GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

GORDONS FUNCTIONAL HEALTH

PATTERN

Gordon’s Functional Health Pattern for Adult (General)

Health Management and Perception Pattern

 Do you understand your medical diagnosis? Yes No

 Cause of Hospitalization (Chief Complaint)?_____________________

 Has been hospitalized before? When? Why?

________________________________________________________________________

 How did you have such disease? ____________________________________

 When did it start? How did it progress?_______________________________

 How had this affected your normal ADLs?_____________________________

 Expecting to go home in a day or two? yes no

 Other health problems?________________________

 Family History? HPN DM Heart Conditions Renal Problems Bleeding disorders

Others:_______________________

 Has been compliant to the doctor’s orders? yes no Why?_____________________________

 What do you usually do to prevent this disease from occurring?____________________________

 Taking vitamins? yes specify:____________ no

 Use of Herbal Plants? no yes What plant?______________ Told by:____________________

 Use of tobacco? None Quit What date?______________Why?____________________

pipe cigarette How many sticks?___________________________

 Use of alcohol? None Yes

Type:_____________Since:____________Amount of intake:______________Frequency?____________

 Drugs? no yes Type:_______________Date:_________________

 Allergies (drugs, foods, tape, dyes): NKA Yes Reaction:_________________________________

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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

Nutritional/ Metabolic Pattern

 Weight/Height?________/__________ BMI:____________

24 hour food recall

Time

Food/
Drin
ks
Con
sum
ed

 You consider yourself as? Right Overweight Underweight

 Weight Fluctuations: None Gained Lost

Lbs: ___________ During?____________Date:______________

 Special Diet/ Supplements:________________Date:______________

 Previous Dietary Instructions:_______________________

 Eating? How many times? Amount?

o Before:__________________

o Today:__________________

 Favorite food:_________________________

 Foods you don’t eat:____________________________

 Eating with whom?_____________________________

 Appetite: Normal Increased Decreased Decreased taste sensation Nausea

Vomiting Date of Change:___________________Cause of change:_______________

 Swallowing difficulty: Since when?_______________

None Solids Liquids

 Dentures: None Yes Date: ____________

Upper ( ) partial ( ) total How it limits eating?_______________

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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

Lower ( ) partial ( ) total

 Skin Problems:_____________________________

 Skin turgor:________________

 Temperature:___________Warm to touch?___________

 IVF:_______________

 Drinking how much?

o Before:_______________

o After:________________

 What? water milk coffee tea juice soft drinks Others:________________

 Favorite Drink:________________

 Changes in thirst: Increased Decreased Since:________________

Elimination Pattern

 Bowel Habits:

During Admission
Before Admission
* Use of enemas laxatives suppositories
Before:________BMs/Day Usual Time:_________
Before:________BMs/Day Usual Time:_________
WNL Constipation Date of Last:
WNL Constipation Date of Last:
Diarrhea Incontinence Excessive flatus ostomy
Diarrhea Incontinence Excessive flatus
Amount: Color: Odor: Self Care:
yes no
Amount: Color: Odor: Self Care:
yes no

*Assisstive Devices: catheter

Others:

*Bladder Habits:

*BEFORE: Frequency:

WNL dysuria nocturia urgency

Hematuria retention Amount:

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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

Color: Odor:

*AFTER:Frequency:

WNL dysuria nocturia urgency

Hematuria retention Amount:

Color: Odor:

Activity & Exercise Pattern

*Feeling of weakness yes no

*Daily Activity Level:

*What activities do you carry out during routine day?

Self-care Independent Assistive Assistive from Others Unable

Ability device others +
devices
Eating
Drinking
Dressing
Toileting
Bed Mobility
Transferring
Ambulating
*Assistive Device: none crutches walker

Bedside commode splint/brace wheelchair

*Tolerance in Activities: WNL

*Increased cardiac output? (Refer to PE)

*Rate self as: independent partially dependent

*Task is achieved with help of:

*Activity Tolerance: How much and what type of activities make you tired?

*Experienced SOB? yes no

*Exercise: Type: Length:

Believe exercise as beneficial? yes no

*Factors affecting mobility

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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

*Musculoskeletal impairment?

*Daily living before?

Cognitive/Perceptual Pattern

*Mental Status? alert oriented confused combative/hostile

unresponsive poor historian

*Speech? normal slurred scrambled

repetitive flight of ideas unable

*Able to: read speak

*Vision: WNL eyeglasses contact lenses

impaired ( )right ( )left

blind ( )right ( )left

cataract ( )right ( )left

prostheses ( )right ( )left

glaucoma

vertigo

*Pupils reaction?

*Hearing: WNL hearing aids tinnitus

impaired ( )right ( )left

deaf ( )right ( )left

*Smell:

*Taste:

*Touch Sensation: numbness tingling

*Discomfort/Pain: none acute chronic

Description:

Onset: Location:

Duration: Frequency:

Aggravates when?
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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

Pain management:

*responsive to: verbal physical stimuli?

* time place person oriented?

*Remote/recent memory? ok abnormal

*Decisions? ok abnormal

Roles/ Relationship Pattern

 Lives with whom?__________________

 How those people:_________________

 Works as a?_______________________

 Gets along with: friends classmates co-worker

 Major roles, relationship, responsibilities at present:___________________________________

*how is it?

*Breastfeeding? yes no

*how was your illness affected your roles/responsibilities?

*roles/responsibilities you want to change?

*satisfactions/disturbances in roles/responsibilities?

*support system?

Value/Belief Pattern

*Religion: RC Alliance INC Others:

*Practing being in that religion? yes no

*request chaplain to visit or go to chapel?

*how illness interfere with religion?

*goes to church every?

*perceived conflicts in values, beliefs that are health related

Self-Concept/Perception Pattern
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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

*ways you feel different because of illness?

*Strengths:

*Weaknesses:

*Body posture & movement/Voice & speech pattern: refer

*Eye contact:

*Grooming:

*Concern about family?

Work/school?

Sexuality and Reproduction Pattern

*Marital status: single married widow/er

*For women: Menarche: y.o Duration: days

regular irregular

menopause: yes no When:

Been pregnant? yes no How many? Gap:

Delivery: normal CS Complications:

History of miscarriage:

*BSE? TSE? Frequency?

*For men: Circumcised at y.o

*Family planning?

Coping/ Stress Tolerance Pattern

 Concerns: Home Work/ School Finance Health

 Who’s with you? Partner Relatives Friends Parents Children

 Outlook on the future? (let patient rate from 0-100):____________

 Major loss/change this year: None Yes Specify:______________How was it:________________

 How handle:
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 GORDONS FUNCTIONAL HEALTH PATTERN FOR ADULT CLIENTS

Cry Gets Angry Talks to someone Who?_______________

Withdraws from the situation Go for walk/ exercise finds solution Pray Laughs

 Are these method successful?___________

 What do you do to relax?_______________

 Afraid ? Yes No Why?__________________

 Muscle Trembling? Yes No

 Support system:___________________________

Sleep/ Rest Pattern

Before Admission During Admission

# of hours:________ # of hours:________

Sleeps at:________Wakes up:______ Sleeps at:________Wakes up:______

AM nap PM nap AM nap PM nap

 Feels rested after sleep? Yes No

 Always feel dizzy? Yes No

 Sleep Problems: None Early Waking Insomnia Difficulty falling asleep

Cause:______________

 Disturbances:________________ How often awake?__________________

 Deprived sleep? No Yes Cause:________________

 Snore Talk Walk Don’t breathe at night

 How you deal?_____________________

 Sleeping Aids?_____________________Others:__________________

 Perception of Quality/ Quantity of sleep?_______________________

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