Gordons Functional Health Pattern Assessment Tool

Highlight or indicate the correct response.

Student: ___________________ Date: ___________Rotation: _____________ Medical Diagnosis: _______________________ Instructor: _________________ I. Health Perception/Management Changes in cognition: Yes No Changes in memory: Yes No Problems with coordination: Yes No Fainting spells: Yes No Tremor: Yes No Changes in sensation: Yes No Headaches: Yes No Dizziness: Yes No Perception of Illness: Compliance of prescribed meds: Yes No Side rails x ______ Special equipment: cane walker tripod Risk for aspiration: Yes No Risk for infection: Yes No Risk for injury: Yes No If yes to the above information include other data from subjective or objective data___________________________________________________________________ Nursing Diagnosis: II. Nutrition-Metabolic Temperature: ____________ Route: ____________ Height________ Weight: ___________ Change in skin color/texture: Yes No Excessive bruising: Yes No Skin lesions: Yes No Sores that dont heal: Yes No Change in mole: Yes No Temperature of skin: __________________ Skin Turgor: _____________ Pruritis: Yes No Condition of mucous membranes: ____________ Condition of hair____________ Condition of nails: _______________ Tubes: IV_______________ Drainage________________ Suction: __________________ If yes to the above information include other data from subjective or objective data_______________________________________________________________________ Nursing Diagnosis: III. Elimination Pain: Yes No Nausea: Yes No Vomiting: Yes No Diarrhea: Yes No GERD/heartburn: Yes No Jaundice: Yes No Change in appetite: Yes No Constipation: Yes No Flatus: Yes No Change in bowel habits: Yes No Hemorrhoids: Yes No Abdominal distention: Yes No Bowel sounds: identify: ________________ Last BM: _____________ Urinary hesitancy: Yes No Frequency: Yes No Change in stream: Yes No Nocturia: Yes No Pain with urination: Yes No Flank pain: Yes No Blood in urine: Yes No Excessive urinary volume: Yes No Decreased urinary volume: Yes No If yes to the above information include other data from subjective or objective data________________________________________________________________________ Nursing Diagnosis: IV. Activity-Exercise Pulse: _______ Heart Sounds: ______________ Respirations: _______ Blood pressure: _________ R arm L arm Pedal pulses: Present Absent O2: ____ L/min cannula mask Breath sounds: anterior: identify: ______________ Posterior: Identify: ____________ Cough: Yes No Frequent colds: Yes No Shortness of breath: Yes No Wheezing: Yes No Pain with breathing: Yes No Coughing up blood: Yes No Night sweats: Yes No Chest pain: Yes No Palpitations: Yes No Dyspnea: Yes No Dyspnea during sleep: Yes No Edema: upper extremities: Yes No Edema: lower extremities: Yes No Coldness of extremities: Yes No Discoloration: Yes No Varicose veins: Yes No Leg pain with activity: Yes No Paresthesia: Yes No Muscle pain: Yes No Weakness: Yes No Joint swelling: Yes No Joint pain: Yes No Stiffness: Yes No Limitations of range of motion: Yes No Limitations in mobility: Yes No Back pain: Yes No If yes to the above information include other data from subjective or objective data_______________________________________________________________________ Nursing Diagnosis: V. Sleep Rest Early waking: Yes No Insomnia: Yes No Nightmares: Yes No am Nap: Yes No Feels rested after sleep: Yes No Sleep: ______hrs/night Sleep distracters: Yes No Sleep aides: Yes No Night waking: Yes No If yes to the above information include other data from subjective or objective data________________________________________________________________________ Nursing Diagnosis:

Accepted FA 07

VI. Self Perception/Self Concept Makes eye contact: Yes No Statement of self: Positive Negative Body Image: Positive Negative General Appearance: groomed neglected Fears: Yes No Anxieties: Yes No If yes to the above information include other data from subjective or objective data_______________________________________________________________________ Nursing Diagnosis: VII. Cognitive-Perceptual Pain scale: ________ Pain Management controlled: Yes No PERRLA: Rt eye____ Lt eye_______ Eyes: Change in vision: Yes No Discharge: Yes No Excessive tearing: Yes No Eye pain: Yes No Sensitivity to light: Yes No Flashing lights: Yes No Halos around lights: Yes No Difficulty reading: Yes No Do you wear corrective lenses: Yes No If yes: eyeglasses contacts Ears: Ear pain: Yes No Drainage: Yes No Recurrent infections: Yes No Excessive ear wax: Yes No Changes in hearing Yes No Ringing in ears: Yes No Sensitivity to noises: Yes No Use of hearing aides: Yes No Nose: Nasal drainage: Yes No Frequent nose bleeds: Yes No Sneezing: Yes No Nasal obstruction: Yes No Sinus pain: Yes No Postnasal drip: Yes No Change in smell: Yes No Snoring: Yes No Mouth: Sore throat: Yes No Sores in mouth: Yes No Bleeding gums: Yes No Change in taste: Yes No Trouble chewing: Yes No Dental prosthesis: Yes No upper lower Change in voice: Yes No Neck: lymph node enlargement: Yes No swelling or mass in neck: Yes No Neck pain: Yes No Neck stiffness: Yes No If yes to the above information include other data from subjective or objective data_______________________________________________________________________ Nursing Diagnosis: VIII. Role Relationship Occupation: _______________ Siblings: Yes No Nursing Diagnosis: Employed: Yes No Retired: Yes No How many: _____________ Disabilities: Yes No Lives with: ____________ Family concerns: Yes No

IX. Sexuality (Nursing II, III and IV students only) Lesions: Yes No Discharge: Yes No Pain or masses: Yes No Females: Dysmenorrhea: Yes No Menorrhagia: Yes No Amenorrhea: Yes No Are you currently involved in a sexual relationship: Yes No Do you protect yourself from STDs: Yes No Do you use birth control: Yes No Problems with sexuality activity: Yes No Painful intercourse: Yes No Change in sexuality activity: Yes No Infertility: Yes No Impotence: Yes No If yes to the above information include other data from subjective or objective data_______________________________________________________________________ Nursing Diagnosis:
X. Coping-Stress Support systems: Identify: _________________ Coping methods: Yes No Stress: Yes No Major loss in past: Yes No If yes to the above information include other data from subjective or objective data________________________________________________________________________ Nursing Diagnosis: XI. Values-Belief Religion or Spiritual belief: __________________ Religious restrictions: Yes No Chaplain visit: Yes No Values: Yes No Goals: Yes No If yes to the above information include other data from subjective or objective data_________________________________________________________________________ Nursing Diagnosis: Comments: ___________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________

Accepted FA 07