GORDON’S 11 FUNCTIONAL

HEALTH
ASSESSMENT

BY: ROMMEL LUIS C. ISRAEL III

 Marjorie Gordon (1987)
proposed functional health
patterns as a guide for
establishing a comprehensive
nursing data base.
FUNCTIONAL
HEALTH These 11 categories make
PATTERN possible a systematic and
standardized approach to data
collection, and enable the nurse
to determine the following
aspects of health and human
function:
BY: ROMMEL LUIS C. ISRAEL III
1. Health Perception and Health
Management
2. Nutrition and Metabolism
3. Elimination
4. Activity and Exercise
5. Cognition and Perception
6. Sleep and Rest
7. Self-Perception and Self-Concept
8. Roles and Relationships
9. Sexuality and Reproduction
10.Coping and Stress Tolerance
11.Values and Belief
BY: ROMMEL LUIS C. ISRAEL III
 HEALTH PERCEPTION AND
HEALTH MANAGEMENT

Data collection is focused on the person's

perceived level of health and well-being, and on
practices for maintaining health.

Habits evaluated includes smoking and alcohol

or drug use.

Actual or potential problems related to safety

and health management may be identified as
well as needs for modifications in the home or
needs for continued care in the home.

BY: ROMMEL LUIS C. ISRAEL III

Client’s general health?
Any colds in past year?
If appropriate: any absences from work/school?
Most important things you do to keep healthy?
Use of cigarettes, alcohol, drugs?
Perform self exams, i.e. Breast/testicular self-
examination?
Accidents at home, work, school, driving?
In past, has it been easy to find ways to carry out
doctor’s or nurse’s suggestions?
(If appropriate) What do you think caused current illness?
What actions have you taken since symptoms started?
Have your actions helped?
(If appropriate) What things are most important to your
health?
How can we be most helpful?
How often
BY: ROMMEL do you
LUIS C. ISRAEL III exercise?
 Assessment is focused
on the pattern of food
and fluid consumption
relative to metabolic
need.

NUTRITION The adequacy of local

AND nutrient supplies is
evaluated.
METABOLIS
M
Actual or potential
problems related to fluid
balance, tissue integrity,
and host defenses may
be identified as well as
problems with the
gastrointestinal system.

BY: ROMMEL LUIS C. ISRAEL III

HISTORY (SUBJECTIVE
DATA):
TYPICAL DAILY FOOD INTAKE? (DESCRIBE)
USE OF SUPPLEMENTS, VITAMINS, TYPES OF SNACKS?
TYPICAL DAILY FLUID INTAKE? (DESCRIBE)
WEIGHT LOSS/GAIN? HEIGHT LOSS/GAIN?
APPETITE?
BREASTFEEDING? INFANT FEEDING?
FOOD OR EATING: DISCOMFORT, SWALLOWING
DIFFICULTIES, DIET RESTRICTIONS, ABLE TO FOLLOW?
HEALING – ANY PROBLEMS?
SKIN PROBLEMS: LESIONS? DRYNESS?
DENTAL PROBLEMS?

BY: ROMMEL LUIS C. ISRAEL III

 EXAMINATION
(EXAMPLES OF
OBJECTIVE DATA):

SKIN ASSESSMENT,
ORAL MUCOUS
MEMBRANES, TEETH,
ACTUAL
WEIGHT/HEIGHT,
TEMPERATURE.
ABDOMINAL
ASSESSMENT.
BY: ROMMEL LUIS C. ISRAEL III
ELIMINATION

• Data collection is focused on

excretory patterns (bowel,
bladder, skin).
• Excretory problems such as
incontinence, constipation,
diarrhea, and urinary retention
may be identified.
BY: ROMMEL LUIS C. ISRAEL III
 History (subjective data):
Bowel elimination pattern (describe)
Frequency, character, discomfort, problem with
bowel control, use of laxatives (i.e. type,
frequency), etc.?
Urinary elimination pattern (describe)
Frequency, problem with bladder control?
Excess perspiration? Odour problems?
Body cavity drainage, suction, etc.?

BY: ROMMEL LUIS C. ISRAEL III

Examination (examples of
objective data):
• If indicated, examine excretions or
drainage for characteristics, colour,
and consistency.
• Abdominal assessment.
BY: ROMMEL LUIS C. ISRAEL III
 Assessment is focused on
the activities of daily
living requiring energy
expenditure, including
self-care activities,
ACTIVIT exercise, and leisure
activities.
Y AND
The status of major body
EXERCI systems involved with
SE activity and exercise is
evaluated, including the
respiratory,
cardiovascular, and
musculoskeletal systems.

BY: ROMMEL LUIS C. ISRAEL III

 History (subjective data):
• Sufficient energy for desired and/or
required activities?
• Exercise pattern? Type? regularity?
• Spare time (leisure) activities?
• Child-play activities?
• Perceived ability for feeding, grooming,
bathing, general mobility, toileting, home
maintenance, bed mobility, dressing and
shopping?

BY: ROMMEL LUIS C. ISRAEL III

Examination (examples of objective
data):
Demonstrate ability for the following:
• Gait.
• Posture.
• Absent body part.
• Range of motion (ROM) joints.
• Hand grip - can pick up pencil? Respiration.
Blood pressure.
• General appearance.
• Musculoskeletal, cardiac and respiratory
assessments.
BY: ROMMEL LUIS C. ISRAEL III
 COGNITION AND
PERCEPTION
• Assessment is focused on
the ability to comprehend
and use information and on
the sensory functions.
• Data pertaining to
neurologic functions are
collected to aid this
process.
• Sensory experiences such
as pain and altered sensory
input may be identified and
further evaluated.
BY: ROMMEL LUIS C. ISRAEL III
 History (subjective data):
• Hearing difficulty?
• Hearing aid?
• Vision? Wears glasses? Last checked? When
last changed?
• Any change in memory? Concentration?
• Important decisions easy/difficult to make?
• Easiest way for you to learn things? Any
difficulty?
• Any discomfort? Pain?

BY: ROMMEL LUIS C. ISRAEL III

 History (subjective data):
If appropriate – PQRST questions :

• P – Palliative, Provocative
• Q - Quality or quantity
• R – Region or radiation
• S - Severity or scale
• T - Timing
-(Morton, 1977) COLDSPA C - Character O - Onset L - Location D - Duration S –
Severity P - Pattern A - Associated factors (Weber, 2003)

BY: ROMMEL LUIS C. ISRAEL III

Examination (examples of objective
data):
• Orientation.
• Hears whispers?
• Reads newsprint?
• Grasps ideas and questions (abstract,
concrete)?
• Language spoken.
• Vocabulary level.
• Attention span.
BY: ROMMEL LUIS C. ISRAEL III
 SLEEP AND REST
• Assessment is focused
on the person's sleep,
rest, and relaxation
practices.

• Dysfunctional sleep
patterns, fatigue, and
responses to sleep
deprivation may be
identified.
BY: ROMMEL LUIS C. ISRAEL III
History (subjective data):
• Generally rested and ready for
activity after sleep?
• Sleep onset problems? Aids?
• Dreams (nightmares), early
awakening?
• Rest / relaxation periods?
• Sleep routine?
• Sleep apnea symptoms?

BY: ROMMEL LUIS C. ISRAEL III

EXAMINATION (EXAMPLES
OF OBJECTIVE DATA):

OBSERVE SLEEP PATTERN AND

REST PATTERN.

BY: ROMMEL LUIS C. ISRAEL III

 Assessment is
focused on the
person's attitudes
toward self,
including identity,
SELF- body image, and
PERCEPTION sense of self-worth.
AND SELF- The person's level of
CONCEPT self-esteem and
response to threats
to his or her self-
concept may be
identified.

BY: ROMMEL LUIS C. ISRAEL III

History (subjective data):
• How do you describe yourself?
• Most of the time, feel good (or not so good)
about self?
• Changes in body or things you can do?
• Problems for you?
• Changes in the way you feel about self or body
(generally or since illness started)?
• Things frequently make you angry? Annoyed?
Fearful? Anxious? Depressed?
• Not able to control things? What helps?
• Ever feel you lose hope?
BY: ROMMEL LUIS C. ISRAEL III
Examination (examples of objective
data):
• Eye contact.
• Attention span (distraction?).
• Voice and speech pattern.
• Body posture.
• Client nervous (5) or relaxed (1) (rate
scale 1-5) Client assertive (5) or
passive (1) (rate scale 1-5)

BY: ROMMEL LUIS C. ISRAEL III

 Assessment
is focused on
the person's
roles in the
world and
relationships
with others.
ROLES AND
RELATIONSHIP Satisfaction
S with roles,
role strain, or
dysfunctional
relationships
may be
further
evaluated.

BY: ROMMEL LUIS C. ISRAEL III

 History (subjective data):
• Live alone? Family?
• Family structure?
• Any family problems you have difficulty handling
(nuclear/extended family)?
• Family or others depend on you for things?
• How well are you managing?
• If appropriate – How families/others feel about your
illness?
• Problems with children?
• Belong to social groups? Close friends? Feel lonely?
(Frequency)
• Things generally go well at work / school?
• If appropriate – income sufficient for needs?
Feel part of (or isolated in) your neighbourhood?

BY: ROMMEL LUIS C. ISRAEL III

Examination (examples of objective
data):

Interaction with family

members or others if present.

BY: ROMMEL LUIS C. ISRAEL III

 Assessment is focused on
the person's satisfaction
or dissatisfaction with
sexuality patterns and
reproductive functions.

SEXUALITY AND
REPRODUCTION

Concerns with sexuality

may he identified.

BY: ROMMEL LUIS C. ISRAEL III

 History (subjective data):
• If appropriate to age and situation – Sexual
relationships satisfying? Changes?
Problems?
• If appropriate – Use of contraceptives?
• Problems? Female – when did menstruation
begin? Last menstrual period (LMP)? Any
menstrual problems?
• (Gravida-Number of Pregnancy/Para-
Number of Births if appropriate)

BY: ROMMEL LUIS C. ISRAEL III

Examination (examples of objective
data):
None unless a problem is identified or a pelvic examination is
warranted as part of full physical assessment (advanced nursing
skill).

BY: ROMMEL LUIS C. ISRAEL III

 COPING AND STRESS
TOLERANCE
• Assessment is focused on the
person's perception of stress and on
his or her coping strategies
• Support systems are evaluated, and
symptoms of stress are noted.
• The effectiveness of a person's
coping strategies in terms of stress
tolerance may be further evaluated.
BY: ROMMEL LUIS C. ISRAEL III
History (subjective data):
• Any big changes in your life in last year or
two?
• Crisis? Who is most helpful in talking things
over? Available to you now?
• Tense or relaxed most of the time? When
tense, what helps?
• Use any medications, drugs, alcohol to relax?
• When (if) there are big problems in your life,
how do you handle them? Most of the time,
are these ways successful?

BY: ROMMEL LUIS C. ISRAEL III

 VALUES AND
BELIEF

• Assessment is focused
on the person's values
and beliefs (including
spiritual beliefs), or on
the goals that guide his
or her choices or
decisions.

BY: ROMMEL LUIS C. ISRAEL III

History (subjective data):
• Generally get things you want from
life?
• Important plans for future?
• Religion important to you? If
appropriate - Does this help when
difficulties arise?
• If appropriate – will being here
interfere with any religious practices?

BY: ROMMEL LUIS C. ISRAEL III

FUNCTIONAL
ASSESSMENT
TESTS
BY: ROMMEL LUIS C. ISRAEL III
ASSESSMENT OF
NEWBORN
BY: ROMMEL LUIS C. ISRAEL III
 • The test is
generally done
Appearance at one and five
(skin color), minutes after
birth, and may
Pulse (heart be repeated
later if the
rate), score is and
remains low.
Grimace
APGAR (reflex • Scores 7 and
irritability),
SCORE above
generally
are

Activity normal,
(muscle
• 4 to 6 fairly
tone), and low,
Respiration
• 3 and below
BY: ROMMEL LUIS C. ISRAEL III
are generally
regarded as
 NEWBORN
• APGAR SCORING TEST

BY: ROMMEL LUIS C. ISRAEL III

 NEWBORN SCREENING
Republic Act 9288
•Newborn screening (NBS) is a public
health program aimed at the early
identification of infants who are
affected by certain genetic/metabolic/
infectious conditions. Early
identification and timely intervention
can lead to significant reduction of
morbidity, mortality, and associated
disabilities in affected infants.
•NBS in the Philippines started in June
1996 and was integrated into the
public health delivery system with the
enactment of the Newborn Screening
Act of 2004 (Republic Act 9288).
• From 1996 to December 2010, the
program has saved 45 283 patients.

BY: ROMMEL LUIS C. ISRAEL III

 NEWBORN SCREENING
Republic Act 9288

Five conditions are

currently
screened: -
 Congenital Hypothyroidism,
 Congenital Adrenal
Hyperplasia,
 Phenylketonuria,
 Galactosemia, and
 Glucose-6-Phosphate
Dehydrogenase Deficiency.
BY: ROMMEL LUIS C. ISRAEL III
BY: ROMMEL LUIS C. ISRAEL III

ASSESSMENT
OF
INFANT AND
CHILDREN
 •Growth is not only a result
of nutrition but also a result
HEIGHT of inherited factors.

AND •Ethnicity can influence a

LENGTH child’s growth patterns, and
so some countries have their
own growth charts.

BY: ROMMEL LUIS C. ISRAEL III

 HOW TO MEASURE

BY: ROMMEL LUIS C. ISRAEL III

 Typical
measurements
taken for children 0-
24 months include:
HOW TO TAKE
MEASUREMENT
S • Head circumference
• Length
• Weight

BY: ROMMEL LUIS C. ISRAEL III

Measurements should be taken at regular
intervals in order to observe reliable
trends. Recommendations for
measurement intervals include:

Infants (0-12 months): every 2 months

Young Children: at 15, 18, 24 and 30

months

Ages 3+: every year

BY: ROMMEL LUIS C. ISRAEL III

 GROWTH
CHARTS
MODULE
BRANDED
MEASUREME
NT
SCHEDULE
HANDOUT

BY: ROMMEL LUIS C. ISRAEL III

 HEAD CIRCUMFERENCE
Head circumference is a measurement
taken around the largest part of a child’s
head. This measurement is typically
taken with children ages 0-3 years old.

The measurement should be taken with a measuring tape

that cannot be stretched. This is typically a flexible, metal
measuring tape. To measure, securely wrap the tape
around the widest possible circumference of the head.
Typically, this is from 1-2 finger-widths above the eyebrow
on the forehead to the most prominent part of the back of
the head. Take the measurement three times and select the
largest measurement to the nearest 0.1cm.

BY: ROMMEL LUIS C. ISRAEL III

• Height
• - it is good determination of
health and normal nutrition as
weight
• -male infant is an average of 2-
3cm longer than of female at
birth
• -During first year of the life the
infant HT should increase by
25-30 cm
- by age 2 yrs , the child will be an
average of 12.5 cm taller -most
toddlers have reached
approximately 1\2 of their adult
height.

• -AT birth: 46-56cm ,

BY: ROMMEL LUIS C. ISRAEL III
average( 50cm)
 LENGTH

• Length is the linear

measurement for
infants up to 24
months. Length
measurements (instead
of height) are also
taken for children 24 to
36 months who cannot
stand without
assistance.
BY: ROMMEL LUIS C. ISRAEL III
 LENGTH
• Length is measured when children are
in a recumbent (lying down) position.
The most accurate way to measure
length is by using a calibrated length
board. Length boards should have a
fixed headpiece and a moveable foot
piece perpendicular to the surface of
the board.
• To measure, lay the child on the board with their head against
the fixed headpiece. Make sure the child is not wearing shoes
or a hairpiece. An assistant may be helpful to hold the child
still and centered on the board. Straighten the child’s legs and
adjust the moveable foot piece so the soles of the feet are
against the foot piece. Record the length to the nearest 0.1
cm.

BY: ROMMEL LUIS C. ISRAEL III

 WEIGHT

• Weight is a measurement taken

throughout the lifespan to help
determine trends and current
nutritional status.

BY: ROMMEL LUIS C. ISRAEL III

 • Infant weight can be accurately
measured using one of several
different pieces of equipment.

• If available, a pan-type pediatric

scale allows a child to be weighed
while lying down. These pediatric
scales are either electronic or
WEIGHT beam scales with non-detachable
weights, and are accurate to the
nearest 10 gram.

• Another option is a hanging scale.

A hanging scale needs to be
attached to a sturdy structure (e.g.
building rafter, door frame) and the
child is suspended from the scale
in weighing pants.

BY: ROMMEL LUIS C. ISRAEL III

 WEIGHT
• To measure, make sure the child is wearing as little
clothing as possible and that no one is touching the
child.

• Read the scale at eye-level and record weight to the

nearest 10 gram.
•
• Repeat the measurement three times, exclude values
that appear skewed, and find the average.

BY: ROMMEL LUIS C. ISRAEL III

 WEIGHT

BY: ROMMEL LUIS C. ISRAEL III

• In the event a baby scale is unavailable, an adult
standing scale can be used to measure infant weight.
Weigh an adult first, and then weigh the same adult
while holding a child. Find the difference between the
two weights – this is the infant’s weight.

• Weight-for-age is an important indicator of a child’s

nutritional status over time, such as trends in
underweight.

BY: ROMMEL LUIS C. ISRAEL III

 Weight:
• Average newborn boy weight=3400g,
and girl= 3200g

• - infant lose 5-10% of birth weight at

age 3-4 days to gain it back in 2 weeks
with a steady growth rate.

• Infant double birth Weight by 6 months

• They triple the body weight by 12

month= 10 kg.

BY: ROMMEL LUIS C. ISRAEL III

 CHEST, AND
ABDOMINAL
CIRCUMFERENCE.
Whaley and Wong

BY: ROMMEL LUIS C. ISRAEL III

ABDOMINAL
GIRTH
•Abdominal girth
should be
measured over
the umbilicus

•Whenever
possible.

BY: ROMMEL LUIS C. ISRAEL III

 Head circumference and
chest circumference :
• Measure at birth and routinely until age 3 yrs.
• HC measures directly skeletal growth (skull), and indirectly
cerebral growth.
• Measurement at birth = 33-35 cm
• Chest circumference : CC = 31-33 cm at birth
• Ratio of head to chest circumference:
• birth : HC is larger than CC by 2 cm
• 1 yr-18 month : HC=CC
• 2-3 yrs HC slightly smaller than CC
• > 3 yrs :HC is smaller than CC by 5-7 cm

BY: ROMMEL LUIS C. ISRAEL III

 Developed for health
professionals (MDs, RNs,
etc)

METRO It is not an intelligence

MANILA test
DEVELOPMEN
T SCREENING It is a screening
TEST instrument to determine if
(MMDST) child’s development is
within normal

Children 6 ½ years and

below

BY: ROMMEL LUIS C. ISRAEL III

 Purposes
METRO
MANILA Measures
DEVELOPMEN developmental
T SCREENING delays
TEST
(MMDST) Evaluates 4
aspects of
development

BY: ROMMEL LUIS C. ISRAEL III

 Personal-Social – tasks which
indicate the child’s ability to get
along with people and to take
care of himself

Fine-Motor Adaptive – tasks which

indicate the child’s ability to see
4 SECTORS and use his hands to pick up
objects and to draw
OF
DEVELOPMEN
T Language – tasks which indicate
the child’s ability to hear, follow
directions and to speak

Gross-Motor – tasks which

indicate the child’s ability to sit,
walk and jump

BY: ROMMEL LUIS C. ISRAEL III

 MMDST KIT
Preparation for test administration involves the
nurse ensuring the completeness of the test
materials contained in the MMDST Kit. These
materials should be followed as specified:
• MMDST manual
• test Form
• bright red yarn pom-pom
• rattle with narrow handle
• eight 1-inch colored wooden blocks (red, yellow, blue green)
• small clear glass/bottle with 5/8 inch opening
• small bell with 2 ½ inch-diameter mouth
• rubber ball 12 ½ inches in circumference
• cheese curls
• pencil
BY: ROMMEL LUIS C. ISRAEL III
 EXPLAINING THE
PROCEDURE.

AGE & THE AGE

LINE.

TEST ITEMS.

SCORING.

BY: ROMMEL LUIS C. ISRAEL III

 • The Barthel Index consists
of 10 items that measure
a person's daily
functioning specifically
WHAT IS the activities of daily
THE living and mobility.
BARTHEL
• The items include feeding,
INDEX? moving from wheelchair
to bed and return,
grooming, transferring to
and from a toilet, bathing,
walking on level surface,
going up and down stairs,
dressing, continence of
bowels and bladder.

BY: ROMMEL LUIS C. ISRAEL III

 HOW IS THE BARTHEL
INDEX USED?
• The assessment can be used to determine
a baseline level of functioning and can be
used to monitor improvement in activities
of daily living over time.
• The items are weighted according to a
scheme developed by the authors.
• The person receives a score based on
whether they have received help while
doing the task. The scores for each of the
items are summed to create a total score.
• The higher the score the more
"independent" the person.
• Independence means that the person
needs no assistance at any part of the
task.
• If a persons does about 50%
independently then the "middle" score
would apply.

BY: ROMMEL LUIS C. ISRAEL III

 • WHY: Normal aging changes and health
problems frequently show themselves
as declines in the functional status of
older adults.

• Decline may place the older adult on a

KATZ spiral of iatrogenesis leading to further
health problems.
INDEX
• One of the best ways to evaluate the
health status of older adults is through
functional assessment which provides
objective data that may indicate future
decline or improvement in health
status, allowing the nurse to plan and
intervene appropriately.

BY: ROMMEL LUIS C. ISRAEL III

 • BEST TOOL: The Katz Index of Independence in
Activities of Daily Living, commonly referred to as
the Katz ADL, is the most appropriate instrument to
assess functional status as a measurement of the
client’s ability to perform activities of daily living
independently.

• Clinicians typically use the tool to detect problems in

performing activities of daily living and to plan care
accordingly.

• The Index ranks adequacy of performance in the six

functions of bathing, dressing, toileting,
transferring, continence, and feeding.

• Clients are scored yes/no for independence in each of

the six functions.

• A score of 6 indicates full function, 4 indicates

moderate impairment, and 2 or less indicates severe
functional impairment.

BY: ROMMEL LUIS C. ISRAEL III

 Your BMI is based on your height
and weight. It's one way to see if
you're at a healthy weight.

Underweight: Your BMI is less

than 18

Healthy weight: Your BMI is 18.5

BMI to 24.9

Overweight: Your BMI is 25 to

29.9

Obese: Your BMI is 30 or higher

BY: ROMMEL LUIS C. ISRAEL III

 HOW TO CALCULATE
YOUR BODY MASS
INDEX OR BMI

BMI is your weight (in

kilograms) over your
height squared (in
meters). Let’s
calculate, however,
using pounds and
inches.
• BMI = weight in kg / height
in m²

BY: ROMMEL LUIS C. ISRAEL III

 Example:

• For instance, the BMI of a person who is

5’3" and weighs 125 lbs is calculated as
follows:
• BMI= 125 lbs ÷ 0.45 kg
5 x 12 in + 3 in.

= 56.25 kg__
63 in x .0254 m

BY: ROMMEL LUIS C. ISRAEL III

1. Multiply the weight in
pounds by 0.45 (the metric
conversion factor)

125 X 0.45 = 56.25 kg

2. Multiply the height in

inches by 0.025 (the metric
conversion factor)

63 X 0.025 = 1.575 m
BY: ROMMEL LUIS C. ISRAEL III
 •1.575 X 1.575 = 2.480625

3. Square the answer from step 2

1.575 X 1.575 = 2.480625

4.Divide the answer from step 1 by the

answer from step 3

56.25 : 2.480625 = 22.7

BY: ROMMEL LUIS C. ISRAEL III

 • The BMI for a person
who is 5’3" and
weighs 125 lbs is
22.7 or practically, 23
which means a
healthy weight.

BY: ROMMEL LUIS C. ISRAEL III