Mindanao State University – Iligan Institute of Technology

COLLEGE OF NURSING

Maternal and Child Nursing

NURSING ASSESSMENT II
Gordon’s Assessment

Name of Patient: Kane Nicholai Cababat Age: 1 y/o

Chief Complaint/s: Vomiting, LBM Sex: Male

Allergies: N/A Diet: Cerelac exclusive

breastfeeding
Impression/Diagnosis: Urinary Tract Infection (UTI) Type of
Operation N/A
Date and Time of November 24, 2022 9:00 AM (If any):
Admission:

Student: Kyla Mae M. Jumarito _____ Group: L ______

Inclusive Dates of Duty: November 26-27, 2022 ___________
Patient: Kane Nicholai Cababat _____ Room No.: _______

Before Hospitalization Initial

Normal Pattern
(Typical Pattern) (Current Pattern)
1. Health Perception-Health
Management N/A
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 Eat 3x a day
consumption
b. Food preferences Eggs, vegetables
c. Use of dietary supplements
d. Skin lesions and ability to
heal
e. Integumentary condition
f. Weight, height, temperature

3. Elimination
a. Bowel and urinary excretion Liquid Stool
patterns

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, energetic, jolly 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- Sleeps @2pm in the afternoon
relaxation in a 24-h period
Sleeps between 8-9pm in the evening
b. Perception of quality and
quantity of sleep and rest

c. Use of sleep aids and

routines

6. Cognitive – Perceptual
a. Adequacy of vision, hearing,
5 senses are fine
taste, touch, smell

b. Pain perception and

management

c. Language, judgment,
memory, decisions

7. Self-Perception – Self-
Concept
Smiley kid, easy to cry, the child’s
a. Attitudes about self
body posture and physical movements
b. Perceived abilities, worth,
are fine, says mama and often imitates
self-image, emotions
2-3 words.
c. Body posture and
movement, eye contact,
voice and speech patterns

8. Role-Relationships
a. Perception of major roles,
relationships, and
responsibilities in current life
situation

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
The mother breastfeed him to stop
to self-integrity
crying, give toys or foods to him, and
b. Methods of handling stress
make him watch coco melon.
c. Support systems

d. Perceived ability to control

and manage situations

11.Value-Belief
a. Values, goals, or beliefs
Goes to church sometimes.
(including spirituality) that
guide choices or decisions

b. Perceived conflicts in values,

beliefs, or expectations that
are health related