GORDON'S FUNCTIONAL HEALTH PATTERNS

#1 HEALTH MAINTENANCE MGMT. #5 COGNITIVE/PERCEPTUAL

 Admit Date  Pain (scale, characteristics)

 Medical Diagnosis  Glasgow Score
 Pertinent Medical History  Sensory Aids
 Pertinent Psychosocial History  Level of Consciousness
 Insurance  Circulation, Motion, Sensation (CMS)
 Age
 Allergies-Food and Medicines #6 SLEEP/REST SUBJECTIVE OBJECTIVE
 Erikson's Developmental Level
 Tendency Toward which Pole  Pattern of Sleep
 Perception of Health Status  Quality/Quantity
 Immunization Status
#7 SELF-PERCEPTION/SELF-ESTEEM
 Risk Behaviors
 Discharge Needs  Describes Attitudes about Self and Perception
 Medications Prior to Admission of Abilities.
 Attitudes about Self
#2 NUTRITION/METABOLIC
 Impact of Illness on Self
 Diet  Desire to Change Self
 Recent Intake (% of meals)  Nervous or Relaxed: rate 1-5
 Food Preferences  Perceived Powerlessness
 Abdomen  Body Posture
 Bowel Sounds  Eye Contact
 Nausea  Assertive or Passive: rate 1-5
 NG Tube  Nonverbal Cues to Altered Self-esteem
 IV Fluids  Facial Expressions
 Intake/Output (no. of hours) #8 ROLE/RELATIONSHIP
 Temperature
 Edema  Occupation
 Height, Weight  Recent change in Role
 Body Mass Index  Comfort with Change
 Marital Status
#3 ELIMINATION  Family Structure
 Bladder #9 SEXUALITY
 Bowel Patterns
 Last BM  Menstrual History: Children
 Skin  Self-breast/Testicular Exams
 Braden Scale Score  Impact of Illness on Sexuality
 Birth Control
#4 ACTIVITY/EXERCISE
#10 COPING/STRESS
 Respiratory – Rate
 Character of Respirations  Expression of Stress
 Color  Stressors
 Breath Sounds  Usual Coping Mechanisms
 SpO2  Support Systems
 Cardiac  Family Support
 Apical Pulse (rate, rhythm, sounds)  Community Resources
 Peripheral Pulses
 Capillary Refill Time #11 VALUE/BELIEF
 Blood Pressure
 Homan's Sign  Religious Preference
 ROM  Spirituality
 Mobility (Describe extent)  Cultural Beliefs and Practices
 Assistive Equipment  Practice of Values/Beliefs
 ADL Performance  Advanced Directives
 Leisure and Recreation
 PEROS (Physical Assessment and Review of Systems)
Note: Assessment should follow IPPA / IAPP fashion if applicable. This serves as guide in performing
assessment thoroughly.
In writing your PEROS requirement, please draw your own table following this format in a clean
sheet of long bond paper so that you can utilize more space for your assessment findings.
Areas Assessed Subjective Findings Objective Findings Problem Identified
General Health -Have you been feeling Inspection
Survey well? Inspect overall The following may be
-Have you lost or gained appearance noting applicable:
weight recently? appropriate growth and -Anxiety (specify level)
-Check patient’s development according -Body Image Disturbance
orientation and intactness
to age (for children). -Altered Comfort
of memory. -Describe the posture, -Impaired Verbal
body size and type, Communication
height, weight and -Acute Confusion
grooming (dress and -Risk for Acute
hygiene). Confusion
-How does the pt. smell? -Ineffective Individual
-Watch signs of distress Coping
and check facial -Ineffective Denial
characteristics. -Risk for Developmental
-Inspect level of alertness Delay
(alert, lethargic or -Delayed Growth and
stuporous), memory, Development
coherence and speech. -Impaired Memory
-Assess the client’s -Risk for Injury
attitude, affect and mood. -Powerlessness
-Note for any -Social Isolation
deformities, check -Fear
coordination of -Imbalanced Nutrition:
movements when sitting, Less than Body
standing and walking. Requirements
-Describe gait (does the -Imbalanced Nutrition:
patient need assistance in More than Body
walking? If so – describe. Requirements
-Describe the strides -Disturbed Thought
upon walking, is the gait Process
steady?) If client is -Self Care Deficit
bedridden, describe the
level and kind of
assistance the client
needs.
Integumentary System -Do you have skin rashes Inspection -Altered Body
or lesions? -Inspect skin color and Temperature:
-Do you have excessive uniformity. Hyperthermia
itching? -Inspect skin for -Injury
-Do you sweat a lot? Any intactness. Note location -Impaired Skin Integrity
odor problems? of any break in skin -Risk for Impaired Skin
-Are you exposed to the integrity and describe its Integrity
 sun? appearance. -Ineffective
-Do you use sunblock? -Note distribution of hair Thermoregulation
all over the body and -Self Care Deficit
note location of -Impaired Tissue
unevenness of hair Integrity
distribution. -Body Image Disturbance
-Note hair distribution on -Pain, Acute or Chronic
the head, texture, color -Allergy Response, Latex
and length of hair. -Hypothermia
-Note presence of lice, -Infection
nits, dandruff, and -Risk for Infection
condition of the scalp.
-Describe nail condition
on both upper and lower
extremities giving
emphasis on its shape,
curvature and angle,
color and texture. Also
inspect the tissues
surrounding the nail.
Palpation
-Palpate skin and note its
turgor, mobility and
moisture.
-If there’s presence of
edema, apply pressure on
skin surface and note for
pitting.
------------------------------- Head and face – Head and face – -Body Image Disturbance
------------------------------- (Palpation) (Inspection) note -Pain, Acute or Chronic
------------------------------- -Palpate the head and symmetry, size, -Impaired Verbal
------------------------------- face for any tenderness or proportion and contours Communication
------------------------------- pain. If there is, ask of the head. -Impaired Dentition
HEENT COLDSPA. -Note symmetry of facial -Impaired Swallowing
a. Head and face movements -Altered Sensory
b. Eyes (Percussion) (Palpation) Perception
c. Ears -Percuss sinuses for any -Palpate for presence of -Impaired Oral Mucous
d. Nose tenderness (COLDSPA). any masses. Membrane
e. Oral Cavity Eyes – Do you have any Eyes – (inspection) -Ineffective Airway
visual problem? Inspect eyebrows and eye Clearance
-Do you wear glasses? If lashes for shape, size and
yes, do you wear them evenness of hair
consistently, specially distribution. (Eye lashes
while at school/work? may be pointing
-Do you wear contact internally – a
lenses? phenomenon called
-When was your last eye trichiasis)
examination? What was -Inspect pupils and note
the result? if PERRLA (pupils that
-Do you use any eye does not assume a
medications? If yes, circular shape is called
identify. coloboma), determine
 color of sclera, describe
Inspection corneal size, light reflex
-Check the vision using and color (corneal scars
Snellen’s chart or may appear white over
Rosenbaum card. the cornea and may
-Describe peripheral impede vision).
vision and any -Inspect for presence of
limitations. redness, swelling and
Palpation discharges.
-Palpate the periorbital -Note presence of
area for presence of periorbital edema.
tenderness (COLDSPA). -Test muscle strength of
Ears – Do you have any the eyes (note presence
hearing problem? of nystagmus and
-Do you listen to loud strabismus) using
music? cardinal fields of gaze
-When was your last test, cover and uncover
hearing exam? test and corneal light
-Check hearing acuity reflex test.
using whisper test, watch -Check corneal
tick test, Weber test and sensitivity using a wisp
Rinne test. of cotton.
Nose. Ears –(Inspection) Note
–Do you use any inhalers symmetry, size and
or nebulization? How position of ears, assess
often? for presence of
-Check ability to discharges and note odor
distinguish different and color.
scents. (Palpation)
(Palpation) -Palpate auricles for
-Palpate externally for texture, elasticity and
any tenderness areas of tenderness.
(COLDSPA). Nose – (Inspection)
Oral cavity – How many describe symmetry, size
second teeth do you and distribution of hair
have? When was your within the nostrils.
last visit to the dentist? -Note presence of
- Do you see an discharges, if there is,
orthodontist? describe color,
-Note presence of tooth consistency, quantity and
and gum pain. odor.
-Assess presence of pain -Note patency of nares,
on tonsils and uvula. color of nasal mucosa
and check for flaring.
-Lightly palpate the
external nose for
presence of masses and
displacement of bone and
cartilage.
Oral cavity–(inspection).
Describe contour,
symmetry, moisture,
 color and intactness of
lips.
-Describe texture, color
and intactness of gums,
oral mucosa as well as
the tonsils and uvula.
-Describe color, presence
of carries, decays and
number of teeth.
-Inspect tongue color,
symmetry, size, shape
and position.
-Assess swallowing
ability and ability to
determine taste (anterior
and posterior).
(Palpation)
Neck -Note for presence of -Palpate tongue and -Impaired Mobility
pain, always take the check for strength, -Body Image Disturbance
COLDSPA. nodules and lumps. -Risk for Ineffective
-Do you experience stiff Inspection Airway Clearance
neck? How often? -Note symmetry of -Infection
Palpation appearance including -Risk for Infection
-Palpate for any size, contours, and
tenderness (COLDSPA). presence of distended
veins.
- Note the location and
symmetry of the trachea.
-Inspect the neck muscles
(sternocleidomastoid and
trapezius muscle).
-Observe head movement
in all directions.
Palpation
-Palpate for enlargement
of cervical nodes and
enlargement of thyroid
gland of the neck.
-Palpate the trachea for
any deviation.
-Palpate neck muscle for
tone, strength, deviation
and presence of lumps or
masses.
-Check shoulder strength
by instructing the client
to shrug shoulders with
or without resistance.
Auscultation
-Auscultate carotid artery
for bruit sounds.
Respiratory System -Do you have asthma? Inspection -Ineffective Airway
-Do you ever have -Inspect shape and Clearance
trouble breathing or do symmetry of the thorax -Risk for Ineffective
you wheeze when from posterior and lateral Airway Clearance
exercising / running? views, Inspect the spinal -Risk for Aspiration
-Are you exposed to air alignment for -Impaired Gas Exchange
pollutants, smoke, or deformities. -Impaired Spontaneous
second-hand smoke? -Note symmetry of chest Ventilation
-Do you feel any expansion, any abnormal -Dysfunctional Ventilator
discomforts or pain when retractions of the ribcage, Weaning Response
breathing? supraclavicular -Infection
Palpation retractions, rate, depth -Pain
-Palpate for any and rhythm of
tenderness on both respirations.
anterior and posterior Palpation
chest wall. -Palpate for vocal
(tactile) fremitus on the
entire chest while the
patient says “99” noting
its symmetry of
vibrations with the other
lung and area of
diminishing vibrations.
Percussion
-Percuss each intercostal
spaces for resonance –
normal sound (never
percuss over a bone as
this will create flat
sounds).
-Note the hyper-
resonance of the left
lower anterior chest due
to air filled stomach.
Normally, the rest of the
lung fields are resonant.
-Abnormal (dullness –
decreased air in lungs
such as atelectasis,
pulmonary edema and
hemothorax;
hyperresonance –
pneumothorax, acute
asthma.
-Percuss for
diaphragmatic excursion
– point where resonance
changes to dullness.
(Normal diaphragmatic
excursion is 5-6 cm.).
Auscultation
-Auscultate for
breathing / lung sounds
 and describe (note any
adventitious lung
sounds).
-Normal sounds:
bronchial sound – main
bronchus,
bronchovesicular sounds
– lower part of the
bronchial tree, vesicular
sounds – lung field.
Cardio- -Do you have any chest Inspection -Decreased Cardiac
vascular System pain? If yes, identify -Inspect for presence of Output
COLDSPA. edema on other body -Ineffective Tissue
-Does your heart ever parts Perfusion
skip -Inspect jugular vein for -Fluid Volume Excess
distention and identify -Fluid Volume Deficit
the highest point a.k.a
point of maximal
impulse- PMI (at which
a beat? pulsations can be seen or -Pain
palpated). -Altered Comfort
Palpation -Anxiety
-Check capillary refill -Fear
time and record, palpate -Knowledge Deficit
peripheral pulses and
compare them in all four

extremities and count in

one full minute. Describe
strength of each pulse
whether thready or strong
bounding.
-Palpate carotid artery
with extreme caution.
-Palpate pulsations on the
anterior chest wall
(sternoclavicular area,
aortic area, pulmonic
area and left clavicular
area) and note any lifts,
heaves or vibrations.
Auscultation
-Auscultate heart rate,
rhythm, or presence of
adventitious and extra
heart sounds, bruits of
thrills using both bell and
diaphragm of the
stethoscope in the
 following areas:
(APe To Man and Erbs
point –mnemonics)
Aortic – 2nd intercostal
space near right sternum
Pulmonic – 2nd intercostal
space near left sternum
Tricuspid – 5th intercostal
space near left sternum
Mitral – 5th intercostal
space mid clavicular line
left thorax
Erbs point – 3rd
intercostals space near
left sternum
Breast and axilla -Do you perform breast Inspection -Ineffective
self-examination? How -Inspect the breast for Breastfeeding
often? size, symmetry, contour -Interrupted Breast
-Have you undergone (dimpling), shape, color, Feeding
mammography presence of lesions and -Pain
procedures? discharges (including -Impaired Skin Integrity
-Have you had any breast areola and nipples). -Body Image Disturbed
surgery? Palpation
-Do you experience -Using spiral/circular,
breast tenderness? How wedge, vertical/ lateral,
often? COLDSPA. horizontal / transverse
Palpation technique, palpate the
-Note presence of pain / whole breast area
tenderness upon breast including tail of Spence.
palpation. -Palpate the axillary, sub
clavicular, and
supraclavicular lymph
nodes while the client
sits.
Gastro-intestinal -Do you have any Note: Order of -Bowel Incontinence
System and the stomach problems? abdominal assessment -Constipation
abdomen Vomiting? should always be -Perceived Constipation
-How often do you have inspection, auscultation, -Risk for constipation
a bowel movement? percussion and palpation. -Diarrhea
-Do you feel any Warning: it may cause -Risk for Diarrhea
pulsations in your death for the ff reasons: -Ineffective Infant
abdomen? Adults – Abdominal Feeding Pattern
Inspection Aortic Aneurysm -Risk for Impaired Liver
-Check sensitivity of the Children – Wilms Tumor Function
abdomen using open Inspection: -Nausea
safety pin – noting its -Assess ability to
sensitivity to dull or swallow.
sharp object. -Inspect contour, size and
Palpation shape of abdominal area.
-Palpate for any pain -Inspect umbilicus noting
starting with light position, contour, color
palpation to deep and discharge.
 palpation. -Ask client to raise head
off bed and any bulges or
hernias.
-Observe abdominal
movements and
pulsations.
-Stroke the abdomen
upward using a tongue
blade and toward the
umbilicus in each
quadrant and note
reflexes.
Auscultation
-Auscultate bowel sounds
in all four quadrants of
the abdomen and note
each of them.

-Auscultate for presence

of pulsations on the
abdomen.
Percussion
-Percuss for presence of
distention caused by gas,
size of liver and spleen.
Palpation
-Palpate for presence of
masses (from light to
deep palpation).
Genito-urinary / -Do you have bladder Inspection -Fluid Volume Deficit
Reproductive system control? (Female and Male) -Risk for Fluid Volume
-Do you wet the bed? -Inspect genitalia and Deficit
Palpation note its color, intactness, -Fluid Volume Excess
-Palpate genitalia for lesions and discharges. -Risk for Fluid Volume
presence of tenderness -Note the smell. Excess
and note COLDSPA. (Male) -Sexual Dysfunction
Percussion -Shine a light on the -Ineffective Sexuality
-Ask pt to sit and place posterior part of the Pattern
non-dominant hand over scrotum and visualize the -Situational Low Self
kidney. Make a fist with testicles. Esteem
the dominant hand and Palpation
strike non dominant hand (Female)
noting any pain. -Palpate for presence of
masses.
(Male)
-Palpate scrotum and
note its descend and
presence of hernias.
M -Do you have any back Inspection - Activity Intolerance
U problems? -Inspect posture, -Risk for Activity
S -Have you ever been told symmetry, body size and Intolerance
C you had a spinal irregularity in shape of -Risk for Falls
U problem? the whole -Fatigue
L -Assess for pain upon musculoskeletal system -Impaired Physical
O movement as well as any limitation Mobility
S (COPLDSPA). in movement. -Risk for Injury
K -Neck muscle symmetry,
E Palpation range of motion and size.
L -Assess tenderness upon -Arm muscle
E palpation. measurement and
T compare with other arm,
A also test range of motion.
L -Leg muscle
System measurement and
compare with other leg.
-Inspect curvature of the
spine.
-Inspect joint for any
deformities.
Palpation
-Palpate all joins for any
joint deformities.
-Palpate for any
abnormal
growth/protrusion of
bone, crepitus in the
whole system.
-Check the range of
motion in all joints and
note for any limitation of
movement.
-Palpate muscle `for
presence of any masses.
-Note muscle strength of
all four limbs (5/5),
including fingers or
phalanges / tarsals and
metatarsals and elbows
or knees, neck, waist.
Indicate muscle strength
with and without
applying resistance.
Neurologic System -How would you Cerebellar, motor -Unilateral Neglect
describe your mood? a. Balance -Impaired Physical
-Do you feel any -Let the patient do heel to Mobility
numbness? toe walking. -Disturbed Sensory
-Let the patient stand Perception
closing the eyes and -Risk for Injury
observe for swaying of -Risk for Fall
arms.
-Let the patient hop in
one foot then the other
finger to nose alternate
with other arm (open and
close eyes).
-From my hand to nose.
-Pronation and supination
of both hands.
-Fingers to thumb.
-Feet to my hand.
-Heel move from anterior
knee to feet.
b. Strength

-Arm strength with and

without resistance.
-Squeeze fingers.
-Leg strength with and
without resistance.
Sensory (comparing with
other side of body).
-Soft cotton sensation all
over body moving from
distal to proximal.
-Sharp and dull sensation
-Vibration feeling of a
tuning fork. Tell when it
stops.
-Moving fingers up and
down. Identify direction
while eyes are closed.
-Identifying numbers of
pricking pins.
-Identifying number of
hands holding.
-Identifying objects
whether coin or pencil.
Reflexes
-Biceps tendons
(clenched teeth).
-Triceps tendons.
-Brachioradialis tendon.
-Patellar tendons (grasp
hands).
-Achilles tendon.
-Babinski reflex.
-Abdominal reflex.
Cranial nerves
I – Olfactory – identify
different scents
II – optic – visual acuity,
 visual field, fundoscopic
exam
III – Oculomotor, IV –
trochlear and VI –
abducens - eye
movement , pupillary
reflexes (PERRLA),
V – Trigeminal –
sensations of face using
soft and sharp objects,
corneal reflexes with
wisp of cotton
VII – Facial – make
faces, open eyes against
resistance
VIII – Acoustic – test
hearing acuity using
tuning fork and whisper
test
IX – Glossopharyngeal
and X vagus – taste buds
test - test bitter taste last
as this interferes with the
different tastes, watch
uvula rising, check gag
reflex
XI – Spinal accessory
muscle shoulder strength,
tongue
XII – Hypoglossal –
tongue strength
Lymphatic / Hemato- -Have you been tired? Inspection -Infection
logic System -Do you have any lumps -Inspect any enlargement -Risk for Infection
in your neck, underarms of the limb due to -Risk for Fluid Volume
or groin? lymphatic obstruction. Deficit
Palpation -Inspect skin for signs of -Body Image Disturbance
-Palpate nodes for paleness or flushed
presence of pain. appearance.
-Assess for signs of
bleeding in the different
areas of the body
including the oral
mucosa, nose and rectal
bleeding by noting the
stool color. Also inspect
the skin for easy
bruising, petechial
rashes, ecchymosis and
other bleeding
tendencies.
Palpation
-Palpate for enlargement
 of the lymph nodes.

NOTE: Create a nursing diagnosis here based on the abnormal findings you have identified. You can
write as many nursing diagnosis as you can. More nursing diagnosis will mean more points