ST.

MICHAEL’S COLLEGE
College of Nursing
Iligan City

I. DEMOGRAPHIC DATA
Admission Assessment: Date: _________ Time: ________

Name: ________________________________ Date of Birth: _____________ Age: ________ Sex: _____

Primary Significant Others: _______________ Telephone: ________ Name of Primary Source: ________
Admitting Diagnosis: _____________________________________________________________________

GENERAL INFORMATION
Vital Signs
When was the last time you had your blood pressure taken? Where?
Do they tell you what the reading is? YES NO What is the reading?
Do you know what important vital signs data are? YES NO
Heart Rate : Respirations: Height:

If none, how will you know if you and

Do you have a thermometer at home? YES NO any member of the family has fever?

Have you been hospitalized in the past three months? YES NO Name of the Hospital:

What was the reason of your hospitalization?

Review admission CBC, U/A. CXR and other diagnostic exam: Note any
abnormalities:

GORDON’S FUNCTIONAL HEALTH PATTERNS

Health Perception/Health Management Pattern
This pattern is related to the client’s perceived pattern of health and or well-being, knowledge of lifestyle and the relationship
to health, knowledge of preventive health practices and adherence to medical and nursing prescriptions. Data collection is
focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be
detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to
safety and health management may be identified as well as needs for modifications in the home or needs for continued care
in the home.

Noncompliance Ineffective Health

Maintenance
Growth and Development, Delayed Ineffective Protection
Energy Field Disturbance Risk for Infection
Risk for Injury Effective Management of
Therapeutic Regimen
Health-Seeking Behaviors
Ineffective Management of Therapeutic Regimen (individual, family and community)

1. Kindly describe any health concerns that you would like to improve?
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________

2. What do you do to improve/maintain your health?

____________________________________________________________________________________________________________
__________________________________________________________________________________________________________
3. Do you have any Preexisting conditions, surgeries, procedures in the past? What and When?
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________

4. Are you exposed to any communicable diseases within the past year? [ ] No [ ] Yes
Kindly specify: ____________

5. Kindly enumerate if you are taking any medications at home? (Include prescription, over the counter, herbal remedies, vitamins)
Name Dose/Frequency/Route Reason for taking Remarks (Prescribed or Self-Medication)
1. ____________ _________________________ __________________________________________________________
2. ____________ _________________________ __________________________________________________________
3. ____________ ________________________ __________________________________________________________
4. ____________ _________________________ __________________________________________________________
5. ____________ _________________________ __________________________________________________________
6. ____________ _________________________ __________________________________________________________
7. ____________ _________________________ __________________________________________________________
8. ____________ _________________________ __________________________________________________________

6. Do you encounter any problems from your medications?

[ ] No [ ] Yes
What do you do to improve the problem encountered? ____________________________________

7. Do you have any difficulty buying your medications/supplies?

[ ] No [ ] Yes
If yes, what: _______________________________________________

8. Do you have any allergies to medications, food, dust, and the like? How do you manage the reactions?
Sources ______________________________________ Management: ______________________________

9. Have you ever had a blood transfusion?

[ ] No [ ] Yes
When? _____________ Reaction? (Type) ____________________
10. Did you have the following screenings done in the past year?
[ ] Breast self exam [ ] Prostate check [ ] Vision check
[ ] Mammogram date: _____ [ ] Testicular check [ ] Glaucoma
[ ] Pelvic exam/Pap smear [ ] Rectal check [ ] Dental exam

NUTRITIONAL-METABOLIC PATTERN
Usual pattern of food, fluid intake, types of food, fluid intake, actual weight loss or gain, appetite, preferences. Inquire about
– nutrition, fluid intake, peripheral edema, infection, oral cavity health. Assessment is focused on the pattern of food and
fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential
problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the
gastrointestinal system.

Fluid Volume Deficit High Risk for Imbalanced Body

Temperature
Fluid Volume Excess Hypothermia
Impaired Swallowing Hyperthermia
Ineffective Infant Feeding Pattern Impaired Skin Integrity
Impaired Dentition Impaired Tissue Integrity
Nausea related to pain, medications, activity, (labor), and stress.
High Risk for Aspiration Adult Failure to Thrive
Imbalanced Nutrition: Less than Body Requirements
Imbalanced Nutrition: More than Body Requirements
Impaired Oral Mucus Membrane

1. Do you have a special diet? [ ] No [ ] Yes, If yes, kindly indicate________________________________

2. When was the last time you ate? ____________________________________
3. Did you receive some instructions from the medical team to increase/restrict your fluid intake?
[ ] No [ ] Yes _________ Amount __________________ /day
4. Dentures? [ ] Upper [ ] Lower [ ] Partial
5. Appetite [ ] Normal [ ] Increased [ ] Decreased
6. Do you have difficulty with?
[ ] No [ ] Choking [ ] Smell [ ] Chewing
[ ] Swallowing [ ] Tasting [ ] Following diet
Related to: ________________________________________________
7. Do you have? [ ] No [ ] Nausea [ ] Vomiting
[ ] Indigestion [ ] Weight loss/gain ______ kg/lbs.
[ ] Mouth [ ] Persistent fever
Soreness
8. Skin/Mucosa
Color: [ ] Pink [ ] Flushed [ ] Cyanotic [ ] Ashen
[ ] Pale [ ] Mottled [ ] Jaundiced

Temperature/Moisture: [ ] Warm [ ] Cool

[ ] Hot/dry [ ] Cold/clammy
Turgor: [ ] Normal [ ] ____________________________________
Edema: [ ] None [ ] Generalized [ ] Localized: ____________________
(Describe location and degree 1-4+)

9. Wounds/Drains/Tubes/Catheters/Dressings: [ ] None _______________________

10. Oral Mucous Membranes: [ ] Not Applicable
[ ] Intact [ ] Lesions ______________________________________________
[ ] Moist [ ] Dry
Color: [ ] Pink [ ] Pale [ ] Cyanotic [ ] Other________________________

11. Braden Skin Risk Assessment Score

15-16 Low risk 13-14 Moderate risk 12 or less Severe risk

Elimination Pattern
Bowel and bladder elimination patterns, changes, control problems, use of assistive devices, use of medications. Inquire
about – bowel elimination, incontinence. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory
problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.

Constipation Functional Urinary Incontinence

Diarrhea
Bowel Incontinence
Urinary Retention
Stress Urinary Incontinence
Impaired Urinary Retention
Incontinence, urinary, reflex
Altered Patterns of Urinary Elimination
Total Incontinence
Functional Urinary Incontinence

1. Do you have any problems with bowel/bladder elimination? [ ] No [ ] Yes, describe: ______________________
2. Assess the abdomen
[ ] Soft [ ] Firm
[ ] Nontender [ ] Tender: Location ____________________________
[ ] Nondistended [ ] Distended: Girth _____________________________
[ ] Ostomies/tubes: type _______________________________________
Care (circle): independent, needs assistance
Assess Bowel Sounds
[ ] Present [ ] Absent [ ] Other _______________________

3. Assess Bladder: [ ] Nondistended [ ] Distended

Comments: _______________________________________________________
_________________________________________________________________

Activity – Exercise Pattern

Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and
responses to sleep deprivation may be identified. Inquire about- Patterns of sleep, rest, perception of quality and quantity.

Fatigue
Activity Intolerance
Self-Care Deficit (specify) ________________
Impaired Home Maintenance
Impaired Physical Mobility
High Risk for Disuse syndrome
High Risk for Injury
Risk for Falls
Impaired Physical Mobility

1. Do you have enough energy for your daily activities? [ ] Yes [ ] No

2. Desired/required activities? [ ] Yes [ ] No

3. Do you need assistance with ADL’s? ? [ ] Not applicable

[ ] Eating/Drinking [ ] Walking [ ] Sitting
[ ] Toileting [ ] Getting up from bed/chair [ ] Preparing meals
[ ] Bathing [ ] Stair climbing [ ] Shopping
[ ] Dressing [ ] Turning
Comments: _____________________________________________________
 4. Do you have mobility problems?
[ ] None [ ] Unable to assess
[ ] History of falling [ ] Tremors/Spasms____________________
[ ] Dizziness [ ] Paralysis ___________________________
[ ] Unsteadiness/Balance [ ] Decreased Function __________________
[ ] Amputation_________ [ ] Numbness, Tingling, Burning _____________________
[ ] Impaired limb _______

5. Risk Fall Assessment [ ] No Risk [ ] Low Risk [ ] High Risk

6. Gross Motor Movements:

Normal Abnormal Comments______________________________________
Gait [ ] [ ] _______________________________________________
Posture [ ] [ ] _______________________________________________
ROM [ ] [ ] _______________________________________________

7. Do you use any assistive devices at home? [ ] No [ ] Yes

8. Muscle Strength (see Key) Guidelines to assess muscle strength

[ ] Not applicable +5 = able to move against full resistance
left arm _____ +4 = able to move against gravity and mod resistance
right arm _____ +3 = able to move against gravity but no resistance
left leg _____ +2 = weak movement, unable to overcome gravity
right leg _____ +1 = flicker of muscle movement
0 = no movement

Ineffective Airway Clearance

Impaired Gas Exchange
Ineffective Breathing Patterns
Cardiac Output, Decreased
Ineffective __________________
Tissue Perfusion
9. Respiratory Assessment
Respiratory effort [ ] Easy [ ] Use of accessory muscles
Respiratory pattern [ ] Regular [ ] Irregular: ____________________
Breath sounds Right Left
Clear [ ] [ ]
Diminished [ ] [ ]
Coarse/Rhonchi [ ] [ ]
Crackles/Rales [ ] [ ]
Wheezing [ ] [ ]
Absent [ ] [ ]
Cough [ ] No [ ] Yes Sputum [ ] No [ ] Yes:_________________

7. Cardiovascular Assessment
Rhythm_____________________
Heart Sounds________________
Neck Veins [ ] Flat [ ] Distended
Peripheral pulses (0 = absent, +1 = weak, +2 = normal, +3 = bounding
Dorsalis Pedis Posterior tibial Radial Other
Right _____________ ____________ ________ _______
Left _____________ ____________ ________ _______

Sleep Pattern
Disturbance
Sleep – Rest Pattern
Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and
responses to sleep deprivation may be identified. Inquire about- Patterns of sleep, rest, perception of quality and quantity.
[ ] Not applicable
[ ] Deferred
1. Have you had difficulty sleeping prior to admission?
[ ] No [ ] Yes, describe:____________________________________
2. Difficulty falling asleep? [ ] No [ ] Yes
3. Early awakening? [ ] No [ ] Yes
4. Abnormal cycle of sleeping
daytime sleeping [ ] No [ ] Yes
awake at night [ ] No [ ] Yes
 Impaired Parenting Confusion, Acute
Social Isolation Confusion, Chronic
Impaired Comfort Disturbed Thought Processes
Decisional Conflict Impaired Verbal
Communication
Altered thought Process Impaired Memory
Sensory-Perceptual Readiness for Enhanced
Knowledge
Disturbed (specify)_________ Pain Acute

Cognitive – Perceptual Pattern

Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to
neurological functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be
identified and further evaluated. Vision, learning, taste, touch, smell, language adequacy, memory, decision-making ability,
complaints of discomforts. Inquire about – decisions, comfort, knowledge, sensory input, learning.

1. Orientation Level of Consciousness

[ ] Not oriented [ ] conscious
[ ] Oriented to Person [ ] lethargic, sleepy, drowsy
[ ] Oriented to person, place [ ] stupor – aroused by verbal stimuli
[ ] Oriented to person, place, time but responds poorly to pain
[ ] light coma – no response to verbal stimuli
but responds to pain
[ ] deep coma – no response to painful stimuli

2. Pupils [ ] Not applicable Describe:___________________________

3. Clarity of speech [ ] Clear [ ] Slurred [ ] Aphasic

Primary language if not English:______________________________

4. Thought Process [ ] Logical [ ] Illogical (confused) [ ] flight of ideas

5. Deferred [ ]
What is the highest grade in school you have completed? _______
Occupation:___________________________________________
Do you have problems with your memory? [ ] No [ ] Yes ________________
Hearing Aid [ ] No [ ] Right ear [ ] Left ear
Glasses/contacts [ ] No [ ] Yes
Do you have any problem with your ability to feel pain, temperature? [ ] No [ ] Yes
Describe:_______________________________________________________
Have you ever had a seizure? [ ] No [ ] Yes How often? __________________
Describe your seizure _____________________________________________________
When was your last seizure?__________________________________________________
Do you have pain? [ ] No [ ] Yes
If yes, (type, duration, location) Describe: __________________________________________________
How do you get relief from your pain? _____________________________________________________
What do you need to learn to be able to care for yourself after discharge? ____________________________
_____________________________________________________________________________________________________

Self-concept Disturbance
Body Image Disturbance
Anxiety
Fear
Hopelessness
Powerlessness
Self – Perception Pattern
Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-
worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified.
Attitudes about self, sense of worth, perception of abilities, emotional patterns, body image, identity. Inquire
about - Anxiety, fear, control, self concept. Behaviors indicate the following
1. Mood [ ] Calm [ ] Agitated [ ] Angry
[ ] Anxious [ ] Sad [ ] Other _______________

2. Affect [ ] Normal [ ] Labile [ ] Flat

3. Verbal Style [ ] Interactive [ ] Quiet [ ] Talkative [ ] Guarded

4. What outcome do you expect from this hospitalization? _______________________________________________________

 Interrupted Family Processes
Chronic Sorrow
Ineffective Role Performance
Impaired Social Interaction
Social Isolation
Caregiver Role Strain
Grieving, Anticipatory

Role – Relationship Pattern

Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or
dysfunctional relationships may be further evaluated. Patterns of relationships, role responsibilities, satisfaction with
relationships and responsibilities. Inquire about – Communication, family, loss, parenting, socialization, violence,
responsibilities.

1. Lives [ ] Alone [ ] With ___________________________________

2. Who will assist you with your care after discharge? [ ] No one
______________________________________________________________
3. Resides: [ ] House [ ] Apartment [ ] Assisted [ ] Living
[ ] 24 hour nursing care provided
4. Environmental/Safety concerns (stairs, inaccessible bathrooms, etc) [ ] None
Describe: _____________________________________________________
5. Any current family difficulties of concern to you? [ ] None
Describe: _________________________________________________________

Sexual Dysfunction
Ineffective Sexuality Patterns
________________________

Sexuality – Reproductive Pattern

Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions.
Concerns with sexuality may be identified. Menstrual, reproductive history, satisfaction with sexual relationships, sexual
identity, premenopausal or postmenopausal problems, accuracy of sex education. Inquire about – problems with
reproductive system and sexual response.

1. Do you have any questions/concerns about the effects your physical condition
or medications may have on your sexual activity?
[ ] No [ ] Yes ________________
2. Females [ ] post menopausal
date of last menstrual period?_____________________________

Impaired Adjustment
Ineffective Individual Coping
Suicide, Risk for
Post-Trauma Syndrome
________________________
Coping – Stress Pattern
Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated,
and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be
further evaluated. Ability to manage stress, knowledge of stress tolerance, sources of support, number of stressful life events
in last year. Inquire about – coping, stress, events

1. Have you had any recent major life-style changes?

[ ] No [ ] Yes, describe ____________________________________
2. How do you deal with stressful situations? __________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________ Spiritual Distress
________________________

Value – Belief Pattern

Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her
choices or decisions. Values, goals, beliefs, spiritual practices, perceived conflicts in values
1. Religious preference:___________________________________________
2. Are there any religious or cultural practices that may be affected by this hospitalization? [ ] No [ ] Yes,
describe____________________
3. Would you like to see a Chaplain? [ ] No [ ] Yes
4. Advance Directives reviewed for completion [ ] No [ ] Yes
Has patient discussed advanced directives with physician? [ ] No [ ] Yes
5. Further actions if applicable
[ ] patient given additional information
[ ] patient referred to [ ] social work [ ] pastoral services other_______