Nursing Assessment Guide

NURSING ASSESSMENT GUIDE

(based on GORDON’S FUNCTIONAL HEALTH PATTERN)

1. HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

1.1 “How would you usually describe your health?”

(Unsaon man nimo paghulagway ang imong panglawas?)
Excellent (Maayo kaayo) Fair (Arang- Arang)

Good (Maayo) Poor
1.2 “How would you describe your health at this time?”

(Unsaon man nimo paghalugway ang imong panglawas karon?)
1.3 “What do you do to keep healthy and to prevent disorders in yourself?”

(Unsa man imong gibuhat o mga pamaagi nga imong gisunod aron
mamaayo ang imong panglawas ug mahilayo sa mga sakit- sakit? Sa imo
usab nga mga anak?)
Nutrition
Physical Examination (DentaL, Optical, Gynecological, etc.)
Weight Control/ Exercise Program, Self-Examination (Breast, Testicular)
Immunization
1.4 “Reasons for and expectations of hospitalization (and previous experience)

“Describe your illness” Cause, onset. (Unsa man ang sinugdanan sa imong
sakit?)
1.5 What treatments or practices have been prescribed?

(Unsa man ang mga tambal o mga pamaagi nga gitambag kanimo bahin
sa:) Diet (Pagkaon), Weight Loss (Pagkunhod sa imo timbang? Unsa man
kaha hinungdan?)
1.6 “Have you been able to follow the prescribed instruction? If not, what has
prevented you?” (Natuman ba nimo ang mga gitambag kanimo? Ug wala,
unsa man ang nakasagabal o nakapugong kanimo aron tumanon kini?)
1.7 “Have you experienced or do you anticipate a problem with caring for
yourself (Your children, your home)? (Naglisud kaba o nakapan lantaw
kaba ug umaabot nga problema bahin sa paggalam sa imong
kaugalingon? Sa imong anak o sa panimalay?) Mobility problems
(Panglihok) Sensory Deficits (Vision, Hearing) (Panan-aw, Pandungog)
2. NUTRITIONAL- METABOLIC PATTERN
2.1 “What is the usual daily food intake (Meal, snacks)”

(Unsa man ang naandan nimong pagka-on sa adlaw- adlaw?) (pamahaw,
pani-udto, panihapon o painit)
2.2 “What is the usual fluid intake (type, amounts)?”

(Unsa man ang imong na-andang ilimnon? Unsa may gidaghanonon?)
2.3 “How is your appetite?”

(Kumusta man ang imong gana sa pagkaon?)
Indigestion (Dili Hilisan) Nausea (Kasukaon)

Vominiting (Mosuka) Sore Mouth (Sakit sa baba)
2.4 “What ae your food restrictions or preferences?”

(Unsang mga pagkaon ang imong gusto ug usab kadtong gidili kanimo)
2.5 “Any supplements (vitamins, feedings)?”

(Natumar ka ba ug “Supplementary” sama sa bitamina, mineral ug uban
pa?)
2.6 “Has your weight changed in the last 6 months? If yes, why?”
(May kausaban ba ang imong gibugg-aton sa maiging unom (6) ka bulan?
Ug duna, ngano man?)
2.7 “Any problems with ability to eat?”

(Aduna ka bay problema sa pagkaon?)
Swallow liquids (Pagtulon sa tubigon)

Swallow solids (Pagtulon sag ahi)
Chew (Pag-usap)
Feeds Self (Pagkaon nga ikaw ra)
3. ELIMINATION PATTERN
3.1 Bladder
3.1.1 “Are there any problems or complaints with usual pattern of
urination?” (Duna ka bay problema sa pagpangihi?)
Oliguria (Dyutay nga ihi)
Polyuria (Daghan na ihi)
Dysuria (Sakit inig ihi)
Dribbling (Tulo- tulong ihi)
Retention (Dili ka ihi)
Burning (Hapdos o init nig pangihi)
Incontinence (ihi- ihi)
3.1.2 “Any assistive device used?

(Duna ka bay kahimanan nga gigamit alang sa pagpangihi nga imong
gigamit?)
Intermittent catheterization Incontinent Briefs

Catheter Cystostomy
3.2 Bowel
3.2.1 “What is the usual time, frequency, color, consistency, pattern?”
(Kapila ka malibang sa usa ka adlaw? Unsang orasa? Ang color ug ang
halugway sa imong hugaw?)
3.2.2 “Assistive device (typed, frequence?)”

(Duna ka bay paagi/kahimaman nga gigamit alang sa pagkalibang?)
3.2.3 “What is the skin condition?” (Kumusta ang imong pamanit?)
Color (Kolor) Temperature (Gainiton)

Turgor Edema, (Type, Location)
Pruritus (Location) (pangato) (Pnaghupong)
4. ACTIVITY- EXERCISE PATTERN
4.1 “Describe usual daily/ weekly activities of living.”

(Unsa man imong mga kalihokan sa adlaw- adlaw/ semana?)
Occupation
Leisure Activities (Lingaw- Lingaw)
Exercise Pattern (Type, Frequency (Ehersisyo) (unsa- Kapila)
4.2 “Are there any limitations in ability?”
(Duna ka bay kakulian sa imong paglihok?)
Ambulating (Gait weight- bearing, balance)- (Paglakaw)

Batching self (shower, tub)- (Pagkaligo)
Dressing/ grooming (oral hygiene) – (Pagilis/ pagpaguapo/ pagpaguapa)
(Paglimpyo sa baba)
Toileting (commode, toilet, bedpen)- (Pangasilyas)
4.3 “Are there any complaints of dyspnea or fatigue?”
(Duna ka bay problema sa pagginhawa? Pangapooy)
5. SLEEP- REST PATTERN
5.1 “What is the usual sleep pattern?”

(Kumusta man ang imong pagkatulog) Bedtime (Kanus-a matulog?) Hours
slept (Pila ka oras matulog?) Sleep aids (Medication, Food) (unsay
buhaton sa dili pa matulog?) Sleep routine (Duna bay buhatonon aron
makatulog?
5.2. “Any problems?” Difficulty falling/ remaining asleep (Duna ka bay

problema sa pagkatulog?) Not feeling rested after sleep
6. COGNITIVE PERCEPTUAL PATTERN
6.1 “Any deficits in sensory perception (hearing, sight touch)” Glassess

(antiohos) Hearing aid
6.2 “Any complaints?” Vertigo, Insensitivity to cold/heat? (Duna kay

panglipong? Dili makabati ug sakit ang panit?) (Dili makabati ug tugnaw o
init?)
6.3 “Able to read and write?” (Kahibalo ka bo mobasa, mosulat?”)
7. SELF- PERCEPTION PATTERN
7.1 “What are you most concerned about?”
7.2 “What are your present health goals?” (Unsa may imong buot kab-oton
bahin sa imong panglawas karon?)
7.3 “How would you describe yourself?”

(Unsaon man nimo paghalugway ang imong kaugalingon?)
7.4 “To what do you attribute the following?”
(Unsa may imong kasulti bahin sa)
Becoming ill (imong pagsakit)

Getting better (Pagkaayo)
Maintaining Health (Pagsustener sa maayong panglawas)
8. ROLE RELATIONSHIP PATTERN
8.1 Communication
8.1.1 “What language is spoken?”

(Unsa may imong sinultian?)
8.1.2 “Is speech clear? Relevant?”

(Klaro ba?)
8.1.3 “Assess ability to express self and understand others

(verbally, in writing, with gestures)
8.2 Relationship
8.2.1 “Do you live alone?” If not, “with whom?”
(Nag-inusara ka bas a pagpuyo? Ug dili, Kinsa may kauban nimo
pagpuyo?)
8.2.2 “Who do you turn to for help in time of need?”

(Kinsa may imong adtuon kon duna kay problema?)
8.2.3 “Assess family life (members, educational level, occupations)”

Cultural background Decision making
Activities (one or group) Communication patterns
Role discipline Finances
8.2.4 “Any complaints?”

Parenting difficulties Marital Difficulties
Difficulties with relatives Abuse (Phsyical, Verbal, Substance)
(In- Laws, Parents)
9. SEXUALITY- SEXUAL FUNCTIONING PATTERN
9.1 “Has there been or do you anticipate a change in your sexual relations
because of your condition? (Duna ba o nagpaabut kaba ug kausaban sa
imong panglawas nga relasyon tungod sa imong sakit o kondisyon?)
Fertility Pregnancy
Libido Contraceptives
Erections History
Menstruations
9.2 “Assess knowledge of sexual functioning.”
10. COPING- STRESS MANAGEMENT PATTERN
10.1 “How do you make decisions (alone, with assistance, who?)

(Giunsa man nimo paghimo ug mga desisyon) Usara, tabang sa uban- sa
kinsa man?)
10.2 “Has there been a loss in your life in the past year (or changes- moves,
job, health)?
(Duna bay Nawala, nausab sa imong kinabuhi sa inaaging tuig?) Bahin
trabaho, panglawas?)
10.3 “What do you like about yourself?”

(Unsa man ang imong ganahan sa imong kaugalingon?)
10.4 “What would you like to change in your life? (Unsa ang ganahan nimo
mausab sa imong kinabuhi?)
10.5 “What is preventing you?” (Unsa man ang nagpugong kanimo?)
10.6 “What do you do when you are tense or under stress?” (e.g. problems-
solving, eat, sleep, take medications, seek help?)
(Unsa man ang imong buhaton kon ikaw wala mahimutang o adunay
problema kalisdanan?) Solbad sa problema, pagkaon tumar or tambal,
pangita ug tambal?)
10.7 “What can the nurse do to provide you with more comfortable and
security during your hospitalization?
(Unsa man ang mahimo sa mga narses kanimo aron ikaw makomportable
ug mahatag seguridad sa panahon sa imong page star diri sa ospital?)
11. VALUE- BELIEF SYSTEM
11.1 “With what (whom do you find a source of strength or meaning?)

(Unsa o si kinsa man ang makahatag nimo ug kalig-on o kahulugan sa
kinabuhi?)
11.2 “Is religion or God important to you?”

(Mahinongdanon ba kanimo ang relihiyon o Ginoo?)
11.3 “What are your religious practices (type, frequency)?

(Unsa man ang imong mga tulomanon sa imong relihyon?)
11.4 “Have your value or moral beliefs been challenged recently? Described”
11.5 “Is there a religious person or practices (diet, book ritual) that you would
desire during a hospitalization (institutionalization)?
(Duna bay relihiyong tawo, tulomanon (pagka-on, libro, ritual) nga gusto
nimo igkita o buhaton sap ag- estar nimo dnhi sa ospital?)

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NURSING ASSESSMENT GUIDE

(based on GORDON’S FUNCTIONAL HEALTH PATTERN)

1. HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

1.1 “How would you usually describe your health?”

Excellent (Maayo kaayo) Fair (Arang- Arang)

1.2 “How would you describe your health at this time?”

1.3 “What do you do to keep healthy and to prevent disorders in yourself?”

1.4 “Reasons for and expectations of hospitalization (and previous experience)

1.5 What treatments or practices have been prescribed?

2. NUTRITIONAL- METABOLIC PATTERN

2.1 “What is the usual daily food intake (Meal, snacks)”

2.2 “What is the usual fluid intake (type, amounts)?”

2.3 “How is your appetite?”

Indigestion (Dili Hilisan) Nausea (Kasukaon)

2.4 “What ae your food restrictions or preferences?”

2.5 “Any supplements (vitamins, feedings)?”

2.7 “Any problems with ability to eat?”

Swallow liquids (Pagtulon sa tubigon)

3.1.2 “Any assistive device used?

Intermittent catheterization Incontinent Briefs

3.2.2 “Assistive device (typed, frequence?)”

3.2.3 “What is the skin condition?” (Kumusta ang imong pamanit?)

Color (Kolor) Temperature (Gainiton)

4. ACTIVITY- EXERCISE PATTERN

4.1 “Describe usual daily/ weekly activities of living.”

Ambulating (Gait weight- bearing, balance)- (Paglakaw)

5. SLEEP- REST PATTERN

5.1 “What is the usual sleep pattern?”

5.2. “Any problems?” Difficulty falling/ remaining asleep (Duna ka bay

6. COGNITIVE PERCEPTUAL PATTERN

6.1 “Any deficits in sensory perception (hearing, sight touch)” Glassess

6.2 “Any complaints?” Vertigo, Insensitivity to cold/heat? (Duna kay

7. SELF- PERCEPTION PATTERN

7.1 “What are you most concerned about?”

7.3 “How would you describe yourself?”

Becoming ill (imong pagsakit)

8. ROLE RELATIONSHIP PATTERN

8.1.1 “What language is spoken?”

8.1.2 “Is speech clear? Relevant?”

8.1.3 “Assess ability to express self and understand others

8.2.2 “Who do you turn to for help in time of need?”

8.2.3 “Assess family life (members, educational level, occupations)”

8.2.4 “Any complaints?”

10. COPING- STRESS MANAGEMENT PATTERN

10.1 “How do you make decisions (alone, with assistance, who?)

10.3 “What do you like about yourself?”

10.5 “What is preventing you?” (Unsa man ang nagpugong kanimo?)

11.1 “With what (whom do you find a source of strength or meaning?)

11.2 “Is religion or God important to you?”

11.3 “What are your religious practices (type, frequency)?

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