Mindanao State University – Iligan Institute of Technology

COLLEGE OF NURSING

Maternal and Child Nursing

NURSING ASSESSMENT II
Gordon’s Assessment

Name of Patient: Jhanna Macaliag Age: 4 y/o

Chief Complaint/s: Vomiting, diarrhea, stomachache, fever Sex: Female

Allergies: None Diet: B.R.A.T.

Impression/Diagnosis: Amoeba Type of None

Operation
Date and Time of November 18, 2022 (If any):
Admission:

Student: ___________________________ Group: ________

Inclusive Dates of Duty: ______________________________
Patient: __________________________ Room No.: _______

Before Hospitalization Initial

Normal Pattern
(Typical Pattern) (Current Pattern)
1. Health Perception-Health
Management Past health history: fever
a. Perceived health status

b. Perceived health
management

c. Healthcare Behaviors: health

promotion and illness
prevention activities, medical
treatments, follow-up care

2. Nutrition-Metabolic
a. Daily food and fluid Food intake: 2-3 times a day
consumption
No any food allergies
b. Food preferences
c. Use of dietary supplements The patient have no difficulties with
d. Skin lesions and ability to
eating or swallowing foods.
heal
e. Integumentary condition
f. Weight, height, temperature

3. Elimination
a. Bowel and urinary excretion The evacuation of the
patterns bowels;defecation

b. Perceived regularity or
irregularity of elimination

c. Use of laxatives or routines

d. Changes in time, modes.

Quality or quantity of
excretions

e. Use of devices for control

4. Activity Exercise
a. Patterns of personally Active Kid
relevant exercise, activity,
leisure, and recreation

b. ADLs that require energy

expenditure

c. Factors interfering with the

desired pattern

5. Sleep – Rest
a. Patterns of sleep and rest- The patient sleeps at the afternoon at
relaxation in a 24-h period
2pm.
b. Perception of quality and The patient sleeps at night between 8-
quantity of sleep and rest
9pm.
c. Use of sleep aids and
routines

6. Cognitive – Perceptual
a. Adequacy of vision, hearing, The patients Clients five senses are
taste, touch, smell
totally fine.
b. Pain perception and
management

c. Language, judgment,
memory, decisions

7. Self-Perception – Self-
Concept The patient is shy towards other kids,
a. Attitudes about self
kind. She fights back whenever she
b. Perceived abilities, worth, gets bullied by the other kids.
self-image, emotions

c. Body posture and

movement, eye contact,
voice and speech patterns

8. Role-Relationships
a. Perception of major roles, The patient is very active and
relationships, and
energetic with her siblings.
responsibilities in current life
situation Thee patient is living with her parents
and 2 other siblings.
b. Satisfaction with or
disturbances in roles and
relationships

9. Sexuality-Reproductive
a. Satisfaction with sexuality or
sexual relationships

b. Reproductive pattern

c. Female menstrual and

perimeno-pausal history
10.Coping – Stress Tolerance
a. Capacity to resist challenges
to self-integrity
b. Methods of handling stress
The patient has a good memory.
The patient have no difficulties of
learning.

c. Support systems

d. Perceived ability to control

and manage situations

11.Value-Belief
a. Values, goals, or beliefs
The patients religious affiliation is
(including spirituality) that
guide choices or decisions Roman Catholic and she seldom go to
church with her parents
b. Perceived conflicts in values,
beliefs, or expectations that
are health related