KHYBER MEDICAL UNIVERSITY PESHAWAR

ASSESSMENT TOOL: GORDON’S FUNCTIONAL HEALTH PATTERN

Student Name:
Patient Name: ____________________ MR/Bed No: __________ Unit/ ward: _____________

Date of admission: ________________ Age: _______________ Sex: ___________________

Occupation / Profession: ___________________ Language: (1) ___________ (2) __________

Education: _______________________ Marital status: _______________________________

Children: _______________ (Male): __________________ (Female): ___________________

Medical diagnose: ____________________________________________________________

Past medical history: (1) Hospitalization ________________________________________

(2) Surgery ______________________________________________

Present complaints: ____________________________________________________________

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Surgeries: _____________________________ Immunization status: _____________________

Vital signs: B.P: ___________ Pulse: ___________ R.R: ___________ Temp: ____________

1. Health Perception Health Management Pattern:

Patient’s views about his / her health and how he / she manage his / her health:

____________________________________________________________________________

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Patient’s views about his / her illness and how he / she manage his / her illness:

____________________________________________________________________________

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Patient’s knowledge about his / her disease and prevention: ____________________________

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Current Medication

DRUG ROUTE DOSE INDICATIONS

 KHYBER MEDICAL UNIVERSITY PESHAWAR

Over the counter drugs: ________________________________________________________

Allergies: _____________ Drugs: ________________________ Others: __________________

Nursing diagnosis: _____________________________________________________________

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2. Nutrition Pattern

Numbers of meal per day: ______________ Food preferences: _________________________

1. Likes: _____________________________ 2. Dislikes: ______________________________

Amount of fluid per day: ______________________ Route (I / V): _______________________

Tube feeding (explain): __________________ Any Dietary restriction: ____________________

Skin Turgor: ____________ Color: _____________ Texture: _____________ Edema: _______

Hair color: __________ Texture: __________ Distribution: _______________

Oral mucous membrane: _____________ Gums: ____________ No of teeth: ______________

Alignment: ___________ Dentures: ___________ Height: ___________ weight: ____________

Labs:

Hb: ________________ Hct: _____________ WBC: ______________ ESR: _______________

Platelets: ____________ PT: ____________ APTT: ______________ INR: ________________

Albumin: ___________ Na: ___________ K: ___________ Ca: ____________ Mg: _________

Other: _______________________________________________________________________

Nursing Diagnosis: _____________________________________________________________

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3. Elimination Pattern:

Urine:

Frequency / 24 hours _____________ voiding self / catheterized: ________________________

Color: _______ Amount: _______ Odor: ________ any pain / discomfort: __________________

Any problem with bladder control: Retention / Incontinence: _____________________________

 KHYBER MEDICAL UNIVERSITY PESHAWAR
Stool:

Frequency / 24 hours _________Color: _______ Odor: ________ Characteristic ____________

Amount: ____________________ Any laxatives use: _________________________________

Any problem with bladder control: Constipation / Diarrhea: ______________Ostomy: ________

Abdominal assessment:

Auscultation: _______________ Percussion: ___________ Palpation: ____________________

Nursing Diagnosis: _____________________________________________________________

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4. Activity & Exercise Pattern:

Life style (active, sedentary): _____________ Breathlessness: _________________________

Cyanosis: __________________________ Chest shape: ______________________________

Palpation:

Tactile Fermitus: ________________ Respiratory Expansion: ___________________________

Percussion: _____________________ Breath sounds: ________________________________

Cough (Dry / Productive): ________________ If productive: ____________________________

Color: __________ Odor: ___________ Characteristic: ___________ Amount: _____________

SOB: ___________O2/ min: _________ Via: __________ Suction (type):__________________

Chest tubes: _______________ Inhalation therapy: __________________________________

Nursing Diagnosis: _____________________________________________________________

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Circulation

B.P: _________ Pulse rate/ min: _________ Rhythm: ___________ Amplitude: _____________

JVP: ________________ Peripheral pulses: __________________ Edema: _______________

Varicose veins: _________ Peripheral cramps: ______________ Capillary refill: ____________

Extremities: Color: __________ Temp: __________ Heart sounds: _______________________

Murmurs: _______________________ ECG Monitor: _________________________________

Nursing Diagnosis: _____________________________________________________________

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 KHYBER MEDICAL UNIVERSITY PESHAWAR
5. Cognitive perceptual Pattern:

Level of consciousness: _________ Orientation: ______________ Time: ______________

Place: ___________ Person: ____________ If unconscious GCS: ____________________

Memory: Recent: ___________ Remote: __________ Vision: _______ Glasses: ___________

Hearing: _________ Pain :( describe) ______________ 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 sleep: ______________ Use of tranquilizers: ____________________

Any home remedy: _____________________________________________________________

Evidence of lack of sleep:

Posture: ___________ Yawning: ______________ Dark circles under eyes: _______________

Nursing Diagnosis: _____________________________________________________________

_________________________________________________________________________

7. Self Perception / Self Concept Pattern:

Patient’s perception of his / her self: _______________________________________________

Grooming / dressing / make up: _______________ Body parts (likes & dislikes): ____________

Eye contact: ____________ Gesture / Congruent with words: __________________________

Nursing Diagnosis: _____________________________________________________________

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8. Role Relationship Pattern:

Family (extended / nuclear): ______________ Roles in family: __________________________

Role hared by: _________________ Role in decision making: __________________________

Financial status: __________________ Leisure entertainment activities: __________________

 KHYBER MEDICAL UNIVERSITY PESHAWAR
Satisfaction with family / work: ___________________________________________________

Nursing Diagnosis: _____________________________________________________________

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9. Coping / Stress Pattern:

Affect / Mood: Calm: ______________ Angry: ________________ Irritable: _______________

Fearful: ______________ Anxious: _________________ Withdrawal: ____________________

Common Stressors: _________________ Coping behavior during stress: _________________

Sharing f stress with: ___________________________________________________________

Use of Alcohol / Pan / Drug: _____________________________________________________

Nursing Diagnosis: _____________________________________________________________

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10. Sexuality / Reproductive Pattern:

History of birth control: _____________ Age of puberty: ________ Onset of menses: ________

Menstruation cycle: __________ Amount: __________ Pain / problem: ___________________

Frequency: _______________ Menopause: _____________ No of children: _______________

Alive: _________ Dead: _________ Marital relation with spouse: ________________________

Nursing Diagnosis: _____________________________________________________________

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11. Value and belief Pattern:

Things important in life: _________________________________________________________

Professional / Occupational values: ________________________________________________

Spirituality: _________________ Religious beliefs: ___________________________________

Any spiritual conflict: ___________________________________________________________

Satisfaction with life: ___________________________________________________________

Nursing Diagnosis: _____________________________________________________________

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