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Gordon's Functional Health Pattern Form

This document contains a functional health patterns assessment form to gather information about a patient's health history, current condition, and relevant social factors. The assessment covers 12 areas of health including nutrition, elimination, activity, sleep, cognition, self-perception, roles, sexuality, coping, values, and other concerns. For each area, the form prompts the assessor to gather information through patient history questions and physical examination findings.

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Michael Bon Margaja
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© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
942 views

Gordon's Functional Health Pattern Form

This document contains a functional health patterns assessment form to gather information about a patient's health history, current condition, and relevant social factors. The assessment covers 12 areas of health including nutrition, elimination, activity, sleep, cognition, self-perception, roles, sexuality, coping, values, and other concerns. For each area, the form prompts the assessor to gather information through patient history questions and physical examination findings.

Uploaded by

Michael Bon Margaja
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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N. BacalsoAve.

,Cebu City

College of Nursing

Gordon’s Functional Health Patterns


An Assessment

Initial’s of the Client: Occupation:


Complete Address:

Age: Sex: Religion:


Marital Status:
Source of Medical Care:
Reason for Visit/Admission (Complaints of the Client):

I. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN


1. History
a. How was general description of the client’s health prior to
hospitalization or consultation ?
b. Any colds in past year? When appropriate: absences from work?
c. Most important things you do to keep healthy?
Use of cigarettes, alcohol, drugs? Breast self-examination?
d. Accidents (home, work, driving)?
e. In past, are there any health suggestions that were easy for the
patient to comply?
f. When appropriate: what do you think causes this
illness/complaint? Actions taken when symptoms perceived?
Results of action?
g. When appropriate: What are things that are important to the
patient in health care? How can we be most helpful?
h. Describe the patient’s general health appearance

II. NUTRITIONAL-METABOLIC PATTERN

1. History
a. Describe the typical daily food intake? Supplements (vitamins, type
of snacks)?
b. Describe the typical daily fluid intake?
c. State the weight of the patient in relation to the height. What is the
significance of his weight to his height?
d. Can the patient consume his food during meal or snack time? If
not, why?
f. If the patient has wound, does it heal well or poorly?
g. Any skin problems like lesions, dryness and dental problems?

2. Examination
a. Skin: Bony prominences? Lesions? Color changes? Moistness?
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures? Cavities?
Missing teeth?
d. Actual weight, height.
e. Temperature.
f. Intravenous feeding–parenteral feeding (specify)?

III. ELIMINATION PATTERN


1. History
a. Describe the bowel elimination pattern? Frequency? Character?
Discomfort? Problem in control? Laxatives?
b. Describe elimination pattern? Frequency? Problem in control?
c. Presence of excessive perspiration? Odor problems?
d. Any body cavity drainage, suction, and so on that aids the patient
in elimination?

2. Examination: when indicated: examine excreta or drainage color and


consistency.

IV. ACTIVITY-EXERCISE PATTERN


1. History
a. Is there sufficient energy for desired or required activities?
b. Does the patient exercise regularly? What type of exercise?
c. What are the patient’s activities in their spare-time / leisure time? If
the patient is a child, what play activities does he indulge in?
d. Perceived ability (code for level) for:

Functional Level Codes:


*Level 0: full self-care
*Level I: requires use of equipment or device
*Level II: requires assistance or supervision from another
person
*Level III: requires assistance or supervision from another
person and equipment or device
*Level IV: is dependent and does not participate
Criteria Rate Criteria Rate
Feeding Grooming
Bathing General mobility
Toileting Cooking
Home maintenance Shopping
Dressing Bed mobility
Gait Posture
ROM Hand grip

e. General appearance (grooming, hygiene, and energy level)

V. SLEEP-REST PATTERN
1. History
a. Can the patient rest/sleep? What are the usual daily activities of
the patient to induce him to sleep?
b. Are there sleep onset problems? Aids? Dreams (nightmares)? Early
awakening?
2. Examination
a. When appropriate: Observe sleep pattern.

VI. COGNITIVE-PERCEPTUAL PATTERN


1. History
a. Any hearing difficulty? Presence of Hearing aid?
b. Is there a problem in vision? Wear glasses? Last checked? When
last changed?
c. Any change in memory lately?
d. Does the patient experience difficulty in deciding during problems,
family issues, etc. ?
e. What are the patient’s strategies to make decisions easier?
f. Any discomfort? Pain? When appropriate: How do you manage it?

2. Examination
a. Orientation.
b. Hears whisper?
c. Reads newsprint?
d. Grasps ideas and questions (abstract, concrete)?
e. Language spoken.
f. Vocabulary level. Attention span.

VII. SELF-PERCEPTION—SELF-CONCEPT PATTERN


1. History
a. How will the patient describe self? Most of the time, feel good (not
so good) about self?
b. Changes in way the patient feel about self or body (since illness
started)?
c. Things frequently make the patient angry? Annoyed? Fearful?
Anxious?
e. Ever feel that the patient lose hope?

2. Examination
a. Eye contact. Attention span (distraction)
b. Voice and speech pattern. Body posture
c. Nervous: relaxed, passive etc

VIII. ROLES-RELATIONSHIPS PATTERN


1. History
a. Is the patient living alone? With family?
Draw the family structure in diagram
b. Any family problems you have difficulty handling (nuclear or
extended)?
c. Are the family or others depend on the patient for things? How is
the patient managing?
d. When appropriate: How do the family or others feel about illness or
hospitalization?
e. When appropriate: Are problems with children also the concern of
the patient? Does the patient have difficulty in handling the
problems?
f. Is the patient belongs to social groups? Close friends? Is the
patient lonely?
g. Are things generally go well at work or school?
h. When appropriate: Does the income sufficient for their needs?

2. Examination a. Interaction with family member(s) or others (if present).

IX. SEXUALITY-REPRODUCTIVE PATTERN


1. History
a. When appropriate to age and situations: Does the patient’s sexual
relationships satisfying? Any changes? or problems?
b. When appropriate: Use of contraceptives? Problems?
c. Female: When menstruation started? Last menstrual period, if with
relation? Menstrual problems? Para? Gravida?

2. Examination
a. None unless problem identified or pelvic examination is part of full
physical assessment.

X. COPING-STRESS TOLERANCE PATTERN


1. History
a. Is there any big changes in the patient’s life in the last year or two?
Any crisis?
b. Who is the most helpful in talking things over? Is this person
available to you at present?
c. Is the environment tense or relaxed most of the time? When tense,
what coping strategy helps?
d. Use any medicines, drugs, alcohol?
e. How do the person handle stress?
f. Most of the time, is the coping strategies successful?

2. Examination: None.

XI. VALUES-BELIEFS PATTERN


1. History
a. Important health plans for the future?
b. Is religion important in life? When appropriate: Does this help when
difficulties arise?
c. When appropriate: Does religion interfere with health practices?

2. Examination: None.

XII. Other concerns


a. Any other things we haven’t talked about that you would like to mention?
b. Any questions?

Prepared by:

________________________
Printed Name Over Signature
Section: ____

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