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Gordon's (functional ) approach guide for nurses
1. Gordon’s (Functional) Approach of health patterns
Prepared by: Abebe Dilie (BSc, MSc), DMU, Department of Nursing Page 1
Nursing Assessment using Functional Health Pattern
Name_____________________________ ID _______________ ward/OPD________________
Demographic data
Date
Time
Identification
Name
Age
Address
Ethnicity
Source of referral
Source of information.
Date of admission(if admitted)
Medical diagnosis(if established)
Surgical procedure if any
Condition on admission
Vital sign
Temperature
Blood pressure
Pulse rate
Respiratory rate
1. Health perception and health management pattern
Reason for seeking health care / chief complain
Where did you go when you are sick?
Family history of chronic illness
Any absences from work/school?
Most important things you do to keep healthy?
Use of cigarettes, alcohol, drugs?
Perform self-exams, i.e. Breast/testicular self-examination?
What do you think caused current illness?
What actions have you taken since symptoms started?
Have your actions helped? (if appropriate)
Significant clustered data: _______________________________________________
Nursing diagnosis _____________________________________________________
2. Gordon’s (Functional) Approach of health patterns
Prepared by: Abebe Dilie (BSc, MSc), DMU, Department of Nursing Page 2
2. Nutritional and metabolic pattern
Appetite
Taste sensation
Blood glucose monitoring
Tube feeding
Total parenteral nutrition
Output
Nails: color, shape
General skin color/ texture
Skin
Edema
Skin turgor
Skin lesion
Braden scale
Height
Weight
Body mass index
Undernourished
Eating /digesting problems
Antacid use or other / explain
Dentition
Oral mucosa
Significant clustered data _____________________________________________
Nursing diagnosis ___________________________________________________
3. Elimination pattern
Bowel sound
Abdomen
Bowel habit
Stool: color, consistency, amount
Rectum
Bladder function
Urine: color, odor
Skin
Significant clustered data________________________________________________
Nursing diagnosis _____________________________________________________
4. Activity and exercise pattern
Date Temperature Pulse Respiration Blood pressure
o Apical rhythm
o Capillary refill
o Supplemental oxygen
o Use of tobacco currently
o Respiratory effort, depth
o Response to activity of daily living
o Musculoskeletal: gait
o Upper extremities
o ROM
o Difficulty of breathing
o Cough
o Breath sounds
o Suctioning
o Artificial airway
o Chest tube
o Lower extremities: strength
3. Gordon’s (Functional) Approach of health patterns
Prepared by: Abebe Dilie (BSc, MSc), DMU, Department of Nursing Page 3
o ROM
o Assistive devices
o Physical therapy
o History of falls
Significant clustered data _______________________________________________
Nursing diagnosis _____________________________________________________
5. Sleepand rest pattern
Typical home sleep pattern
Typical hospital sleep pattern
Sleep difficulties
Naps
Significant clustered data ____________________________________________
Nursing diagnosis __________________________________________________
6. Sexuality and reproduction pattern
Verbalized impact of illness, medication and treatment on sexuality
History of STD’s
Sexually active
Annually/monthly screening exams: prostate/ testicular
7. Cognitive and perception pattern
Mental status: PPT
Level of consciousness
Memory
Thought
Pupils :PERRLA
Vision
Hearing
Peripheral sensory perception
Pain assessment
Pain lasting longer than six
months
8. Role and relationship pattern
Current occupation
Support systems: marital status
Socialization
Changes in life/ roles/
relationships
Verbalized fears of violence
Significant clustered data __________________________________________
Nursing diagnosis ________________________________________________
9. Self-perception and self-concept pattern
Erickson’s age related developmental stage
Clients developmental stage (from Erickson’s)
Identified major losses or life changes
Emotional/ behavioral state
Significant clustered data__________________________________________
Nursing diagnosis _______________________________________________
4. Gordon’s (Functional) Approach of health patterns
Prepared by: Abebe Dilie (BSc, MSc), DMU, Department of Nursing Page 4
10. Coping and stress tolerance pattern
Mechanism to cope the stressors
Use of drugs or alcohol for coping
Interest in alternative coping strategies
Significant clustered data__________________________________________
Nursing diagnosis _______________________________________________
11. Values and belief pattern
Most valued thing for him/ her in his / her life
Consider himself as religious person
Request of spiritual support in hospitals
Spiritual cues around him
Significant clustered data__________________________________________
Nursing diagnosis _______________________________________________
Future health care needs/ discharge plans
Anticipated discharge needs _______________________________________
Nursing/ nurses aid______________________________________________
Dietary/nutrition________________________________________________
Equipment/ medication___________________________________________
Medical _______________________________________________________
Specific discharge instruction______________________________________
Nursing diagnosis: knowledge deficit________________________________
Medications currently prescribed including IV solutions
Name
Dose,
frequency,
time , IV rate
Major
action
Common
side effect
Nursing
action and
implication
Why this
medication is
prescribed
Diagnostic studies /procedures (include date, time & diagnostic finding)
Procedure Normal value Result Date Explain why
the test is
ordered
5. Gordon’s (Functional) Approach of health patterns
Prepared by: Abebe Dilie (BSc, MSc), DMU, Department of Nursing Page 5
Nursing care plan
Assessment
Nursing
diagnosis
Plan Implementation Evaluation
Goal Expected outcome
Subjective data
Objective data
Case of the patient (Literature review)
Text book description of medical diagnosis
Etiology
Pathophysiology
Diagnostics- how the condition diagnosed
Signs and symptoms
Medical and nursing management