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PDF Health Assessment)

This document contains a template for assessing a patient's functional health patterns, including sections on health perception and management, nutrition, elimination, activity, cognition, rest/sleep, self-perception, roles/relationships, coping/stress, sexuality/reproduction, and values/beliefs. Each section includes spaces to document relevant information like diet, medications, vital signs, lab results, pain characteristics, stressors, and more. The template is designed to guide nurses in performing a comprehensive patient assessment and identifying nursing diagnoses across multiple domains of functioning.

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jawad8851kp
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17 views6 pages

PDF Health Assessment)

This document contains a template for assessing a patient's functional health patterns, including sections on health perception and management, nutrition, elimination, activity, cognition, rest/sleep, self-perception, roles/relationships, coping/stress, sexuality/reproduction, and values/beliefs. Each section includes spaces to document relevant information like diet, medications, vital signs, lab results, pain characteristics, stressors, and more. The template is designed to guide nurses in performing a comprehensive patient assessment and identifying nursing diagnoses across multiple domains of functioning.

Uploaded by

jawad8851kp
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Gordons Functinal Health Pattern

Patent Name Mr No; Unit/Ward .

Date Of Addmision Age Sex

Occupation /Profession Language;1 2

Education Marital Status

Children; M F

Medical Diagnose

Past Madical History; 1) Hospitalization

2)Surgery

3)Medications At Home

Chief Complaints

Present Surgeries Immunization Status

Vital Signs;BP PULSE RR

Temp

1.Health perception health management pattern

Patient views about his/her health,and how he/she manage his/her health

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

Patient knowledge about his/her disease

Patient knowledge about disease prevention

Page 1 of 1
List of current medications

Over The Counter Drugs

Allergies; Food Drugs Other

NURSING DIAGNOSE

2. NUTRITION PATTERN

Number of Meal per Day; Breakfast Lunch Dinner


Snacks

Food Prefrences; 1.Likes 2.Dislikes

Amount of Fluid per Day Route I/V Oral


Tube Feeding (Explain) Any Dietary Restriction

Any Fluid Restriction

Skin

Turgor Color Texture Edema

Hair; Texture Distribution

Oral Mucous Membrane Gums No Of Teeth

Alignment Dentures Height Weight


BMI

Labs;HB HCT WBC ESR RBC


Page 2 of 2
Platlets PT APTT INR

Albumin Na K Ca
Mg Others

NURSING DIAGNOSE

3. ELIMINATION PATTERN

Urine; Frequency /24 Hours Voiding; Self/Catheterized

Color Amount/24 Hours Any Pain /Discomfort


during Urination

Any Problem With Bladder Conntrol; Retention/Incontinence


Stool/24 Hours Color Odor
Characteristics Amount
Any Laxative Used
Any Problem With Bowel Control; Constipation/Incontinence

NURSING DIAGNOSE

4. ACTIVITY EXERCISE PATTERN

Life Style active/Sedentary Breathlessness during Activity or


at Rest Cough Dry, Productive If Productive
Color odor Characteristics
Amount SOB O2/Min
Via Inhalational Therapy Sputum Test

NURSING DIAGNOSE

CIRCULATION;

Pulse Rate/Min Rhythm


Amplitude Peripheral Pulses
Capillary Refill Extremities; Color
Temp
Page 3 of 3
NURSING DIAGNOSE

5. COGNITIVE PERCEPTUAL PATTREN

Level of Conciousness; Oriented To Time Place Person

If Unconscious GCS Any Speech Difficulty


Memory; Recent Remote Vision Glasses
Hearing

PAIN

Characteristics Onset Location

Duration Exacerbation Radiation

Relieving Factors Associated Factors


NURSING DIAGNOSE

6. REST AND SLEEP PATTERN

No Of Hours Sleep/24 Hours. Home Hospital Naps


Any Problem to Fall/Stay Asleep Use of Tranquilizers

Any Home Remedy to Induce Sleep


Evidence of Lack of Sleep Quality of Sleep

NURSING DIAGNOSE

7. SELF PERCEPTION /SELF CONCEPT PATTERN

Patients Perception of His/Herself Eye Contact


Grooming Voice Tone

Gesture/Congruent With Words


NURSING DIAGNOSE

Page 4 of 4
8. ROLERELATIONSHIP PATTERN

Family; extended/Nuclear Responsibilities In Family


Role Shared By

Role in Decision Making Leisure Entertainment Activities


Socialization Satisfaction
With Family/Work

NURSING DIAGNOSE

9. COPING/STRESS PATTERN

Affect/Mood; Calm Angry Irritable


Anxious Withdrawal
Apathetic Common
stressors Coping Behavior During Stress
Sharing Of Stress With Use Of Alcohol/Pan/Tobacco/Cigarette/Drug

NURSING DIAGNOSE

10.SEXULITY REPRODUCTIVE PATTERN

History Of Birth Control Age Of Puberty


Onset Of Menses (F) Menstruation Cycle
Amount Pain/Problem
Frequency Menopause No Of Children
Alive Dead Marital
Relation With Spouse Self Breast Examination ( F)
Self Testicular Examination( M)

NURSING DIAGNOSE

Page 5 of 5
11. VAUE BELIEF PATTERN

Things Important In Life


Spirituality Religious Beliefs
Any Spiritual Conflict Satisfaction with
Life

NURSING DIAGNOSE

Page 6 of 6

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