Nursing Assessment According to Gordon’s Functional Pattern

A. Health Maintenance-Perception Pattern

Use of:
Tobacco: ___ None _____ Quit (date) ____Pipe _____Cigar _____
___< 1pk/day ____ 1-2 pks/day _____>2 pks/day Pks/year history ___
Alcohol: ___ Date of last drink ___________ Amount/ type
___ No. of days in a month when alcohol is consumed
Other Drugs: ___ No ____ Yes Type ____________ Use _____________
Allergies (drugs, food, tape, dyes): __________________ Reaction _________
__________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

B. Activity – Exercise Pattern

Self-Care Ability:
0 = Independent 1 = Assistive Device 2 = Assistance from others
3 = Assistance from person and equipment 4 = Dependent/ Unable
0 1 2 3 4
Eating/Drinking
Bathing
Dressing/Groomin
g
Toileting
Bed Mobility
Transferring
Ambulating
Stair Climbing
Shopping
Cooking
Home Maintenance
Assistive Devices: ____ None ____ Crutches _____ Bedside Commode ____ Walker
____ Cane ____ Splint/ Brace ____ Wheelchair _____ Other
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

C. Nutrition – Metabolic Pattern

Special Diet/ Supplement __________________________________________________
Previoius Dietary Instruction: _____ Yes _____ No
Appetite: _____ Normal _____ Increased _____ Decreased _____ Decreased taste sensation
_____ Nausea _____ Vomiting
Weight Fluctuations Last 6 Months: ____ None _______________lbs. Gained/ Lost
Swallowing difficulty: _____ None _____ Solids _____ Liquids
Dentures: ____ Upper ( ___ Partial ____ Full ) ____ Lower ( ___ Partial ___ Full )
With Person ____ Yes ____ No
History of Skin/ Healing Problems: _____ None _____ Abnormal Healing ____ Rash
_____ Dryness ____ Excess Perspiration

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
D. Elimination Pattern
Bowel Habits: ____ # BMs/day ____ Date of last BM ____ Within normal limits
____ Constipation ____ Diarrhea _____ Incontinence
____ Ostomy: Type: _____Appliance ____ Self-care ____Yes ____ No
Bladder Habits: ____ WNL ____ Frequency ____ Dysuria ____ Nocturia ____ Urgency
____ Hematuria ____ Retention
Incontinency: ____ No ____ Yes ____ Total ____ Daytime ____ Nighttime
____ Occasional ____ Difficulty delaying voiding
____ Difficulty reaching toilet
Assistive Devices: ____ Intermittent catheterization
____ Indwelling catheter ____ External catheter
____ Incontinent briefs _____ Penile implant type

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

E. Sleep – Rest Pattern

Habits: ____ hrs/night ____ AM nap ____ PM nap
Feel rested after sleep ____ Yes ____ No
Problems: ____ None ____ Early waking ____ Insomnia ____ Nightmares
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

F. Cognitive – Perceptual Pattern

Mental Status: ____ Alert ____ Receptive aphasia ____ Poor historian
____ Oriented ____ Confused ____ Combative ____ Unresponsive
Speech: ____ Normal ____ Slurred ____ Garbled ____ Expressive aphasia
Spoken language ____________________ Interpreter _______________________
Language Spoken: ____ Tagalog _____ Cebuano _____ Ilonggo ____Other ____________
Ability to Read English: ____ Yes ____ No _____________________________________
Ability to Communicate: ____ Yes ____ No _____________________________________
Ability to Comprehend: ____ Yes ____ No ______________________________________
Level of Anxiety: ____ Mild ____ Moderate ____ Severe ____ Panic
Interactive Skills: ____ Appropriate ____ Other __________________________________
Hearing: ____ WNL ____ Impaired ( ___Right ___Left ) ____ Deaf ( ___Right ___Left )
____ Hearing Aid
Vision: ____ WNL ____ Eyeglasses ____ Contact lens
____ Impaired ____ Right ____ Left
____ Blind ____ Right ____ Left
____ Prosthesis ____ Right ____ Left
Vertigo: ____ Yes ____ No memory intact ____ Yes ____ No
Discomfort/ Pain: ____ None ____ Acute ____ Chronic ____ Description _____________
___________________________________________________________________________
Pain Management: __________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
G. Coping – Stress Tolerance / Self – Perception/ Self – Concept Pattern
Major concerns regarding hospitalization or illness (financial, self-care): ________________
___________________________________________________________________________
Major loss/ change in past year: ____ No ____ Yes ________________________________
Fear of Violence ____ Yes ____ No Who _______________________
Outlook on Future __________ (rate 1 – poor – to 10- very optimistic)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

H. Sexuality – Reproductive Pattern

LMP: ____________________ Gravida: _______ Para: _______
Menstrual / Hormonal Problems: ____ Yes ____ No _______________________________
Last Pap Smear: ________________ History of Abnormal PAP _____________________
Monthly Self-Breast/ Testicular Exam: ____ Yes ____ No Last Mammogram: ________
Sexual Concerns: ___________________________________________________________
____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

I. Role – Relationship Pattern

Marital Status: ___________
Occupation: ________________________________________________________________
Employment Status: ____ Employed ____ Short-term disability
____ Long-term disability _____ Unemployed
Support System: ____ Spouse ____ Neighbors/ Friends ____ None
____ Family in same residence ____ Family in separate residence
____ Other ___________________________________________________
Family concerns regarding hospitalization: _______________________________________
___________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

J. Value – Belief Pattern

Religion: __________________________________________________________________
Religious Restrictions: ____ No ____ Yes (Specify) _______________________________
Request Chaplain Visitation at This Time: ____ Yes ____ No

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Signature/ Title _______________________________ Date _______________________

Code: (1) Not applicable (2) Unable to acquire (3) Not a Priority at this time
(4) Other (specify in notes)