A.

Demographic Data
Name:
Age: Sex:
Date of Birth: Marital Status:
Address: Religion:
Educational Attainment: Ethnic Group:
Occupation: Dialect:
Chief Complain:
Admitting Diagnosis/Medical Impression:

B. Gordon’s 11 Health Problem

1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN
History
a. How has general health been?
b. Any colds in past year? When appropriate: absences from work?
c. Most important things you do to keep healthy? Think these things make a difference
to health? (Include family folk remedies when appropriate.) Use of cigarettes, alcohol,
drugs? Breast self-examination?
d. Accidents (home, work, driving)?
e. In past, been easy to find ways to follow suggestions from physicians or nurses?
f. When appropriate: what do you think caused this ill- ness? Actions taken when
symptoms perceived? Results of action?
g. When appropriate: things important to you in your health care? How can we be most
helpful?
Examination—general health appearance
2. NUTRITIONAL-METABOLIC PATTERN
History
a. Typical daily food intake? (Describe.) Supplements (vitamins, type of snacks)?
b. Typical daily fluid intake? (Describe.)
c. Weight loss or gain? (Amount) Height loss or gain? (Amount)
d. Appetite?
e. Food or eating: Discomfort? Swallowing? Diet restrictions?
f. Heal well or poorly?
g. Skin problems: Lesions? Dryness?
h. Dental problems?
Examination
a. Skin: Bony prominences? Lesions? Color changes? Moistness?
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures? Cavities? Missing teeth?
d. Actual weight, height.
e. Temperature.
f. Intravenous feeding–parenteral feeding (specify)?

3. ELIMINATION PATTERN
History
a. Bowel elimination pattern? (Describe) Frequency? Character? Discomfort? Problem in
control? Laxatives?
b. Urinary elimination pattern? (Describe.) Frequency? Problem in control?
c. Excessive perspiration? Odor problems?
d. Body cavity drainage, suction, and so on? (Specify.)
Examination—when indicated: examine excreta or drain- age color and consistency.
4. ACTIVITY-EXERCISE PATTERN
History
a. Sufficient energy for desired or required activities?
b. Exercise pattern? Type? Regularity?
c. Spare-time (leisure) activities? Child: play activities?
d. Perceived ability (code for level) for:
Feeding_________________________ Dressing____________________________
Cooking_________________________ Bathing_________________________
Grooming________________________ Shopping________________________
Toileting________________________ General mobility__________________
Bed Mobility______________________ Home maintenance __________________
Functional Level Codes:
Level 0: full self-care
Level I: requires use of equipment or device
Level II: requires assistance or supervision from another person
Level III: requires assistance or supervision from another person and equipment or
device
Level IV: is dependent and does not participate
Examination
a. Demonstrated ability (code listed above) for:
Feeding_________________________
Dressing________________________ Cooking___________________________
Bathing_________________________ Grooming________________________
Shopping__________________________ Toileting________________________
General mobility___________________
b. Gait_____________________________
Posture__________________________ Absent body
part?__________________ (Specify)_________________________
c. Range of motion (joints) ___________________ Muscle____________________
Firmness_________________
 d. Hand grip _________________________Can pick up a pencil?
________________________
e. Pulse (rate) _______________________ (rhythm) ______________________
Breath sounds ___________________
f. Respirations (rate) __________________ (rhythm) ______________________
Breath sounds ____________________
g. Blood pressure ______________________
h. General appearance (grooming, hygiene, and energy level)

5. SLEEP-REST PATTERN
History
a. Generally rested and ready for daily activities after sleep?
b. Sleep onset problems? Aids? Dreams (nightmares)? Early awakening?
c. Rest-relaxation periods?
Examination
a. When appropriate: Observe sleep pattern.

6. COGNITIVE-PERCEPTUAL PATTERN
History
a. Hearing difficulty? Hearing aid?
b. Vision? Wear glasses? Last checked? When last changed?
c. Any change in memory lately?
d. Important decision easy or difficult to make?
e. Easiest way for you to learn things? Any difficulty?
f. Any discomfort? Pain? When appropriate: How do you manage it?
Examination
a. Orientation.
b. Hears whisper?
c. Reads newsprint?
d. Grasps ideas and questions (abstract, concrete)?
e. Language spoken.
f. Vocabulary level. Attention span.

7. SELF-PERCEPTION—SELF-CONCEPT PATTERN
History
a. How describe self? Most of the time, feel good (not so good) about self?
b. Changes in body or things you can’t do? Problem to you?
c. Changes in way you feel about self or body (since ill- ness started)?
d. Things frequently make you angry? Annoyed? Fearful? Anxious?
e. Ever feel you lose hope?
Examination
a. Eye contact. Attention span (distraction)
b. Voice and speech pattern. Body posture
c. Nervous (5) or relaxed (1); rate from 1 to 5.
d. Assertive (5) or passive (1); rate from 1 to 5.

8. ROLES-RELATIONSHIPS PATTERN
History
a. Live alone? Family? Family structure (diagram)?
b. Any family problems you have difficulty handling (nu- clear or extended)?
c. Family or others depend on you for things? How managing?
d. When appropriate: How family or others feel about ill- ness or hospitalization?
 e. When appropriate: Problems with children? Difficulty handling?
f. Belong to social groups? Close friends? Feel lonely (frequency)?
g. Things generally go well at work? (School?)
h. When appropriate: Income sufficient for needs?
i. Feel part of (or isolated in) neighborhood where living?
Examination
a. Interaction with family member(s) or others (if present).

9. SEXUALITY-REPRODUCTIVE PATTERN
History
a. When appropriate to age and situations: Sexual relationships satisfying? Changes?
Problems? b. When appropriate: Use of contraceptives? Problems?
c. Female: When menstruation started? Last menstrual period? Menstrual problems?
Para? Gravida?
Examination
a. None unless problem identified or pelvic examination is part of full physical
assessment.

10. COPING-STRESS TOLERANCE PATTERN

History
a. Any big changes in your life in the last year or two? Crisis?
b. Who’s most helpful in talking things over? Available to you now?
c. Tense or relaxed most of the time? When tense, what helps?
d. Use any medicines, drugs, alcohol?
e. When (if) have big problems (any problems) in your life, how do you handle them?
f. Most of the time is this (are these) way(s) successful?
11. VALUES-BELIEFS PATTERN
1. History
a. Generally get things you want from life? Important plans for the future?
b. Religion important in life? When appropriate: Does this help when difficulties arise?
c. When appropriate: Will being here interfere with any religious practices?

Other concerns:
a. Any other things we haven’t talked about that you would like to mention?
b. Any questions?

C. Assessment (Physical Assessment)

GENERAL APPEARANCE
 Level of consciousness:
 Vital signs:
Temperature:
Pulse Rate:
Respiratory Rate:
Blood Preassure:
 Skin color:
 Physical Deformities:
 Signs of acute distress:
 Nutrition:
 Mobility:
 Facial expression:
 Speech:
 Personal hygiene:
 D. History of Substance Abuse

 Smoke: YES NO
 Drink Alcohol Beverages: YES NO, specify:
Before pregnancy: glasses/day
During pregnancy: glasses/day
 Illegal Drugs: YES NO, specify:
Before pregnancy: day
During pregnancy: day
 Does anyone smoke in the house? YES NO

E. Pre-natal History
Prenatal case

 AOG:
 Number of recent prenatal visit:
 Are you experiencing any of the following danger signs?
o Severe headache
o Convulsion
o Severe abdominal pain
o Vaginal bleeding
o Fever
o Paleness
 Are you aware of the essential care for your baby within the first 24 hours of life? YES
NO
 How is your recent pregnancy?
 Do you intent to practice family planning after giving birth? YES NO
 How much did you weigh before this pregnancy?
 Current weight: lbs/kg
Height: Date:
 Date of Name & Address Services Provided Instruction Follow Up
Consultation of Services
Provider

 Last menstrual cycle:

 Age of gestation:
 Estimated date of confinement:
 Fundic height:
 Pediatrician:

F. Nutritional and Dental Status

 Do you ever run out of food before the end of the month or count down the amount to
fit the others? YES NO
 Do you have any special dietary requirements? YES NO, specify:
 Weight (kg):
Height (m):
BMI:
 Quality of Diet
 Do you eat meat or chicken? 2to 3 times a week? YES NO
 Do you regularly eat more than 2-3 portion of fruits/vegetables a day? YES NO
 Do you consume dairy products; milk, cheese, yogurt a day? YES NO
 Do you eat whole grains carbohydrates foods? Brown bread, Brown Pasta,
Brown Rice?
 Do you consume package snacks; cakes, pastries, sugar sweetened drinks? YES
NO, less than 5 times a week
  If you are pregnant, do you take folate or folic acid in pre-pregnancy and early
pregnancy? YES NO
 Do you get regular exposure to the sun? (face, arms, hands for atleast 15 mins)
 Has the doctor tested your hemoglobin?
DENATL STATUS

 When was the last time you saw a dentist?

 Do you have any problems with your teeth or gums that affect how you eat? YES NO,
specify:

G. Abuse and Violence

1. Have you ever been emotionally abuse by your partner or someone who is
important to you? YES NO
2. Did you experienced being slapped, kicked or otherwise physically hurt by someone:
o Husband
o Ex-husband
o Boyfriend
o Stranger
o Specify: multiple total no. of times:
3. Does anyone force you to have sexual activities? YES NO
o Husband
o Ex-husband
o Boyfriend
o Stranger
o Specify:
4. Are you afraid of your partner? YES NO
 H. Obstetric History

Year Place of Duration Type of Complication Sex or Birth Present

Delivery of Delivery (Mother or Gender Weight Health
Pregnancy Infant) of the
baby

 GTPAL:
 Did you have G. D, hypertension, depression during your last pregnancy? YES NO, If yes,
elaborate.
 Did your baby have any Health problem at birth? YES NO
Surgery:
 Medication Problem:
 Laboratory Result:
 System Illness Condition:
 Nursing Care Plan

QUESTIONS:
1. What is the important nursing assessment for nutrition evaluation and nutritional
requirements during pregnancy?
2. Outline all NCP that promotes Nutritional Health addressing identified problems and
educational needs?
3. What would be important factors to assess if she is well hydrated?
4. What would be the best advice to a known smoker like her taking into consideration the
teratogenic effects of cigarette smoking?
5. Recommendation:

Wuv u all
-hani