Institute of Health Sciences

College of Nursing IHS Peshawar

Assessment tool: Gordon’s Functional Health Pattern

Patient Name:___________________MR No:______________Unit/Ward_______________

Date Of Admission:_________________ Age:_______________Sex:____________________
Occupation/Profession:______________ Language: (1)______________(2)______________
Education:_______________________Marital Status:_______________________________
Children:__________________M____________F____________
Medical Diagnose:___________________________________________________________
Past Medical History:(1)Hospitalization__________________________________________
(2)Surgery________________________________________________
(3)Medication at home_____________________________________
Chief Complain: ____________________________________________________________
_________________________________________________________________________
Present Surgeries:______________________Immunization Status:___________________
Vital signs: B.P:________________ Pulse:___________RR_____________Temp:________
1. Health perception Health Management Pattern:
Patient’s views about his/ her health and how she/he manages his/her health:
__________________________________________________________________________
__________________________________________________________________________
Patient knowledge about his/her disease: _________________________________________
__________________________________________________________________________
Patient’s knowledge about disease prevention: ____________________________________
___________________________________________________________________________

List of current medication

Medication Generic Indication

Over the counter drugs: __________________________________________________________

Allergies: Food:________________________Drug:____________________Other___________
Nursing Diagnosis:_____________________________________________________________
_____________________________________________________________________________

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2.) Nutrition And Metabolic Pattern

Number of meals per day. Break fast:_____________Lunch__________Dinner__________

Snacks ______________________
Food Preference :(1)Like:___________________(2)Dislikes__________________________
Amount of fluids per day:_________________Rout(I/V)_________Oral________________
Tube feeding __________________Any dietery restriction__________________________
Any fluid restriction________________________________________
Skin
Turgor _________________Color______________Texture______________Edema_______
Hair : Texture______________________Distribution__________________________
Oral mucus membrane:_______________Gums______________No of teeth_____________
Alignment:___________________Dentures:________ Hieght_________ Wieght________
Labs; HB____________ HCT_____________ WBC ______________ESR _________
RBC_____________ Platlets ____________PT_________ APTT _________INR ________
Albumin _____________ Na_____________ K __________Ca______
Mg___________ Others___________________
Nursing Diagnosis:__________________________________________________________
__________________________________________________________________________

3.)Elimination Pattern

Urine : Frequency/24 hr________________Voiding self/Catheterized__________________

Color ____________________Amount /24hr________________Any pain/discomfort during
urination_____________________________Any problem with Bladder control:
Retension/incontinence:_______________________Stool/24hr___________________
Color____________Odor_________________Charactaristic__________________________
Amount_____________________ Any problem with bowel control:
Constipation/Incontenence___________________________________________
Nursing Diagnose: ___________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

4.) Activity Exercise Pattern:

Life style (active, sedentary) Breathlessness during activity or at

Rest_______ Cough (dry, productive)_________ if productive______________ Color
_______ order _________Characteristic _________ Amount _______SOB ________
O2/min ______ via______________ Inhalation therapy _________Sputum tests______
Nursing Disgnosis: _______________________________________________________
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 _______________________________________________________________________
Calculation:
Pulse rate/min___________ Rhythm________________ Amplitude________________
Peripheral pulses________________ Capillary refill________________________
Extremities: Color__________Temp_________________
Nursing Diagnosis________________________________________________________
_______________________________________________________________________

5) . Cognitive perceptual pattern

Level of consciousness: Oriented to time ________ place _________ person__________

If unconsciousness GCS________Any speech difficulty _____________
Memory: Recent _________ Remote ________Vision _________Glasses_________
Hearing ___________ Pain: Characteristic___________ Onset_______________
Location ________ Duration __________________ Exacerbation _______________
Radiation ___________ associated with __________ Relieving factors _____________
Nursing diagnosis____________________________________________________

6). Rest and sleep pattern

No of hours sleep/24 hours: Home ____________Hospital __________ Naps__________
Any problem to fall/stay asleep ____________ Use of tranquillizers ____________
Any home remedy to induce sleep ______________________________________
Evidence of lack of sleep _________________ Quality of sleep _____________
Nursing diagnosis: __________________________________________________
_________________________________________________________________

7). Self Perception/Self Concept Pattern

Patient’s perception of his or herself___________________________________
Grooming ___________ Voice tone _____________ Eye contact ___________
Gesture /Congruent with words ________________________________________
_________________________________________________________________

8). Role Relationship Pattern

Family (extended/nuclear) _________ Responsibilities in family ________

Role shared by _______ Role in decision making __________
Leisure entertainment activities _______ Socialization __________
Satisfaction with family / work __________________
Nursing diagnosis: ___________________________________________________
_____________________________________________________________________

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9). Coping / stress Pattern

Affected/Mod: Calm ______ Angry __________ Irritable ______________

Anxious _______ Withdrawal __________ Apathetic ____________
Common stressors ____________ coping behavior during stress ___________
Sharing of stress with ____________________
Use of Alcohol/Pan/Tobacco/Drug:
Nursing Daignosis:_________________________________________________________
____________________________________________________________________________

10). Sexuality / 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 diagnosis: __________________________________________________
_________________________________________________________________

11). Value belief Pattern

Things important in life ___________________ Spirituality __________________

Religious beliefs _______________________________
Any spiritual conflict ____________
Satisfaction with life +_______________________
Nursing diagnosis: _________________________________________________
________________________________________________________________

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