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    Nursing History and Gordon's

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    Carlo bersamira
    The document outlines a nursing health history template that covers 13 functional health patterns: biographical data, chief complaint, history of present hospitalization, medical diagnosis, and patterns related to health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, home environment, sexuality, coping and stress, values and beliefs. The template includes questions to assess each of the patient's functional health patterns and identify any relevant changes from their usual status.

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    Nursing History and Gordon's

    Uploaded by

    Carlo bersamira
    380 views2 pages
    The document outlines a nursing health history template that covers 13 functional health patterns: biographical data, chief complaint, history of present hospitalization, medical diagnosis, and patterns related to health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, home environment, sexuality, coping and stress, values and beliefs. The template includes questions to assess each of the patient's functional health patterns and identify any relevant changes from their usual status.

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    Nursing history and Gordon's

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    The document outlines a nursing health history template that covers 13 functional health patterns: biographical data, chief complaint, history of present hospitalization, medical diagnosis, and patterns related to health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, home environment, sexuality, coping and stress, values and beliefs. The template includes questions to assess each of the patient's functional health patterns and identify any relevant changes from their usual status.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    380 views2 pages

    Nursing History and Gordon's

    Uploaded by

    Carlo bersamira
    The document outlines a nursing health history template that covers 13 functional health patterns: biographical data, chief complaint, history of present hospitalization, medical diagnosis, and patterns related to health perception, nutrition, elimination, activity, sleep, cognitive function, self-perception, roles and relationships, home environment, sexuality, coping and stress, values and beliefs. The template includes questions to assess each of the patient's functional health patterns and identify any relevant changes from their usual status.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    NURSING HEALTH HISTORY

    A. BIOGRAPHICAL DATA
    NAME:
    AGE:
    SEX:
    HOME ADDRESS:
    HIGHEST EDUCATIONAL ATTAINMENT:
    OCCUPATION:
    HOSPITAL, WARD/AREA, AND BED NUMBER:
    CIVIL STATUS:
    NAME OF SPOUSE:
    AGE OF SPOUSE:
    OCCUPATION OF SPOUSE:
    NUMBER OF CHILDREN, AGES OF EACH CHILD:

    B. CHIEF COMPLAINT

    C. BRIEF HISTORY OF PRESENT HOSPITALIZATION

    D. MEDICAL DIAGNOSIS

    E. GORDON’S FUNCTIONAL HEALTH PATTERNS

    I. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN


    1. How has the general health been? Personal and family history of illnesses?
    2. Any illnesses in the past 6 months? Allergies?
    3. Most important things done to keep health?
    4. Use of cigarettes, alcohol, or drugs?
    5. In the past, has it been easy for you to follow doctors or nurses suggestions?
    6. Traditional concepts of health and illness? Beliefs and practices?

    II. NUTRITIONAL AND METABOLIC PATTERN


    1. Typical daily food intake? Describe. Get the 24-hour diet recall.
    2. Supplements?
    3. Typical fluid intake? Describe. How many glasses per day?
    4. General appetite?
    5. Food or eating discomforts? Diet restrictions or allergies?
    6. Height and weight compared to age? Compute for the body mass index (BMI).

    III. ELIMINATION PATTERN


    1. Bowel elimination pattern? How often per day? Color, consistency, odor? Any discomforts? Is
    there a change before and during hospitalization?
    2. Urinary elimination pattern? How often per day? Amount per urination, color, odor? Any
    discomforts? Is there a change in the pattern before and during hospitalization?
    3. Excess perspiration? Odor problems?

    IV. ACTIVITY-EXERCISE PATTERN


    1. Activities of daily living? Identify what you usually do everyday.
    2. Sufficient energy for completing desired or required daily activities?
    3. Exercise pattern? Type and regularity?
    4. Spare time. What are your leisure activities?
    5. Is there a change in the activity and exercise pattern before and during hospitalization?
    V. SLEEP-REST PATTERN
    1. What time do you sleep at night? What time do you wake up in the morning?
    2. Length of sleep? Any discomforts? Nightmares?
    3. Naps during the day?
    4. Do you get enough rest?
    5. Is there a change in the sleep pattern before and during hospitalization?

    VI. COGNITIVE-PERCEPTUAL PATTERN


    1. Any change in the memory lately?
    2. Easiest way for you to learn things? Listening, reading, or watching?
    3. Hearing difficulty? Hearing aid?
    4. Visual disturbances? Visual acuity? Last checked?

    VII. SELF-PERCEPTION AND SELF-CONCEPT PATTERN


    1. How do you describe yourself before and after hospitalization?
    2. Any changes in your body?
    3. Any changes in the things you can do?
    4. What are the things that frequently make you angry, annoyed, or frustrated?

    VIII. ROLE-RELATIONSHIP PATTERN


    1. Live with whom? Family structure?
    2. Any family problems you have difficulty handling?
    3. How does family usually handle problems?
    4. How do your family members feel about your hospitalization?
    5. Belong to social groups? Close friends?

    IX. HOME AND ENVIRONMENT


    1. Describe your home? How big or small, type of house, how many floors?
    2. Describe the neighborhood you live in.

    X. SEXUALITY-REPRODUCTIVE PATTERN
    1. If appropriate, any changes or problems in sexual relations?
    2. For female, when menstruation started? Last menstrual period? Menstrual problems? Gravida,
    paragravida, TPAL score?
    3. For male, circumcision?

    XI. COPING-STRESS TOLERANCE PATTERN


    1. Any big changes in your life the past year?
    2. During times of stress, what usually helps?
    3. How do you usually handle problems? Are your strategies successful?

    XII. VALUE-BELIEF PATTERN


    1. Most important things in life?
    2. What is you religion? Is it important to you?
    3. How often do you attend mass, services, or other activities in your church?
    3. Does this help when difficulties arise?

    XIII. OTHERS
    1. Any other things that you like to mention?
    2. Do you have any question?

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