GORDON’S FUNCTIONAL HEALTH ASSESSMENT
Pattern Information from History
Health Perception-Health
Management
Includes health status; health promotion
and illness prevention practices; medical
or nursing prescriptions; follow-up care
Pattern
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Information from Examination
 Clients description of general health status  Observe general appearance
 Past illness, operations and hospitalizations  This health pattern is determined
 Changes in health status over time from history
 Health promotion activities  Examination of patient generally
 Illness prevention activities (last pap smear, follows the history interview
breast self exam, last physical exam, last
tetanus shot, etc)
 Current medications and supplements
 Current therapeutic interventions
 Allergies to food/medicines/other
 Perception of cause(s) of current illness and
actions taken
 How current encounter might be helpful
 Anticipated plans for discharge or further care
 Use of alcohol, tobacco, and illicit drugs
 Significant family history of illnesses
 Ob – gravida, para, time and type of delivery
if postpartum, gestation at first prenatal visit,
compliance with prenatal care
 Pedi – gestational age at birth, apgar scores,
compliance with child care
Information from History Information from Examination
Gordons Functional Health Assessment
Nutritional-Metabolic
Includes food and fluid consumption;
types and quantities of food and fluid;
food preferences and timing of intake;
special diet(s)
Also includes hydration status, skin and
tissue integrity, and thermoregulation.
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 Typical daily food intake
 Last intake of food and fluid
 Types and quantity of foods
 Types and quantity of fluids
 Restricted diet or type of diet prescribed
 Timing of meals and snacks
 Use of supplements, i.e. Vitamins, energy
foods, hyperail, tube feedings, etc
 Appetite status, loss of or change in
 Difficulties swallowing, chewing, digesting,
 Recent weight loss or gain
 Use of artificial nutritional devices
 Use of dentures, partial plates, etc.
 Problems with nausea, heartburn, indigestion,
excessive hunger or thirst etc
 Family or personal history of diabetes, thyroid
problems
 Lab results including hct, hgb, thyroid levels,
blood sugars, blood chemistries, cholesterol
levels, urinalysis (sp grav, protein, glucose,
ketones)
 Problems with skin or healing (rashes, open
areas, lesions)
 Ob – prepregnant weight, weight gain/loss in
pregnancy, perception of breastfeeding
 Pedi – birth weight, type of formula or breast
as infant, introduction of solid foods, self
feeding behaviors, pattern of weight gain
Gordons Functional Health Assessment
 Assess overall appearance (well
nourished, well developed,
overweight, underweight)
 Assess skin appearance: color,
lesions, pressure areas, moisture,
texture, open areas, dressings,
rashes, scars, ecchymosis, diaphoresis
 Obtain body temperature
 Obtain height and weight, calculate
bmi
 Observe condition of mouth, lips and
other mucous membrane areas
(include moistness)
 Assess skin turgor
 Observe condition of teeth; present,
absent, gum problems, dentures,
partial plates, obvious decay or
bleeding
 Inspect for evidence of tissue healing
processes
 Inspect integrity of hair and nails
 Record intake of oral and intravenous
fluids if applicable.
 Ob – assess condition of nipples and
breasts, assess effectiveness of
breastfeeding
 Pattern Information from History Information from Examination
Elimination  Frequency, character of bowel movements,  Examine, if indicated, color,
Includes patterns of bowel, bladder, and including last bowel movement consistency, character, frequency, and
skin excretory functions; devices used for  Frequency, character of urine excretion, any quantity of feces and urine
elimination difficulty, incontinence or dsyuria  Examine, if indicated, color, character
 Any changes in usual patterns, or history of and quantity of output from other
problems, kidney or liver disease excretory sites
 Use of laxatives/ diuretics  Abdominal assessment including
 Use of artificial excretory devices, e.g. bowel sounds, flatus, softness,
Colostomy, ureterostomy distention, masses, girth,
 Degree of perspiration hemorrhoids, drains, or collection
 Any other excretory sites, e.g. Drains, chest devices.
tubes suction, ng drainage, vomiting
 Lab/ test results including urinalysis, stool for
occult blood, stool cultures, kidney function
tests, liver function tests, gi studies, etc
 Ob – note any difficulties with nausea,
constipation, hemorrhoids, urinary frequency
or stress incontinence.
 Pedi – note diapering or toileting routines,
note special words utilized

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 Pattern
Activity-Exercise
Includes exercise pattern; activities of
daily living; leisure/recreation activities,
energy balance; focus on activities of
importance.
Also includes cardiac and pulmonary
status and responses to activity.
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Information from History
 Type and regularity of exercise
 Usual activity requirements at home and work
 Perceived response to activity ( sob, dizzy,
weak ,etc)
 Perceived energy level (note any changes)
 Recreational activities
 Leisure activities, i.e. Hobbies, clubs
 Perceived ability to carry out feeding,
bathing, toileting, bed mobility, dressing,
grooming, cooking, shopping, home
maintenance
0 Level 0 = full self care
1 Level 1 = requires use of equipment or device
2 Level 2 = requires supervision from a person
3 Level 3 = requires assistance from a person
4 Level 4 = dependent/does not participate
 Use of prosthesis
 History of joint and back problems or
weakness
 Use of tobacco-, how much, for how long?
 Family or personal history of heart disease,
hypertension, asthma or tb
 Lab/test results including chest xray, ekg,
abgs, cardiac enzymes, pulse oximetry, peak
flow, pft’s, sputum cultures.
 Ob – changes in mobility related to
pregnancy, any symptoms of preeclampsia
(headache, changes in vision, epigastric pain,
nausea, edema), knowledge of exercises to
restore tone.
 Pedi – note age when met various gross
motor and fine motor milestones
Gordons Functional Health Assessment
Information from Examination
 Observe function in areas listed in
history and code each according to
level 0, 1, 2, 3, or 4
 Examine gait, posture
 Note any joint deformity or missing
body structures, e.g. Amputee
 Test range of motion of joints
 Test muscle strength, mass and tone
 Test equilibrium/balance
 Palpate pulse; note rate, rhythm, and
quality
 Note heart sounds and presence of
murmur
 Record bp, note any changes with
position or activity
 Auscultate breath sounds; note
presence of adventitious sounds
 Note rate and character of
respirations, presence of any
difficulties (retractions, coughing,
sputum, use of accessory muscles,
flaring, etc), and any oxygen
requirement.
 Assess vascular status, e.g.
Peripheral pulses, varicosities,
capillary refill in nail beds, signs of
atrophic skin changes, color of skin
and nail beds, edema, dryness or
moistness of skin, and homan’s sign.
 Observe general hygiene, dress, and
grooming appearance
 Pattern
Sleep-Rest
Includes frequency and duration of sleep
and rest periods; use of sleep-inducing
medications; environmental sleeping
conditions
Information from History Information from Examination
 Number of hours of sleep/24 hours  Observe sleep/rest pattern if possible
 Frequency of rest periods; do they include  Observe sleep/rest disruptions
sleeping?  Observe alertness and mental status
 Time of night retire
 Time of day awake
 Any perceived problems – difficulty falling
asleep, frequent or early waking
 Sleep/ rest reversal, e.g. Sleep day, work
night
 Degree of perceived energy upon awakening
 Frequency of dreams or nightmares, what
seems to aggravate them or induce them
 Use of sleeping aids such as medications
 Use of other sleep-inducing practices
 Environmental conditions such as number of
pillows to sleep, type of bed used
 Pedi – bedtime routine and rituals, security
items,
 Ob – difficulty sleeping as a result of
pregnancy, timing of labor in relation to sleep,
length of labor

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 Pattern
Cognitive-Perceptual
Includes sensory function (hearing,
vision, taste, smell, touch); comfort and
pain perception; cognitive functions
(language, memory, judgment, decision-
making)
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Information from History
 Hearing status; need for hearing devices,
date of last hearing test
 Vision status; need for eyewear, last eye
exam
 Problems with taste or smells
 Problems with touch sensation, any
numbness or tingling
 Pain (level, location, frequency, duration,
character, aggravating circumstances, relief
methods, and tolerance level)
 Cognitive function in terms of memory, short
term and long term
 History of any changes in level of
consciousness or periods of confusion
 Communication – primary language spoken,
other languages spoken, educational level,
perceived ability to read and write
 Degree of problem-solving capabilities
 Degree of decision-making capabilities
 Perceived attention span
 History of fainting, seizures or dizziness
 History of headaches – location, frequency,
associated factors
 Ob – attendance at prenatal classes,
knowledge of self care and baby care.
 Pedi – note age when various language
milestones met, grade level, any behavioral or
learning difficulties in school.
Gordons Functional Health Assessment
Information from Examination
 Test special senses of hearing, vision,
taste, touch and smell
 Test orientation to person, time, and
place
 Determine level of consciousness as
measured by responses to various
stimuli
 Listen to language used
 Listen to quality, pace, articulation of
speech
 Test recent memory, remote
memory, and new learning, as
indicated
 Perform developmental screening
tests, as indicated
 Determine ability to comprehend
words, read and write, thought
processes
 Access behavioral clues to pain level
and tolerance (grimacing, guarding,
irritability, distractibility, etc)
 Pattern
Self-Perception/Self-Concept
Includes feelings of general self-worth;
attitudes about self, image, identity;
general emotional pattern
Role-Relationship
Includes family and social roles; work
role; satisfaction or not with roles;
perception of major roles in life
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Information from History Information from Examination
 How do you feel about self most of the time?  Observe use or nonuse of eye contact
 What can you tell me about yourself?  Note attention span or distraction
 How will this issue affect your life?  Observe body posturing
 Description of self  Note voice and speech quality, intensity
 Any fears, anxieties, reason to be depressed or  Rate on scale of 1-5, relaxed to nervous
feel loss of control  Rate on scale of 1-5, assertive to passive
 Measures used to improve feelings regarding self-  Note both verbal and nonverbal cues to
concept indicate expressions of self-concept
 Experiences related to feelings of hopelessness
 Construct of family structure  Observe interaction between family
 Living arrangements, e.g. Alone, family, members
roommates, etc.  Ob/pedi – evidence of bonding and
 Role within family, e.g. Father, mother, financial attachment behaviors of both mother and
earner father of baby, assess parenting skills
 Self or family care-giver or care-receiver role
 Perception of effect of current health problem or
current situation on role(s)
 Occupation/profession/work role
 Student role
 Satisfaction or non-satisfaction with all roles
 Difficulties or problems in maintaining roles
defined
 Health insurance status and influence on current
encounter and role-relationships
 Financial income sufficient to meet current needs
or not
 Family relationships sufficient to meet current
needs or not
 Ob – pregnancy planned?, feelings about and
Gordons Functional Health Assessment

relationship with father of baby, plans for feeding
baby
Pattern
Sexuality-Reproductive
Includes a male & female focus related
to satisfaction or dissatisfaction with
sexuality; describes reproductive pattern;
if female, phase of reproductive cycle
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plans for pregnancy/labor and delivery / childcare,
Information from History Information from Examination
 Any sexual concerns  Usually no examination indicated
 Sexual orientation unless skilled and capable of doing
 Sexual relationships and degree of pelvic examination of female or
satisfaction testicular and prostrate examination
 Female phase of reproductive cycle, such as of male
child-bearing, premenses, peri or post  If pregnant - fundal height, vaginal
menopausal exams, palpation of contractions, fetal
 Female menstrual history; age of menarche, heart tracing (rate, variability, periodic
duration, frequency, regularity, problems changes), discharge, bleeding or
 Female reproductive history; past leaking of fluid
pregnancies and deliveries, any difficulties  If postpartum – fundus (location and
 Family history of multiple birth, congenital firmness), lochia (color, amount and
anomalies or genetic disorders presence of clots), perineum,
 Birth control practices both male and female, episiotomy and/or lacerations
in past and planned  If newborn – circumcised?, testes
 Type of practices used to prevent sexually descended?, vaginal discharge or
transmitted diseases, both male and female swelling?
 History of sexually-transmitted diseases
 Frequency and perceived thoroughness of
performing either self-breast examination or
self-testicular exam
 OB – LMP, EDC, pregnancy planned ?,
problems with current or past pregnancies or
deliveries (spotting, PIH, diabetes,
hemorrhage, surgery, etc), Lab/test results –
pregnancy test, AFP, amniocentesis,
ultrasound results (amniotic fluid volume,
estimated fetal weight), non stress tests,
biophysical profile, L/S ratio, culture results,
Gordons Functional Health Assessment

Pattern
Coping-Stress Tolerance
Includes methods or ways to handle or
cope with stress; defines stressors or
events that threaten a person; coping is
how one responds to stressors; stress
tolerance is level of effective coping
Value-Belief
Includes values, goals, and beliefs as
related to choices or decisions made;
spiritual beliefs, issues of life importance;
relationship of such value-belief pattern
on health issues and practices
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GBS status
 PEDI – circumcised?, Tanner stage of
development
Information from History Information from Examination
 recent changes, problems, or events causing  conduct stress scale analysis, as
concern or stress indicated
 any crisis recently, i.e. illness or  note behavioral or physiological
hospitalization manifestations of mood, affect,
 description of current stress level anxiety and stress.
 use of medications or alcohol to cope
 methods used to cope with stress that are not
drug or alcohol-related, e.g. taking walks,
reading, engaging in hobbies, talking to
someone
 degree of success of current coping strategies
 perception of stress tolerance level
 perception of safety status at home, i.e.
episodes of physical and/or emotional abuse
 OB – plans for coping during labor,
perception of coping during labor and delivery
 PEDI – parents plans for dealing with various
childhood stages and issues
 religious choice, if indicated  none indicated, according to Gordon
 spiritual beliefs that influence health decisions  determine cultural, ethnic
or practices background
 degree of goals of life attainment
 perception of satisfaction with life and the
way “things are”
 cultural beliefs that reflect on health or values
 cultural beliefs that reflect on choices for
health promotion and illness prevention
Gordons Functional Health Assessment
 Pattern
Safety/Protection
Includes environmental hazards,
potential sources of physical harm or
injury, exposure to communicable
diseases and pathogens, allergies, and
the body’s attempts to protect itself and
respond to pathogens
Growth/Development
Includes age appropriateness of physical
and psychosocial development and
attainment of developmental milestones
in various areas
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Information from History Information from Examination
 exposure to hazards at home or work  temperature
(including xrays, chemicals, machinery,  any signs and symptoms of injury to
pollutants, animals) tissue (scars, bruises, swelling,
 possible exposure to communicable diseases wounds)
and pathogens (including blood transfusions,  any signs and symptoms of infection
ingestion of raw meats, animal or insect bites, (enlarged lymph nodes, odor,
exposure to infectious persons) discharge, redness, warmth, rashes,
 history of accidents and injuries, at risk for etc)
falls
 history of allergies, communicable diseases,
STDs, and immunizations
 Lab results – WBC with differential, culture
results, sensitivities, titers, HIV tests, sickle
cell screen, lead level, PPD results,
 OB/Newborn - Rh factor, ABO
incompatibility, Coombs test, length of time
membranes ruptured, meconium in fluid?
 PEDI – Is environment safe, childproofed?
exposure to lead?, immunizations up to date?
 age when pertinent milestones or tasks  assessment depends on the particular
achieved. milestones or developmental tasks
that are appropriate in a variety of
areas including physical, cognitive,
emotional, social, language, and
moral development.
Gordons Functional Health Assessment
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