Date 1-29-2020_ Time_3pm_Primary Language_English__ Recent Stress“mediocre relationship with my
Arrived Via: ☐ Wheelchair ☐ Stretcher ☒ Ambulatory spouse”
PSYCHOSOCIAL HISTORY
From: ☐Admitting ☒ ER ☐ Home ☐ Nursing Home ☐Other Coping Mechanism“strength is God & my children”
Support System children, friends, co workers____
Admitting M.D. _Cathy Den___ Time Notified __3.30pm__
ORIENTATION TO UNIT Calm:☒Yes ☐No __________________________
YES NO YES NO Anxious:☐Yes ☐No tense facial muscle; trembling
Arm Band Correct ☒ ☐ Visiting Hour ☒☐ Religion ______________ Roman Catholic______
Allergy Band ☒☒ Smoking Policy ☒☐ Tobacco Use:☒Yes ☐No _____1 pack/day______
Telephone ☒☐ TV, Lights, Bed Controls, Alcohol Use:☒Yes ☐No ____occasionally______
Electrical Policy ☒☐ Call Lights, Side Rails ☒ ☐ Drug Use:☐Yes ☒No ______________________
ADMISSION DATA
Educational Mat’l ☒☐ Nurses Station ☒☐
(TV Brochure) ☒☐ Oriented:☒Person ☒Place ☒Time ☐Confused
Family M.D., ___Dr. Nick Cole____________ ☐Sedated
NEUROLOGICAL
Weight __38 kg__. Height ____5”__. BP: R125/79_ L _ ☐Alert ☐Restless ☒Lethargic ☐Comatose
Temp. 37.9˚C__ Pulse _93; weak__ Resp.30; shallow_ Pupils: ☒Equal ☐Unequal ☒Reactive ☐Sluggish
Source Providing Information ☒ Patient ☐ Other _____ ☐Others __________________________
Unable to Obtain History ☐ ______________________ Extremity Strength:☒Equal ☐Unequal
Reason for Admission (Onset, Duration, Pt.’s Perception)
Speech:☒Clear ☐Slurred ☐Other
__S.O.B. on exertion, “chest pain when
______________
coughing, cold x wk., unable to sleep properly,
Normal ROM of Extremities ☒Yes ☐No
fever” “Dr. says I have Pneumonia” and “I feel
MUSCULO-
☒Weakness ☐Paralysis ☐Contractures
SKETAL
exhausted” _______________________________
☐Joint Swelling ☒Pain
☐Other weakness(fatigue); pain (when coughing)
Pattern: ☐Even ☐Uneven ☒Shallow ☒Dyspnea
Drugs _______________Amoxycillin_______________
RESPIRATORY
☐Other ___diminished breath sounds___
Food/Other ___________________________________
Breathing Sounds:☐Clear ☒Other inspiratory
ALLERGIES &
REACTION
Signs & Symptoms _____rash, nausea_____________
crackles
Blood Reaction ☐ Yes ☒ No Dyes/Shellfish ☒ Yes ☐ No
Secretions:☐None ☒Other pink-tinged, thick
sputum
Cough: ☐None ☐Productive ☐Nonproductive
Pulse: Apical Rate __93 - w_ ☒Reg. ☐Irregular
Current Meds- Dose/Freq. Last Dose
CARDIOVASCULAR
_______________ _______________ _____________ ☐Pacemaker
S = Strong W = Weak A = Absent D = Doppler
MEDICATIONS
_______________ _______________ _____________
Disposition of Meds: ☐Home Radial R _93__ L ______ Pedal R _____ L ______
☐Pharmacy ☐Safe *At Bedside Edema: ☒Absent ☐Present Site
_____________
Perfusion:☐Warm ☐Dry ☒Diaphoretic ☐Cool (hot)
Oral Mucosa ☐Normal ☒Other pale and dry______
GASTROINTESTINAL
☒No Major Problems ☐Gastro__________ Bowels Sounds: ☒Normal ☐Other
☐Cardiac__________________ ☐Arthritis_________ Wt. Change: ☐☒N/V
MEDICAL HISTORY
☐Hyper/Hypotension_________ ☐Stroke__________ Stool Frequency/Character1/day; soft abdomen__
☐Diabetes_________________ ☐Seizures_________ Last B/M 12-28-2020 ☐Ostomy (type)__________
☐Cancer___________________ ☐Glaucoma________ Equip.
☐Respiratory_____ ☒Other____childbirth-2017_____ ___________________________________
Surgery/Procedures Date Urine: Last Voided ________after lunch_______
_____Cesarean Section_______ _______2017_______ ☒Normal ☐Anuria ☐Hematuria ☐Dysuria
____________________________ ________________
GENITOURINARY
☐Incontinent
☐Wheelchair ☐Contacts ☐Venous ☐Dentures ☒Other decrease amount and frequency since ill
SPECIAL ASSISTIVE
☐Braces ☐Hearing Aid Access ☐Partial ☐Catheter (type) ___________ Other
☐Cane/Crutches ☐Prosthesis Device ☐Upper __________
DEVICES
☐Walker ☒Glasses ☐Epidural Catheter ☐Lower LMP ___12-18-2020___ ☐Vaginal/Penile
☐Other_____for astigmatism____________________ Discharge
Other ___________________________________
Need Assist with: ☐Ambulating ☐Elimination
SELF CARE
Patient informed Hospital not responsible for personal ☐Meals ☒Hygiene ☐Dressing
belongings. ____________while fatigue__________________
VALUABLES
Valuables Disposition:☐Patient☐ Safe☐ Given to_____
Patient/SO Signature_____________ none_________ ADDRESSOGRAPH PLATE
Patient’s name: Dara, Cok (F, 46y/o)
File number: 38706
NUTRITION General Appearance: ☒Well Nourished ☐Emaciated 1. What do you know about your present illness? “Dr.
☐Other _____________________ says I have Pneumonia” “ I’ll have an I.V.” ______
Appetite: ☐Good ☐Fair ☒Poorx3 days 2. What information do you want or need about
your illness? ______________________________
Diet ____liquid____ Meal Pattern __3x/day________
_________________________________________
☒Feeds Self ☐Assist ☐Total Feed 3. Would you like family/SO involved in your care?
Color:☒Normal ☐Flushed ☒Pale ☐Dusky ☐Cyanotic _______________just my children_____________
☐Jaundiced ☒Other __cheek flushed hot______ 4. How long do you expect to be in the hospital?
General Description _____________ __________________”2-3 days”____________
__surgical scar:_________________ 5. What concerns do you have about leaving the
______LLQ abdomen____________ hospital? _________________________________
_____________________________ CHECK APPROPRIATE BOX
_____________________________ Will patient need post discharge assistance with
_____________________________ ADLs/physical functioning? ☐Yes ☒No ☐Unknown
Does patient have family capable of and willing to
provide assistance post discharge?
PRESSURE SORE “AT RISK” SCREENING CRITERIA ☒Yes ☐No ☐Unknown ☐No family
OVERALL SKIN BOWEL & BLADDER REHABILITATIVE
CONDITION CONTROL STATE Is assistance needed beyond that which family can
provide? ☐Yes ☒No ☐Unknown
GRADE GRADE GRADE
Previous admission in the last six months?
☐ 0 Turgor (elasticity ☒ 0 Always able to ☐ 0 Fully ambulatory
adequate, skin ask for bedpan ☐Yes ☒No ☐Unknown
warm and moist
Patient lives with _mother and children__________
Planned discharge to __________home_________
SKIN ASSESSMENT
☒1 Poor turgor, skin ☐1 Incontinence of ☒1 Ambulated with
cold & dry urine assistance Comments: fatigue and anxiety may have________
interfered with learning, Re-teach anything covered
☐2 Areas mottled, ☐2 Incontinence of ☐2 Chair to bed
red or denuded feces ambulation only at admission later___________________________
☐3 Existing skin ☐3 Totally ☐3 Confined to bed
Social Services Notified ☐Yes ☒No
ulcer/lesions incontinent
confined to bed NARRATIVE NOTES
☐4 Immobile in bed
S – Pt. stated with chest pain on coughing,
NUTRITIONAL STATE MENTAL STATE CHRONIC DISEASE dyspnea on exertion and unable to carry out
STATUS
(i.e., PVD,BM,CA,
ADL for past week. Coughing relieved “when I
Others) sit-up and sit still”. Having occasional “chills”.
GRADE GRADE GRADE Well-groomed but “having difficulty/tired to
☐ 0 Eats all ☒ 0 Alert and clear ☒ 0 Absent put on make-up”
☒ 1 Eats very little ☐ 1 Confuse ☐ 1 One present
O – no nasal flaring or use of accessory
☐ 2 Refuses food ☐ 2 Disoriented/ ☐ 2 Two present
often senile
muscle, chest expansion <3cm. Breath sound
☐3 Tube feeding ☐3 Stuporous ☐3 Three or more
and inspirational crackles in ® lower and
present upper chest.
☐4 Intravenous ☐4 Unconscious
feeding Assess own support as good “with children”
and “indifferent with husband”, worried about
TOTAL __________ Refer to Skin Care Protocol her 6 years old boy left with her old mother.
Concerned about her work stating “too much
work to do”. Informed of need to save urine
for urinalysis. IV started to keep vein open.
NURSE SIGNATURE/TITLE DATE TIME Keeping head of the bed up to facilitate
breathing.
TessieReyta, R.N.
Universidad de STA. Isabel de Naga Inc.
COLLEGE OF HEALTH SCIENCES
NURSING PROGRAM
Health Assessment
LESSON _: GFHP, V&D of Data
Name: ________________________________________________________BSN 1_____
DATE: ____________________ SCORE: ________________ EQUIVALENT: ___________
Instruction: Select all the information/data from the above tables, that belongs or related to
Gordon’s functional health pattern. Write your answers on the space provided.
Gordon’s Functional Health Client’s Data
Pattern
Health Perception and Health
Management
Nutritional and Metabolic
Pattern
Elimination Pattern
Activity and Exercise Pattern
Sleep and Rest Pattern
Cognitive and Perception
Pattern
Self-Perception and Self-
Concept Pattern
Roles and Relationship
Pattern
Sexuality and Reproduction
Pattern
Coping and Stress Tolerance
Pattern
Values and Belief Pattern
