GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx

GORDON’S 11 FUNCTIONAL HEALTH
ASSESSMENT
BY: ROMMEL LUIS C. ISRAEL III

FUNCTIONAL
HEALTH
PATTERN
Marjorie Gordon (1987) proposed
functional health patterns as a guide
for establishing a comprehensive
nursing data base.
These 11 categories make possible a
systematic and standardized
approach to data collection, and
enable the nurse to determine the
following aspects of health and
human function:

1. Health Perception and Health Management
2. Nutrition and Metabolism
3. Elimination
4. Activity and Exercise
5. Cognition and Perception
6. Sleep and Rest
7. Self-Perception and Self-Concept
8. Roles and Relationships
9. Sexuality and Reproduction
10.Coping and Stress Tolerance
11.Values and Belief

HEALTH PERCEPTION AND
HEALTH MANAGEMENT
Data collection is focused on the person's perceived level
health and well-being, and on practices for maintaining
Habits evaluated includes smoking and alcohol or drug
Actual or potential problems related to safety and
management may be identified as well as needs for
modifications in the home or needs for continued care
the home.

Client’s general health?
Any colds in past year?
If appropriate: 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?
Accidents at home, work, school, driving?
In past, has it been easy to find ways to carry out doctor’s or
nurse’s suggestions?
(If appropriate) What do you think caused current illness?
What actions have you taken since symptoms started?
Have your actions helped?
(If appropriate) What things are most important to your health?
How can we be most helpful?
How often do you exercise?

NUTRITION
AND
METABOLISM
Assessment is focused on the
pattern of food and fluid
consumption relative to
metabolic need.
The adequacy of local nutrient
supplies is evaluated.
Actual or potential problems
related to fluid balance, tissue
integrity, and host defenses
be identified as well as
with the gastrointestinal

HISTORY (SUBJECTIVE DATA):
TYPICAL DAILY FOOD INTAKE? (DESCRIBE)
USE OF SUPPLEMENTS, VITAMINS, TYPES OF SNACKS?
TYPICAL DAILY FLUID INTAKE? (DESCRIBE)
WEIGHT LOSS/GAIN? HEIGHT LOSS/GAIN?
APPETITE?
BREASTFEEDING? INFANT FEEDING?
FOOD OR EATING: DISCOMFORT, SWALLOWING
DIFFICULTIES, DIET RESTRICTIONS, ABLE TO FOLLOW?
HEALING – ANY PROBLEMS?
SKIN PROBLEMS: LESIONS? DRYNESS?
DENTAL PROBLEMS?

EXAMINATION (EXAMPLES
OF OBJECTIVE DATA):
SKIN ASSESSMENT, ORAL
MUCOUS MEMBRANES,
TEETH, ACTUAL
WEIGHT/HEIGHT,
TEMPERATURE.
ABDOMINAL

ELIMINATION
•Data collection is focused on
excretory patterns (bowel, bladder,
skin).
•Excretory problems such as
incontinence, constipation, diarrhea,
and urinary retention may be
identified.

History (subjective data):
Bowel elimination pattern (describe)
Frequency, character, discomfort, problem with
bowel control, use of laxatives (i.e. type,
frequency), etc.?
Urinary elimination pattern (describe)
Frequency, problem with bladder control?
Excess perspiration? Odour problems?
Body cavity drainage, suction, etc.?

Examination (examples of
objective data):
• If indicated, examine excretions or
drainage for characteristics, colour,
and consistency.
• Abdominal assessment.

ACTIVITY
AND
EXERCISE
activities of daily living
requiring energy expenditure,
including self-care activities,
exercise, and leisure activities.
The status of major body
systems involved with activity
and exercise is evaluated,
including the respiratory,
cardiovascular, and
musculoskeletal systems.

• Sufficient energy for desired and/or required
activities?
• Exercise pattern? Type? regularity?
• Spare time (leisure) activities?
• Child-play activities?
• Perceived ability for feeding, grooming,
bathing, general mobility, toileting, home
maintenance, bed mobility, dressing and
shopping?

Examination (examples of objective
data):
Demonstrate ability for the following:
• Gait.
• Posture.
• Absent body part.
• Range of motion (ROM) joints.
• Hand grip - can pick up pencil? Respiration. Blood
pressure.
• General appearance.
• Musculoskeletal, cardiac and respiratory assessments.

COGNITION AND PERCEPTION
• Assessment is focused on the
ability to comprehend and use
information and on the sensory
functions.
• Data pertaining to neurologic
functions are collected to aid
this process.
• Sensory experiences such as
pain and altered sensory input
may be identified and further
evaluated.

• Hearing difficulty?
• Hearing aid?
• Vision? Wears glasses? Last checked? When last
changed?
• Any change in memory? Concentration?
• Important decisions easy/difficult to make?
• Easiest way for you to learn things? Any difficulty?
• Any discomfort? Pain?

If appropriate – PQRST questions :
• P – Palliative, Provocative
• Q - Quality or quantity
• R – Region or radiation
• S - Severity or scale
• T - Timing
-(Morton, 1977) COLDSPA C - Character O - Onset L - Location D - Duration S – Severity P
- Pattern A - Associated factors (Weber, 2003)

data):
• Orientation.
• Hears whispers?
• Reads newsprint?
• Grasps ideas and questions (abstract,
concrete)?
• Language spoken.
• Vocabulary level.
• Attention span.

SLEEP AND REST
• Assessment is focused
on the person's sleep,
rest, and relaxation
practices.
• Dysfunctional sleep
patterns, fatigue, and
responses to sleep
deprivation may be
identified.

• Generally rested and ready for activity
after sleep?
• Sleep onset problems? Aids?
• Dreams (nightmares), early awakening?
• Rest / relaxation periods?
• Sleep routine?
• Sleep apnea symptoms?

EXAMINATION (EXAMPLES OF
OBJECTIVE DATA):
OBSERVE SLEEP PATTERN AND REST
PATTERN.

SELF-
PERCEPTION
AND SELF-
CONCEPT
Assessment is focused on
the person's attitudes
toward self, including
identity, body image,
sense of self-worth.
The person's level of
esteem and response to
threats to his or her self-
concept may be

• How do you describe yourself?
• Most of the time, feel good (or not so good) about
self?
• Changes in body or things you can do?
• Problems for you?
• Changes in the way you feel about self or body
(generally or since illness started)?
• Things frequently make you angry? Annoyed?
Fearful? Anxious? Depressed?
• Not able to control things? What helps?
• Ever feel you lose hope?

data):
• Eye contact.
• Attention span (distraction?).
• Voice and speech pattern.
• Body posture.
• Client nervous (5) or relaxed (1) (rate scale
1-5) Client assertive (5) or passive (1) (rate
scale 1-5)

ROLES AND
RELATIONSHIPS
Assessment is focused
the person's roles in the
world and relationships
with others.
Satisfaction with roles,
role strain, or
dysfunctional
relationships may be
further evaluated.

• Live alone? Family?
• Family structure?
• Any family problems you have difficulty handling
(nuclear/extended family)?
• Family or others depend on you for things?
• How well are you managing?
• If appropriate – How families/others feel about your
illness?
• Problems with children?
• Belong to social groups? Close friends? Feel lonely?
(Frequency)
• Things generally go well at work / school?
• If appropriate – income sufficient for needs?
Feel part of (or isolated in) your neighbourhood?

data):
Interaction with family members or
others if present.

SEXUALITY AND
REPRODUCTION
Concerns with sexuality may he
identified.
person's satisfaction or
dissatisfaction with sexuality
patterns and reproductive functions.

• If appropriate to age and situation – Sexual
relationships satisfying? Changes? Problems?
• If appropriate – Use of contraceptives?
• Problems? Female – when did menstruation
begin? Last menstrual period (LMP)? Any
menstrual problems?
• (Gravida-Number of Pregnancy/Para-Number of
Births if appropriate)

data):
None unless a problem is identified or a pelvic examination is
warranted as part of full physical assessment (advanced nursing
skill).

COPING AND STRESS
TOLERANCE
• Assessment is focused on the person's
perception of stress and on his or her
coping strategies
• Support systems are evaluated, and
symptoms of stress are noted.
• The effectiveness of a person's coping
strategies in terms of stress tolerance may
be further evaluated.

• Any big changes in your life in last year or two?
• Crisis? Who is most helpful in talking things over?
Available to you now?
• Tense or relaxed most of the time? When tense, what
helps?
• Use any medications, drugs, alcohol to relax?
• When (if) there are big problems in your life, how do
you handle them? Most of the time, are these ways
successful?

VALUES AND BELIEF
• Assessment is focused on
the person's values and
beliefs (including spiritual
beliefs), or on the goals
that guide his or her
choices or decisions.

• Generally get things you want from life?
• Important plans for future?
• Religion important to you? If appropriate -
Does this help when difficulties arise?
• If appropriate – will being here interfere
with any religious practices?

FUNCTIONAL
ASSESSMENT TESTS

APGAR
SCORE
• The test is
generally done at
one and five
minutes after
birth, and may be
repeated later if
the score is and
remains low.
• Scores 7 and
above are
generally normal,
• 4 to 6 fairly low,
• 3 and below are
generally
regarded as
critically low.
Appearance
(skin color),
Pulse (heart
rate),
Grimace
(reflex
irritability),
Activity
(muscle tone),
and
Respiration

NEWBORN
• APGAR SCORING TEST

NEWBORN SCREENING
Republic Act 9288
• Newborn screening (NBS) is a public
health program aimed at the early
identification of infants who are affected by
certain genetic/metabolic/ infectious
conditions. Early identification and timely
intervention can lead to significant reduction
of morbidity, mortality, and associated
disabilities in affected infants.
• NBS in the Philippines started in June 1996
and was integrated into the public health
delivery system with the enactment of the
Newborn Screening Act of 2004 (Republic
Act 9288).
• From 1996 to December 2010, the
program has saved 45 283 patients.

NEWBORN SCREENING
Republic Act 9288
Five conditions are
currently screened: -
 Congenital Hypothyroidism,
 Congenital Adrenal
Hyperplasia,
 Phenylketonuria,
 Galactosemia, and
 Glucose-6-Phosphate
Dehydrogenase Deficiency.

ASSESSMENT OF
INFANT AND
CHILDREN

HEIGHT
AND
LENGTH
• Growth is not only a result of
nutrition but also a result of
inherited factors.
• Ethnicity can influence a child’s
growth patterns, and so some
countries have their own growth
charts.

HOW TO MEASURE

HOW TO TAKE
MEASUREMENTS
Typical measurements
taken for children 0-24
months include:
• Head circumference
• Length
• Weight

Measurements should be taken at regular intervals in
order to observe reliable trends. Recommendations for
measurement intervals include:
Infants (0-12 months): every 2 months
Young Children: at 15, 18, 24 and 30 months
Ages 3+: every year

GROWTH
CHARTS
MODULE
BRANDED
MEASUREMENT
SCHEDULE
HANDOUT

HEAD CIRCUMFERENCE
The measurement should be taken with a measuring tape that cannot be
This is typically a flexible, metal measuring tape. To measure, securely wrap
tape around the widest possible circumference of the head. Typically, this is
2 finger-widths above the eyebrow on the forehead to the most prominent
the back of the head. Take the measurement three times and select the
measurement to the nearest 0.1cm.
Head circumference is a measurement taken
the largest part of a child’s head. This
is typically taken with children ages 0-3 years

• Height
• - it is good determination of health
and normal nutrition as weight
• -male infant is an average of 2-3cm
longer than of female at birth
• -During first year of the life the
infant HT should increase by 25-30
cm
- by age 2 yrs , the child will be an
average of 12.5 cm taller -most
toddlers have reached approximately
12 of their adult height.
• -AT birth: 46-56cm , average( 50cm)

LENGTH
• Length is the linear
measurement for infants
up to 24 months. Length
measurements (instead of
height) are also taken for
children 24 to 36 months
who cannot stand without
assistance.

LENGTH
• Length is measured when children are in a
recumbent (lying down) position. The most
accurate way to measure length is by using a
calibrated length board. Length boards
should have a fixed headpiece and a
moveable foot piece perpendicular to the
surface of the board.
• To measure, lay the child on the board with their head against the fixed
headpiece. Make sure the child is not wearing shoes or a hairpiece. An
assistant may be helpful to hold the child still and centered on the
board. Straighten the child’s legs and adjust the moveable foot piece so
the soles of the feet are against the foot piece. Record the length to the
nearest 0.1 cm.

WEIGHT
•Weight is a measurement taken
throughout the lifespan to help
determine trends and current
nutritional status.

WEIGHT
• Infant weight can be accurately
measured using one of several
different pieces of equipment.
• If available, a pan-type pediatric
scale allows a child to be weighed
while lying down. These pediatric
scales are either electronic or beam
scales with non-detachable weights,
and are accurate to the nearest 10
gram.
• Another option is a hanging scale. A
hanging scale needs to be attached
to a sturdy structure (e.g. building
rafter, door frame) and the child is
suspended from the scale in
weighing pants.

WEIGHT
• To measure, make sure the child is wearing as little clothing as
possible and that no one is touching the child.
• Read the scale at eye-level and record weight to the nearest
10 gram.
•
• Repeat the measurement three times, exclude values that
appear skewed, and find the average.

WEIGHT

• In the event a baby scale is unavailable, an adult standing
scale can be used to measure infant weight. Weigh an adult
first, and then weigh the same adult while holding a child.
Find the difference between the two weights – this is the
infant’s weight.
• Weight-for-age is an important indicator of a child’s
nutritional status over time, such as trends in underweight.

Weight:
• Average newborn boy weight=3400g, and
girl= 3200g
• - infant lose 5-10% of birth weight at age 3-4
days to gain it back in 2 weeks with a steady
growth rate.
• Infant double birth Weight by 6 months
• They triple the body weight by 12 month= 10
kg.

CHEST, AND
ABDOMINAL
CIRCUMFERENCE.
Whaley and Wong

ABDOMINAL
GIRTH
• Abdominal girth
should be measured
over the umbilicus
• Whenever
possible.

Head circumference and chest
circumference :
• Measure at birth and routinely until age 3 yrs.
• HC measures directly skeletal growth (skull), and indirectly cerebral growth.
• Measurement at birth = 33-35 cm
• Chest circumference : CC = 31-33 cm at birth
• Ratio of head to chest circumference:
• birth : HC is larger than CC by 2 cm
• 1 yr-18 month : HC=CC
• 2-3 yrs HC slightly smaller than CC
• > 3 yrs :HC is smaller than CC by 5-7 cm

METRO MANILA
DEVELOPMENT
SCREENING
TEST (MMDST)
Developed for health
(MDs, RNs, etc)
It is not an intelligence test
It is a screening instrument to
determine if child’s development
within normal
Children 6 ½ years and below

METRO MANILA
DEVELOPMENT
SCREENING
TEST (MMDST)
Purposes
Measures
developmental
Evaluates 4 aspects
development

4 SECTORS OF
DEVELOPMENT
Personal-Social – tasks which indicate
child’s ability to get along with people
and to take care of himself
Fine-Motor Adaptive – tasks which
indicate the child’s ability to see and
his hands to pick up objects and to
Language – tasks which indicate the
child’s ability to hear, follow directions
and to speak
Gross-Motor – tasks which indicate the
child’s ability to sit, walk and jump

MMDST KIT
Preparation for test administration involves the nurse
ensuring the completeness of the test materials contained
in the MMDST Kit. These materials should be followed as
specified:
• MMDST manual
• test Form
• bright red yarn pom-pom
• rattle with narrow handle
• eight 1-inch colored wooden blocks (red, yellow, blue green)
• small clear glass/bottle with 5/8 inch opening
• small bell with 2 ½ inch-diameter mouth
• rubber ball 12 ½ inches in circumference
• cheese curls
• pencil

EXPLAINING THE
PROCEDURE.
AGE & THE AGE LINE.
TEST ITEMS.
SCORING.

WHAT IS THE
BARTHEL
INDEX?
• The Barthel Index consists of
10 items that measure a
person's daily functioning
specifically the activities of
daily living and mobility.
• The items include feeding,
moving from wheelchair to
bed and return, grooming,
transferring to and from a
toilet, bathing, walking on
level surface, going up and
down stairs, dressing,
continence of bowels and
bladder.

HOW IS THE BARTHEL INDEX
USED?
• The assessment can be used to determine a baseline
level of functioning and can be used to monitor
improvement in activities of daily living over time.
• The items are weighted according to a scheme
developed by the authors.
• The person receives a score based on whether they
have received help while doing the task. The scores
for each of the items are summed to create a total
score.
• The higher the score the more "independent" the
person.
• Independence means that the person needs no
assistance at any part of the task.
• If a persons does about 50% independently then
the "middle" score would apply.

KATZ
INDEX
• WHY: Normal aging changes and health
problems frequently show themselves as
declines in the functional status of older
adults.
• Decline may place the older adult on a
spiral of iatrogenesis leading to further
health problems.
• One of the best ways to evaluate the health
status of older adults is through functional
assessment which provides objective data
that may indicate future decline or
improvement in health status, allowing the
nurse to plan and intervene appropriately.

• BEST TOOL: The Katz Index of Independence in Activities of Daily
Living, commonly referred to as the Katz ADL, is the most
appropriate instrument to assess functional status as a
measurement of the client’s ability to perform activities of daily
living independently.
• Clinicians typically use the tool to detect problems in performing
activities of daily living and to plan care accordingly.
• The Index ranks adequacy of performance in the six functions of
bathing, dressing, toileting, transferring, continence, and feeding.
• Clients are scored yes/no for independence in each of the six
functions.
• A score of 6 indicates full function, 4 indicates moderate
impairment, and 2 or less indicates severe functional impairment.

BMI
Your BMI is based on your height and
It's one way to see if you're at a
Underweight: Your BMI is less than 18
Healthy weight: Your BMI is 18.5 to 24.9
Overweight: Your BMI is 25 to 29.9
Obese: Your BMI is 30 or higher

HOW TO CALCULATE YOUR
BODY MASS INDEX OR BMI
BMI is your weight (in
kilograms) over your
squared (in meters). Let’s
calculate, however, using
pounds and inches.
• BMI = weight in kg / height in m²

Example:
• For instance, the BMI of a person who is 5’3"
and weighs 125 lbs is calculated as follows:
• BMI= 125 lbs ÷ 0.45 kg
5 x 12 in + 3 in.
= 56.25 kg__
63 in x .0254 m

1. Multiply the weight in pounds
by 0.45 (the metric conversion
factor)
125 X 0.45 = 56.25 kg
2. Multiply the height in inches by
0.025 (the metric conversion
factor)
63 X 0.025 = 1.575 m

3. Square the answer from step 2
1.575 X 1.575 = 2.480625
4.Divide the answer from step 1 by the
answer from step 3
56.25 : 2.480625 = 22.7
•1.575 X 1.575 = 2.480625

•The BMI for a person
who is 5’3" and weighs
125 lbs is 22.7 or
practically, 23 which
means a healthy weight.

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