‘GORDON’S ASSESSMENT GUIDE QUESTIONS 11.) Health Perception/Health Management Pattern ‘Hospitalized Client 2) Reason for admission: 2) What is your understanding af the purpose of the Ireatmend? Haw de you think the treatment is working? 3) Have you ever been hospitalized betore? For what reasons? 9) What expectations de you have about this hospitalization? 2.) Nutritional/ Metabolic Pattern Record the diet by a recall of ALL food and beverages taken over the last 24 hours. “Ts that menu typical of most days?” Describe eating habits and current appetite. Ask, “Wha buys and prepares the food?” “Are your finances adequate for foad?" “Who is present at mealtime?” Indicate any fod allergy of intolerance. Record the daly intake of caffeinated beverages. 1) How is your appetite? 2), Describe what you eat in 2 typical day. 3)_Do you have food restrictions or special diet due to allergies, food intolerance, religious practices, or ather health problems? 4) What vitamins or supplements do you take? 5) What are your food preferences? Likes and dislikes? 18) How alten do you ge to fast food restaurants? 7) Do you experience any discomfort in eating or swallowing? 8) Do you have dental problems? 9), Describe your dally uid intake. 3.) Elimination Pattern 1) What is your regular bowel movement pattern? 2) Which of the foliowing do you experience? __Constipation _Diarthea_ Ostomy 3) How is your urinary elimination pattern? 4) Which of the following do you experience? __ Incontinence __Dysuria_ Burning sensation ribbing ___Nocturia___Oliguria_Polyuria Urinary retention ___ Catheter present 5) Urine color 16) Do you have any of the following skin problems? __ Dryness _ Poor skin turgor __ Rashes Lesions __ Swelling __ Acne _ Temperature change 7) Deo you experiance excess perspiration and odor problems? 4) Activity and Exercise Pattern This reflects usual daly activities. Ask, “Tell me how you spend a typical day?” Note abilty to perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed ta chair transfer, walking, standing, or limbing stairs? Any use of wheelchair, prostheses, or mobil aids? Record also leisure activites enjoyed and exercise patter (type, amount per day/weck, method of warm-up session, method ef monitoring the body's response to exercise). 1) Describe a typical day's activity. 2) What are your usual leisure activities? 3) Do you have regular exercise pattern? Type? Frequency? Intensity? Duration? 4) Describe any problem you have experienced with usual activity and exercise? 5) Do you experience the following: Chest Pain? Arm Pain? __Leg Pain? __Back Pain? Dey being ses, whos, apna)? Chih? _Tighng hbase Uightheadedness? ue/Weakness? Palpitations? 6) Fad flesingwcviy taka: De you sake? IF YE, whatare the estimate pecs pe yar? 5.) Sleep/Rest Pattern 2) Timeof arising? __Time of retiring? ___Do you take naps?__If YES, how long? How often? 2), In general, do you fel well-rested and ready for dally activites after sleeping? 3)_Do you have aids to help you sleep? _If YES, what? 9) Do you have dreams or nightmares? —___ If YES, what kind? 5) Do you experience insomnia? IT VES, haw often?”6.) Personal Habits A. Tobacco, 1)_Do you smoke cigarettes (pipe, use chewing tobacco)? 2) Ab what age did you start smoking? 3) How many packs de you smoke per day? 4) How many years have you smoked? __~ (record number of packs smoked per day [PPD] and duration, ‘example: 1 PPD x5 years) 15) Have you ever tried ta quit? 6) How did it go? 8. Alcohol 41) Do you drink alcohol? 2), When was your last drink of aleohol? '3), How much did you drink that time? 3) Out of the last 30 days, about how many days would you say that you drank alcohol? '5) Have you ever had a drinking problem? 6) CAGE (cut down, annoyed, guilty, eye-opener) questions: Have you ever thought you should cut down your drinking? Have you ever been annayed By criticism of your drinking? Have you ever felt quity about your drinking? ‘Do you drink in the morning? ° If person answers YES to 2 or more CAGE questions, suspect alcohol abuse 7) If patient ansivers NO to drinking alcohol What are your reasons for this decision? Any history of alcohol treatmert? Ae you involved in recovery acivities? i Do-you have a family member with a problem in drinking? ange Street Drugs 11). Which of these drugs have you taken or are eurrenty taking? __marijuana__cacaine ‘methampethamine (shabu) __ barbiturates/depressants 2), How lten do you take these? 3) Has your use affected your wark or your family? 7.) Cognitive and Perceptual Pattern 2) Eyes and vision last examination resuit? _Do you wear glasses/cuntact lenses? __Do you experience blurring? Diplopia? Pain? Inflammation? Cataract? Glaueama? Headache? Photophobia? _ Unusual discharges? Describe them! 2). Ears and hearing limitations: Pain? Tinnitus? __ Describe discharges: 3) Gthor special senses: any problems with ~ ability to feel pain? abilty to feel temperature changos? ability to distinguish object by touch? ___abilty to smel?____ablity to taste? '4) Pain: are you experiencing pain? if YES, describe the location: __type:___ How does the pain affect your daily activities? 8.) Self-Perception Pattern 1) How do you feel about yourself most of the time? 12), Isthere something about yourself or your appearance that you like to change? '3) How does your illness affect the way you feel about yourself or your body? 3) What things make you anxious? Feartu? Distressed? 5) What do you da to alleviate your feaings? 9.) Role-Relationship Pattern 2) Who do you tive wath? 2) Describe your family structure. 3) Do you get along with your family? with your friends? with your eo-warkers?” '@) Wha do you turn to for help? '5) Do family members depend on you? ___How are they managing while youre iI? 15) How would you describe yaur rae in the faenily? 77), How has your health status affected your relationship with others? '8) What fetings have family members and friends expressed about your iiness and hospitalization?110.) Sexuality and Reproduction Pattern 4) 2) 3) 4 5) 8) 7 a) 9) {Is your sexual relationship satisfying? __Have any changes or problems taken place with these relationships? ‘Bo you take contraceptives? _Have you had any problems with using contraceptives? When was your last menstrual period? Da you have any of the following probleme: amenorrhea ___dysmenerthea profuse bleeding Irregular menstruation When was your last pap smear? __how often do you undergo pap smear? De you perlorm breast sa-examination? Do you have children? _ YES, describe your complaints: ‘Are you currently pregnant? Da you perform testicular examination? 10) De you have prestate problems? iT VES, describe your complaints: 111) Have you ever had infections ofthe reproductive tact? __if YES, what are they? Situations that case stress in the presomt? How do stressful situations affect you? Hw do you usually solve your problems? How do you relieve tension and deal with ress? \Wha do you turn to for help during pessonal crisis? ‘Are you able to handle problems successfully most of the time. 12.) Value and Belief Pattern y 2) 3) 4) 5) 0) \What are the mast important things to you? Do you generally get what you wantin fe? [What are your pians for the future? Do you find prayer and meditations helpful? Has being sick affected your besef and your religion with God Use FICA questions to incorporate the person's spiritual values into the health history: ‘a. Faith: Does religious faith or spirituality lay an important role in your life? Do you consider yourself a retigiaus or spiritual person? ._ Infuence: How does your religious faith or spirituality influence the way you think about your health or the way you care for yourselt? Community: Are you part of any religious or spiritual community or congregation? 1d. Address: Would you ke me to address any religious or spirua lsues or concerns with you?