Gordons Functinal Health Pattern

Patent Name Mr No; Unit/Ward .

Date Of Addmision Age Sex

Occupation /Profession Language;1 2

Education Marital Status

Children; M F

Medical Diagnose

Past Madical History; 1) Hospitalization

2)Surgery

3)Medications At Home

Chief Complaints

Present Surgeries Immunization Status

Vital Signs;BP PULSE RR

Temp

1.Health perception health management pattern

Patient views about his/her health,and how he/she manage his/her health

Patient views about his illness and how he/she manage his/her illness

Patient knowledge about his/her disease

Patient knowledge about disease prevention

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List of current medications

Over The Counter Drugs

Allergies; Food Drugs Other

NURSING DIAGNOSE

2. NUTRITION PATTERN

Number of Meal per Day; Breakfast Lunch Dinner

Snacks

Food Prefrences; 1.Likes 2.Dislikes

Amount of Fluid per Day Route I/V Oral

Tube Feeding (Explain) Any Dietary Restriction

Any Fluid Restriction

Skin

Turgor Color Texture Edema

Hair; Texture Distribution

Oral Mucous Membrane Gums No Of Teeth

Alignment Dentures Height Weight

BMI

Labs;HB HCT WBC ESR RBC

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Platlets PT APTT INR

Albumin Na K Ca
Mg Others

NURSING DIAGNOSE

3. ELIMINATION PATTERN

Urine; Frequency /24 Hours Voiding; Self/Catheterized

Color Amount/24 Hours Any Pain /Discomfort

during Urination

Any Problem With Bladder Conntrol; Retention/Incontinence

Stool/24 Hours Color Odor
Characteristics Amount
Any Laxative Used
Any Problem With Bowel Control; Constipation/Incontinence

NURSING DIAGNOSE

4. ACTIVITY EXERCISE PATTERN

Life Style active/Sedentary Breathlessness during Activity or

at Rest Cough Dry, Productive If Productive
Color odor Characteristics
Amount SOB O2/Min
Via Inhalational Therapy Sputum Test

NURSING DIAGNOSE

CIRCULATION;

Pulse Rate/Min Rhythm

Amplitude Peripheral Pulses
Capillary Refill Extremities; Color
Temp
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NURSING DIAGNOSE

5. COGNITIVE PERCEPTUAL PATTREN

Level of Conciousness; Oriented To Time Place Person

If Unconscious GCS Any Speech Difficulty

Memory; Recent Remote Vision Glasses
Hearing

PAIN

Characteristics Onset Location

Duration Exacerbation Radiation

Relieving Factors Associated Factors

NURSING DIAGNOSE

6. REST AND SLEEP PATTERN

No Of Hours Sleep/24 Hours. Home Hospital Naps

Any Problem to Fall/Stay Asleep Use of Tranquilizers

Any Home Remedy to Induce Sleep

Evidence of Lack of Sleep Quality of Sleep

NURSING DIAGNOSE

7. SELF PERCEPTION /SELF CONCEPT PATTERN

Patients Perception of His/Herself Eye Contact

Grooming Voice Tone

Gesture/Congruent With Words

NURSING DIAGNOSE

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8. ROLERELATIONSHIP PATTERN

Family; extended/Nuclear Responsibilities In Family

Role Shared By

Role in Decision Making Leisure Entertainment Activities

Socialization Satisfaction
With Family/Work

NURSING DIAGNOSE

9. COPING/STRESS PATTERN

Affect/Mood; Calm Angry Irritable

Anxious Withdrawal
Apathetic Common
stressors Coping Behavior During Stress
Sharing Of Stress With Use Of Alcohol/Pan/Tobacco/Cigarette/Drug

NURSING DIAGNOSE

10.SEXULITY 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 DIAGNOSE

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11. VAUE BELIEF PATTERN

Things Important In Life

Spirituality Religious Beliefs
Any Spiritual Conflict Satisfaction with
Life

NURSING DIAGNOSE

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