Nursing Assessment Form Using Modified Gordon’s Functional Health Patterns

STAPLE ALL SHEETS TOGETHER AND EITHER PRINT OR TYPE LEGIBLE ON ALL
FORMS
Student Name: _____________________________ Dates of Care: ___________ Instructor: ________
Patient Initials: _________ Male__ / Female___ Patient Age: ________ Facility: ______________
General Information:
Chief Complaint: ________________________________________________
Has patient been in the hospital or other health facility in past six months? Yes / No
If yes to above, What was the nature of the problem? ____________________________________
What Erikson’s Development Stage is patient in right now? ______________________________
Is patient meeting their tasks in this stage? Yes / No Why or why not? _________________________
Vital Signs: Temperature: ________ Source: _________ Pulse: _________ Source: ________
Respirations: _________ Source: ________ BP: __________ Lying / Sitting / Standing Source: _____
Oxygen Saturation: _________ Room Air / Supplemental Oxygen
Height: _______ Actual / Stated Weight: ________ Actual / Stated
Allergies: (Include those to medications, foods, environment, etc)
Source Reaction
________________________________________________________________________________-

Functional Health Patterns

Health Perception/ Health Maintenance
1. Does the patient have any health issues they would like to improve?
___________________________________________________________________________________
______________________________________________________________________________
2. Preexisting conditions, previous surgeries or procedures?
___________________________________________________________________________________
___________________________________________________________________________________
3. Has the patient been exposed to any communicable diseases within the past year? Yes / No
4. If yes to above, explain:
_________________________________________________________________________________
5. Medications taken at home (include prescribed, OTC, herbals or natural remedies, and/or vitamin or
mineral supplements):
Name (generic if possible) Dose/Frequency/Route Reason patient is taking
_________________________ __________________ ___________________________________
_________________________ __________________ __________________________________
_________________________ __________________ __________________________________
_________________________ __________________ ___________________________________
6. Does the patient have any problems from their medications? Yes _____ / No______
7. If yes to above, explain:
____________________________________________________________________________
8. Does the patient have any problems paying for their medications, supplies, or services? Yes / No
9. If yes to above, explain:
_____________________________________________________________________________
10. Has patient ever had a blood product transfusion? Yes / No
11. If yes to above, what type of blood product? _________________________
12. If yes to #10, did the patient experience a blood reaction with transfusion? Yes / No
13. If yes to above, explain:
_____________________________________________________________________________
14. Please check all screenings the patient has performed or had performed in the past year:
___ Breast Exam ___ Dental Exam ___ Glaucoma ___ Mammogram
___ Pap Smear ___ Pelvic Exam ___ Prostate Check ___ Rectal Check
___ Testicular Check ___ Vision Check
15. Please check all immunizations the patient has had in the past year:
___ Flu ___ Pneumonia ___ Tetanus ___ Other
16. Does the patient smoke? Yes / No If yes, how many pack-years? ________
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Does patient use other tobacco or nicotine products? Yes / No If yes, describe product and pattern of
use:
_____________________
17. Does the patient drink alcohol? Yes / No If yes, describe specifically the pattern of use:
_____________________
When was last drink? __________
18. Does patient use illegal drugs or prescription drugs in a way that is not prescribed for them? Yes /
No
If yes, describe specifically the pattern of use: _______________________________When was last
use? ____________

Nursing Diagnoses MARK APPRORIATE DXS

___ Risk for Falls ___ Ineffective Health Maintenance ___ Health-Seeking Behaviors
___ Readiness for Enhanced Immunization Status ___ Risk for Infection ___ Risk for Injury
___ Noncompliance ___ Readiness for Enhanced Self-Care
___ Effective Therapeutic Regimen Management ___ Ineffective Therapeutic Regimen Management
___ Ineffective Family Therapeutic Regimen Mgnt Other:_______________________________

Nutritional/Metabolic Pattern
1. Does the patient follow a special diet? Yes / No If yes, explain: _________________
2. 2. When was the last time the patient ate? ____________________
3. Has the patient been asked to increase or restrict fluid intake? Yes / No If yes, explain: __________
4. Dentures? ___ None ___ Uppers ___ Lowers ___ Partial Plate
5. If patient has dentures, do they fit well? Yes / No If no, explain: __________________________
6. Appetite? ___ Normal ___ Increased ___ Decreased ___ Unable to Assess
7. Does the patient have difficulty with: ___ None ___ Chewing ___ Choking ___ Following
Prescribed Diet ___ Smelling ___ Swallowing ___ Tasting If any difficulty, explain: _____________
8. Does the patient have: ___ None ___ Indigestion ___ Mouth Soreness ___ Nausea ___ Vomiting
___ Persistent Fever ___ Weight Loss/Gain (how much over how long? _______________)
9. Skin/Mucosa: color: __ Cyanotic ___ Dusky ___ Flushed __ Jaundiced ___ Mottled ___ Pale ___
Pink
Temperature: ___ Hot ___ Warm ___ Cool ___ Cold
Moisture: ___ Dry ___ Clammy ___ Diaphoretic
Turgor: ___ Elastic ___ Inelastic ___ Tenting
Edema: ___ None ___ Generalized ___ Localized
(location/s:__________________________________________)
If patient has edema, grade each location 1-
4___________________________________________________________
10. Oral Mucous Membranes: ___ Dry ___ Intact ___ Moist ___ Lesions (if yes, describe:
_____________________)
11. Wounds/Drains/Tubes/Catheters/Dressings: ___ None If yes, describe:
_____________________________________
___________________________________________________________________________________
_____________
12. Braden Skin Risk Assessment Score: ___ 15-16 Low Risk ___ 13-14 Moderate Risk ___ 12 or <
Severe Risk
13.
Comments:_________________________________________________________________________
_________________
Nursing Diagnoses MARK APPRORIATE DXS
___ Risk for Aspiration ___ Risk for Imbalanced Body Temperature ___ Impaired Dentition
___ Failure to Thrive (Adult)___ Deficient Fluid Volume ___ Excess Fluid Volume
___ Risk for Imbalanced Fluid Volume ___ Hyperthermia ___ Hypothermia ___ Nausea
___ Nutrition, Imbalanced (Less than/More than) Body Requirements ___ Nutrition, Readiness for Enhanced
___ Risk for Imbalanced Nutrition ___ Impaired Oral Mucous Membrane
___ Impaired Skin Integrity ___ Risk for Impaired Skin Integrity ___ Impaired Swallowing
___ Impaired Tissue Integrity ___ Risk for Unstable Glucose Level Other:_____________________

Elimination Pattern
1. Is the patient having any problems with bladder and/or bowel elimination? Yes / No If yes to above,
describe: ________
2. When did patient void last? _______________
3. When did patient have BM last? _______________ What is patient’s usual bowel pattern? _______
4. Abdomen: ___ Soft ___ Firm ___ Non-Tender ___ Tender (location: (___________________) Non-
Distended ___
Distended (girth:_____ Incontinent ___ Ostomies/Tubes (type: __________ Can patient care for this?
Yes / No)Bowel Sounds:___ Active All Quads ___
Hypoactive (which quads? ___________) Absent (which quads? _____________
5. Bladder: ___ Non-Distended ___ Distended ___ Incontinent (describe: ____________Nocturia ___
Urgency
___ Hesitancy ___ Hematuria ___ Urinary Catheter (type: ___ Is catheter anchored to thigh? Yes / No)
6. Comments:
_______________________________________________________________________________

Nursing Diagnoses: MARK APPRORIATE DXS

___ Constipation ___ Risk for Constipation ___ Diarrhea ___ Bowel Incontinence
___ Urinary Incontinence ___ Risk for Urinary Incontinence ___ Impaired Urinary Elimination
___ Readiness for Enhanced Urinary Elimination ___ Urinary Retention Other:

Activity/Exercise Pattern
1. Does the patient have enough energy for their desired or required activities? Yes / No
2. Does the patient need assistance with: ___ None ___ Eating/Drinking ___ Turning ___ Transfer
to/from Bed/Chair
___ Sitting ___ Walking ___ Toileting ___ Bathing ___ Dressing ___ Stair Climbing ___ Shopping
___ Preparing Meals ___ Cleaning House
Comments:
_________________________________________________________________________________
___________________________________________________________________________________
3. Mobility Impairments: ___ None ___ Unable to Assess ___ History of Falling ___ Dizziness
___ Unsteady Balance ___ Tremors/Spasms ___ Paralysis ___ Decreased Function
___ Decreased Sensation ___ Amputation
Comments:
___________________________________________________________________________
___________________________________________________________________________________
4. Gross Motor Movements: ___ Normal Gait ___ Abnormal Gait ___ Normal Posture
___ Abnormal Posture ___ Full/Active ROM
Comments:
___________________________________________________________________________________
5. Does patient use any assistive devices at home? Yes / No If yes, describe:
___________________________________
6. Muscle Strength: (see key) ___ Unable to Assess LUE:_______ LLE: ________ RUE:________
RLE :________
7. Respiratory Assessment
Respiratory Effort: ___ Easy ___ Labored ___ Use of Accessory Muscles ___ Orthopnea ___ None
Respiratory Pattern: ___ Regular ___ Irregular ___ Shallow ___ Deep Breath Sounds: (describe as
clear, diminished,
absent, fine crackles or rales, medium crackles, course crackles or rhonchi, wheezes)
RUL: _________________________ RML: ____________________________ RLL:
__________________-____
LUL: _____________________________ LLL: ________________________
Cough? Yes / No If yes, describe sputum:
_______________________________________________________
Supplemental Oxygen? Yes / No If yes, describe type and amount:
___________________________________
Trachesotomy/Mechanical Ventilation/Chest Tube/s:
_______________________________________________
Comments:
_________________________________________________________________________________
8. Cardiovascular Assessment
Heart Sounds: _________________ ___ Regular Rhythm ___ Regularly Irregular Rhythm
___ Irregularly Irregular Rhythm Telemetry Reading:
____________________________ ___ JVD
Please describe the amplitude of each pulse as 0=absent, +1=weak, +2=normal, +3=bounding or
D=dopper.
Right Radial: ____________ Right Pedal: ______________ Left Radial: _______________ Left
Pedal: ______________
Please describe the capillary refill of each location as brisk, < 3 seconds, or > 3 seconds.
RUE: ________________________ RLE: _____________________ LUE: _______________ LLE:
__________________
Comments:
___________________________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS

___Activity Intolerance ___ Risk for Activity Intolerance ___ Ineffective Airway Clearance
___ Ineffective Breathing Pattern ___ Autonomic Dysreflexia ___ Risk for Autonomic Dysreflexia
___ Decreased Cardiac Output ___ Risk for Disuse Syndrome ___Deficient Diversional Activity
___ Fatigue ___ Impaired Gas Exchange ___ Impaired Home Maintenance ____ Impaired Mobility
___ Risk for Peripheral Neurovascular Dysfunction ___ Self-Care Deficit ___ Delayed Surgical Recovery
___ Ineffective Tissue Perfusion ___ Impaired Spontaneous Ventilation ___ Dysfunctional Ventilatory
Weaning Response ___ Impaired Walking Other: ______________________________

Sleep/Rest Pattern
1. Has the patient had difficulty sleeping prior to admission? Yes / No If yes, describe:
________________________
___ Difficulty Falling Asleep ____ Early Awakening ___ Daytime sleeping ____ Awakening
throughout
Night ___ Unable to Assess
2. Comments:
___________________________________________________________________________________
Nursing Diagnoses MARK APPRORIATE DXS
___ Sleep Deprivation ___ Readiness for Enhanced Sleep Deprivation ___ Insomnia
Other: ________________________________________

Cognitive/Perceptual Pattern
1. Orientation: ___ X1 ___ X2 ___ X3
Comment:__________________________________________________
2. Level of Consciousness: ___ Conscious ___ Lethargic/Sleepy/Drowsiness
3. Glasgow Coma Scale Score: ______
4. Pupils: ___ Equal ___ Unequal ___ Round ___ Irregular ___ Briskly Reactive ___ Sluggishly
Reactive ___ Nonreactive
5. Speech: ___ Clear ___ Slurred ___ Receptive Asphasia ___ Expressive Aphasia
Primary language if not English: ___________________________________________
6. Thought Process: ____Logical ____ Illogical (Confused) ___ Flight of Ideas
7. What is the highest grade the patient completed? _____________________
8. Occupation: ____________________________
9. Does the patient have any problem with ST or LT memory? Yes / No If yes, explain:
________________________________
10. Does the patient have hearing loss? __ R Ear L Ear ___ Both If loss, does patient wear aids? ___ R
Ear ___ L Ear ___ Both
11. Does the patient have vision impairment? Yes / No If yes, ___ Prescription Glasses ___
Prescription Contacts ___ Cosmetic
Contacts If patient wears contacts, describe type of and care of lenses:
_________________________________
12. Does the patient have impaired ability to feel pain or temperature? Yes / No If yes, describe:
________________________
13. Has the patient ever had a seizure? Yes / No If yes, when was last and what type?
________________________________
14. Does the patient currently have pain or any discomfort? Yes / No If yes, use PQRST to thoroughly
describe the pain: ____
15. What does the patient feel he or she needs to be able to take care of him/herself after discharge?
___________________________________________________________________________________
__________________
16. Comments:
___________________________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS

___Acute Confusion ___ Chronic Confusion ___ Risk for Acute Confusion ___ Decisional Conflict
\\\\\\\\\\
___Impaired Environmental Interpretation Syndrome ___ Deficient Knowledge ____Impaired Memory
___ Unilateral Neglect ___ Acute Pain ___ Chronic Pain ____ Disturbed Thought Processes
Other: _________________________________________

Self-Perception/Self-Concept Pattern
1. Mood: ___ Calm ___ Agitated ___ Angry ___ Anxious ___ Sad ___ Labile ___ Other
2. Affect: ___ Congruent to Verbal ___ Incongruent to Verbal ___ Flat
3. Verbal Style: ____ Interactive ___ Quiet ___ Talkative ___ Guarded
4. What outcome does patient expect from this hospitalization?
___________________________________________________________________________________
______________
5. Comments:
___________________________________________________________________________________
Nursing Diagnoses MARK APPRORIATE DXS
___ Anxiety ____ Death Anxiety ___ Disturbed Body Image _____ Fear
___Hopelessness
___ Risk for Compromised Human Dignity ___ Disturbed Personal Identity _____Risk for
Loneliness
___ Powerlessness ____ Risk for Powerlessnes ___ Chronic Low Self Esteem ___ Situational Low Self-
Esteem
___ Risk for Situational Low Self-Esteem ___Risk for Self-Directed Violence Other: _____________

Role/Relationship Pattern
1. Lives: ___ Alone With: __________________________
2. Who will assist the patient with his/her care after discharge?
_________________________________
3. Resides: ___ House ___ Mobile Home ___ Apartment ___ Assisted Living ___ LTC Facility
4. Does the patient have any environmental or safety concerns with living arrangements (ie. stairs,
inaccessible
bathrooms)? Yes / No
If yes, explain:
______________________________________________________________________________
5. Does patient report any family disturbances that are of concern to him/her? Yes / No
If yes, explain:
_________________________________________________________________________________
6.
Comments:
___________________________________________________________________________________
Nursing Diagnoses MARK APPRORIATE DXS
___ Caregiver Role Strain _____ Risk for Caregiver Role Strain ____ Impaired Verbal
Communication
___ Dysfunctional Family Processes ____ Interrupted Family Processes ____ Grieving
___ Risk for Impaired Parenting ____ Ineffective Role Performance ___ Impaired Social
Interaction
___ Social Isolation ____ Chronic Sorrow ___ Risk for Other-Directed Violence
Other: ___________________________________

Sexuality/Reproductive Pattern
1. Does the patient have any questions or concerns about the effects of his/her physical condition or
treatment on his/her sexual activity? Yes / No If yes, explain:
______________________________________________________
2. Females: Date of LMP: _______________ How long is normal menstrual cycle?
__________________
Has the patient experienced any changes in recent menstrual cycles (length/flow)? Yes / No If yes,
explain: _______________________________________G: ___ P: ___ A: ___ L: ___
2. Comments: _____________________________________________________________________
Nursing Diagnoses MARK APPRORIATE DXS
___ Rape-Trauma Syndrome ___ Sexual Dysfunction ____ Ineffective Sexuality Patterns
Other: _________________________________

Coping/Stress Tolerance Pattern

1. Has the patient had any recent major life-style changes? Yes / No If yes, explain:
________________
2. How does the patient deal with stressful situations?
_________________________________________
3. Does the patient feel the coping mechanisms listed in #2 help the patient cope better with the crisis?
Yes / No? If no to above, explain:
_________________________________________________________________
4.Comments:_______________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS

___ Compromised Family Coping _____ Ineffective Coping ___ Risk Prone Health Behavior
___ Self-Mutilation ____ Stress Overload ___ Risk for Suicide
Other: _________________________________________

Value/Belief Pattern
1. Religious Affiliations:
__________________________________________________________________________________
2. Does the patient have any religious or cultural practices that may be affected by this hospitalization?
Yes / No
If yes to above, explain:
__________________________________________________________________________
3. Would the patient like to see a chaplain? Yes / No
4. Does the patient have an advanced directive? Yes / No If yes, what type? __________ Is copy on
chart? Yes / No
If no to above, would the patient like to discuss an advanced directive with physician and/or social
worker? Yes / No
5. Comments:
___________________________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS

___ Moral Distress ____ Spiritual Distress ___ Risk for Spiritual Distress
Other: ______________________________________

Safety
___ Call Light in Reach ___ Correct ID Band On ____ Bed in Low Position ____ Non-Skid Footwear
On
___ Family/Significant Other Present Side Rails Up X ___
___ Wheels Locked IV Location: _______________ Gauge: _________ When Started: __________
IVF or Lock: __________________
S/S of Infiltration and/or Infection? Yes / No If yes, describe:
_________________________________________
List top three Nursing Diagnoses with complete Patient Goals in Order of Importance:
#1: ____________________________________________________________________
_______________________________________________________________________
#2: ____________________________________________________________________
_______________________________________________________________________
#3: ____________________________________________________________________
_______________________________________________________________________