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    Bilal Aslam
    This document contains an assessment tool called Gordon's Functional Health Pattern that collects information about a patient's health in 11 categories: [1] health perception and management, [2] nutrition and metabolism, [3] elimination, [4] activity and exercise, [5] cognitive and perceptual, [6] rest and sleep, [7] self-perception and self-concept, [8] role relationships, [9] coping and stress, [10] sexuality and reproduction, and [11] values and beliefs. For each category, the tool collects relevant information such as diet, elimination habits, stressors, and spiritual beliefs to develop a holistic understanding of the patient's health.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    FHP Form-1

    Uploaded by

    Bilal Aslam
    2K views4 pages
    This document contains an assessment tool called Gordon's Functional Health Pattern that collects information about a patient's health in 11 categories: [1] health perception and management, [2] nutrition and metabolism, [3] elimination, [4] activity and exercise, [5] cognitive and perceptual, [6] rest and sleep, [7] self-perception and self-concept, [8] role relationships, [9] coping and stress, [10] sexuality and reproduction, and [11] values and beliefs. For each category, the tool collects relevant information such as diet, elimination habits, stressors, and spiritual beliefs to develop a holistic understanding of the patient's health.

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    Premier institute of nursing sciences Peshawar

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    This document contains an assessment tool called Gordon's Functional Health Pattern that collects information about a patient's health in 11 categories: [1] health perception and management, [2] nutrition and metabolism, [3] elimination, [4] activity and exercise, [5] cognitive and perceptual, [6] rest and sleep, [7] self-perception and self-concept, [8] role relationships, [9] coping and stress, [10] sexuality and reproduction, and [11] values and beliefs. For each category, the tool collects relevant information such as diet, elimination habits, stressors, and spiritual beliefs to develop a holistic understanding of the patient's health.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views4 pages

    FHP Form-1

    Uploaded by

    Bilal Aslam
    This document contains an assessment tool called Gordon's Functional Health Pattern that collects information about a patient's health in 11 categories: [1] health perception and management, [2] nutrition and metabolism, [3] elimination, [4] activity and exercise, [5] cognitive and perceptual, [6] rest and sleep, [7] self-perception and self-concept, [8] role relationships, [9] coping and stress, [10] sexuality and reproduction, and [11] values and beliefs. For each category, the tool collects relevant information such as diet, elimination habits, stressors, and spiritual beliefs to develop a holistic understanding of the patient's health.

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    Premier Institute Of Nursing Sciences, Peshawar

    Assessment tool: Gordon’s Functional Health Pattern

    Patient Name:___________________MR No:______________Unit/Ward_______________


    Date Of Admission:_________________ Age:_______________Sex:____________________
    Occupation/Profession:______________ Language: (1)______________(2)______________
    Education:_______________________Marital Status:_______________________________
    Children:__________________M____________F____________
    Medical Diagnose:___________________________________________________________
    Past Medical History:(1)Hospitalization__________________________________________
    (2)Surgery________________________________________________
    (3)Medication at home_____________________________________
    Chief Complain: ____________________________________________________________
    _________________________________________________________________________
    Present Surgeries:______________________Immunization Status:___________________
    Vital signs: B.P:________________ Pulse:___________RR_____________Temp:________
    1. Health perception Health Management Pattern:
    Patient’s views about his/ her health and how she/he manages his/her health:
    __________________________________________________________________________
    __________________________________________________________________________
    Patient knowledge about his/her disease: _________________________________________
    __________________________________________________________________________
    Patient’s knowledge about disease prevention: ____________________________________
    ___________________________________________________________________________

    List of current medication


    Medication Generic Indication

    Over the counter drugs: __________________________________________________________


    Allergies: Food:________________________Drug:____________________Other___________
    Nursing Diagnosis:_____________________________________________________________
    _____________________________________________________________________________

    1|Page
    2.) Nutrition And Metabolic Pattern

    Number of meals per day. Break fast:_____________Lunch__________Dinner__________


    Snacks ______________________
    Food Preference :(1)Like:___________________(2)Dislikes__________________________
    Amount of fluids per day:_________________Rout(I/V)_________Oral________________
    Tube feeding __________________Any dietery restriction__________________________
    Any fluid restriction________________________________________
    Skin
    Turgor _________________Color______________Texture______________Edema_______
    Hair : Texture______________________Distribution__________________________
    Oral mucus membrane:_______________Gums______________No of teeth_____________
    Alignment:___________________Dentures:________ Hieght_________ Wieght________
    Labs; HB____________ HCT_____________ WBC ______________ESR _________
    RBC_____________ Platlets ____________PT_________ APTT _________INR ________
    Albumin _____________ Na_____________ K __________Ca______
    Mg___________ Others___________________
    Nursing Diagnosis:__________________________________________________________
    __________________________________________________________________________

    3.)Elimination Pattern

    Urine : Frequency/24 hr________________Voiding self/Catheterized__________________


    Color ____________________Amount /24hr________________Any pain/discomfort during
    urination_____________________________Any problem with Bladder control:
    Retension/incontinence:_______________________Stool/24hr___________________
    Color____________Odor_________________Charactaristic__________________________
    Amount_____________________ Any problem with bowel control:
    Constipation/Incontenence___________________________________________
    Nursing Diagnose: ___________________________________________________________
    ___________________________________________________________________________
    ___________________________________________________________________________

    4.) Activity Exercise Pattern:

    Life style (active, sedentary) Breathlessness during activity or at


    Rest_______ Cough (dry, productive)_________ if productive______________ Color
    _______ order _________Characteristic _________ Amount _______SOB ________
    O2/min ______ via______________ Inhalation therapy _________Sputum tests______
    Nursing Disgnosis: _______________________________________________________
    _______________________________________________________________________
    2|Page
    Calculation:
    Pulse rate/min___________ Rhythm________________ Amplitude________________
    Peripheral pulses________________ Capillary refill________________________
    Extremities: Color__________Temp_________________
    Nursing Diagnosis________________________________________________________
    _______________________________________________________________________

    5) . Cognitive perceptual pattern

    Level of consciousness: Oriented to time ________ place _________ person__________


    If unconsciousness GCS________Any speech difficulty _____________
    Memory: Recent _________ Remote ________Vision _________Glasses_________
    Hearing ___________ Pain: Characteristic___________ Onset_______________
    Location ________ Duration __________________ Exacerbation _______________
    Radiation ___________ associated with __________ Relieving factors _____________
    Nursing diagnosis____________________________________________________

    6). Rest and sleep pattern


    No of hours sleep/24 hours: Home ____________Hospital __________ Naps__________
    Any problem to fall/stay asleep ____________ Use of tranquillizers ____________
    Any home remedy to induce sleep ______________________________________
    Evidence of lack of sleep _________________ Quality of sleep _____________
    Nursing diagnosis: __________________________________________________
    _________________________________________________________________

    7). Self Perception/Self Concept Pattern


    Patient’s perception of his or herself___________________________________
    Grooming ___________ Voice tone _____________ Eye contact ___________
    Gesture /Congruent with words ________________________________________
    _________________________________________________________________

    8). Role Relationship Pattern

    Family (extended/nuclear) _________ Responsibilities in family ________


    Role shared by _______ Role in decision making __________
    Leisure entertainment activities _______ Socialization __________
    Satisfaction with family / work __________________
    Nursing diagnosis: ___________________________________________________
    _____________________________________________________________________

    3|Page
    9). Coping / stress Pattern

    Affected/Mod: Calm ______ Angry __________ Irritable ______________


    Anxious _______ Withdrawal __________ Apathetic ____________
    Common stressors ____________ coping behavior during stress ___________
    Sharing of stress with ____________________
    Use of Alcohol/Pan/Tobacco/Drug:
    Nursing Daignosis:_________________________________________________________
    ____________________________________________________________________________

    10). Sexuality / 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 diagnosis: __________________________________________________
    _________________________________________________________________

    11). Value belief Pattern

    Things important in life ___________________ Spirituality __________________


    Religious beliefs _______________________________
    Any spiritual conflict ____________
    Satisfaction with life +_______________________
    Nursing diagnosis: _________________________________________________
    ________________________________________________________________

    4|Page

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