NURSING ASSESSMENT GUIDE

NAME OF STUDENT: ________________________ SECTION/GROUP: _____ ASSESSMENT

DATE: _____

A. CLIENT PROFILE
I. GENERAL INFORMATION
NAME OF CLIENT: DATE OF ADMISSION:
AGE: HOSPITAL /INSTITUTION:
SEX: WARD/AREA AND BED NUMBER:
Source of Information (if client is child): NAME:
RELATIONSHIP TO CLIENT:

HOME ADDRESS:
OCCUPATION:
CIVIL STATUS:

II. MEDICAL DIAGNOSIS

III. OPERATION (if any)

IV. CHIEF COMPLAINT

V. BRIEF HISTORY OF PRESENT HOSPITALIZATION

(In narrative form, must start hours or days prior to hospitalization.)

GORDON’S HEALTH PATTERN:

B. NURSING HISTORY (narrative format per health pattern)

I. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
▪ How has the general health been? Personal and family history of illnesses?
▪ Any illnesses in the past 6 months? Allergies?
▪ Most important things done to keep health?
▪ Use of cigarettes, alcohol, or drugs?
▪ In the past, has it been easy for you to follow doctors or nurses suggestions?
▪ Traditional concepts of health and illness? Beliefs and practices?

II. NUTRITIONAL AND METABOLIC PATTERN

▪ Typical daily food intake? Describe. Get the 24-hour diet recall.
▪ Supplements?
▪ Typical fluid intake? Describe. How many glasses per day?
▪ General appetite?
▪ Food or eating discomforts? Diet restrictions or allergies?
▪ For adults, BMI? For children, height and weight compared to age?

III. ELIMINATION PATTERN

▪ Bowel elimination pattern? How often per day? Color, consistency, odor? Any discomforts?
Describe any difference prior and during hospitalization.
▪ Urinary elimination pattern? How often per day? Amount per urination, color, odor? Any
discomforts? Describe any difference prior and during hospitalization.
▪ Excess perspiration? Odor problems?
 IV. ACTIVITY-EXERCISE PATTERN
▪ Identify activities of daily living and/or usual routine. Describe difference prior and during
hospitalization.
▪ Sufficient energy for completing desired or required daily activities?
▪ Exercise pattern? Type and regularity?
▪ Spare time. What are your leisure activities?
▪ For children, type of play engaged in? Favorite toys?

V. SLEEP-REST PATTERN
▪ What time do you sleep at night? What time do you wake up in the morning? Describe any
difference prior and during hospitalization.
▪ Length of sleep? Any discomforts? Nightmares?
▪ Naps during the day?
▪ Do you get enough rest?

VI. COGNITIVE-PERCEPTUAL PATTERN

▪ Any change in the memory lately?
▪ Easiest way for you to learn things? Listening, reading, or watching?
▪ Hearing difficulty? Hearing aid?
▪ Visual disturbances? Visual acuity? Last checked?

VII. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

▪ How do you describe yourself before and after hospitalization?
▪ Any changes in your body?
▪ Any changes in the things you can do?
▪ What are the things that frequently make you angry, annoyed, or frustrated?
▪ For postpartum women, observe if there are any signs of postpartum blues, depression, or
psychosis.

VIII. ROLE-RELATIONSHIP PATTERN

▪ Live with whom? Family structure?
▪ Any family problems you have difficulty handling?
▪ How does family usually handle problems?
▪ How do your family members feel about your hospitalization?
▪ Belong to social groups? Close friends?

IX. HOME AND ENVIRONMENT

▪ Describe your home? How big or small, type of house, how many floors?
▪ Describe the neighborhood you live in.

X. SEXUALITY-REPRODUCTIVE PATTERN
▪ If appropriate, any changes or problems in sexual relations?
▪ For adults or married individuals, any family planning method?
▪ For female, when was menarche? Last menstrual period? Menstrual problems?
Gravida/paragravida/TPAL score?
▪ For male, date of circumcision?

XI. COPING-STRESS TOLERANCE PATTERN

▪ Any big changes in your life the past year?
▪ During times of stress, what usually helps?
▪ How do you usually handle problems? Are your strategies successful?
XII. VALUE-BELIEF PATTERN
▪ Most important things in life?
▪ What is your religion? Is it important to you?
▪ How often do you attend mass, services, or other activities in your church?
▪ Does this help when difficulties arise?

XIII. OTHERS
▪ Any other things that you like to mention?
▪ Do you have any question?