________ Inhalation therapy __________ Sputum tests ______________
Nursing Diagnosis:_____________________________________________________
____________________________________________________________________
Circulation:
Pulse rate/min____________ Rhythm ____________ Amplitude____________ _________ Peripheral
pulses ______________ Capillary refill_____________ Extremities: Color____________
Temp___________________
Nursing Diagnosis______________________________________________________
_____________________________________________________________________
5).Cognitive perceptual pattern
Level of consciousness: Oriented to Time _______ Place________ Person ________ if unconscious
GCS _________Any speech difficulty ________________
Memory: Recent________ Remote _________Vision _______Glasses________ Hearing___________
Pain: Characteristic____________ Onset__________ Location_____________ Duration
________________ Exacerbation __________ Radiation ______________ Relieving
factors_____________ Associated factors___________________
Nursing diagnosis:_____________________________________________________
____________________________________________________________________
6). Rest and Sleep Pattern
No of hours sleep/ 24 hours: Home __________ Hospital ________ Naps__________
Any problem to fall /stay asleep ____________Use of tranquilizers _____________ Any home remedy
to induce sleep________________
Evidence of lack of sleep ___________________ Quality of sleep____________
Nursing diagnosis: _____________________________________________________
_____________________________________________________________________
7). Self Perception/Self Concept Pattern
Patient’s perception of his or herself ______________________________________
Grooming _______________ Voice tone _____________ Eye contact ____________
Gesture /Congruent with words ____________________
Nursing diagnosis: _____________________________________________________
____________________________________________________________________
8).Role Relationship Pattern
Family (extended/nuclear) __________Responsibilities in family _________
Role shared by_________Role in decision making _____________
Leisure entertainment activities___________ Socialization_______________ Satisfaction with
family/work _________________________
Nursing diagnosis: _____________________________________________________
_____________________________________________________
9). Coping/ Stress Pattern
Affect/Mood: Calm_______ Angry _________Irritable__________
Anxious _______ Withdrawal____________ Apthetic__________
Common stressors __________________Coping behavior during stress___________ Sharing of stress
With____________________________
Use of Alcohol/Pan/Tobacco/cigarette/Drug: ______________________________________________
Nursing Diagnosis: _____________________________________________________
_____________________________________________________________________
1O). Sexuality /Reproductive Pattern
History of birth control: ___________ Age of puberty___________
Onset of menses (F):___________ Menstruation cycle_________ Amount _______
Pain/problem______________ Frequency ________________ Menopause_________ No of children
______ Alive _____ Dead ______ Marital relation with spouse_______________ Self breast
examination (F):____________
Self testicular examination (M) ________________
Nursing diagnosis: _____________________________________________________
____________________________________________________________________
11). Value belief pattern
Things important in life ___________________Spirituality_____________________ Religious
beliefs___________________________
Any spiritual conflict_____________
Satisfaction with life ________________________
Nursing diagnosis: _____________________________________________________
____________________________________________________________________
