NURSING HISTORY ASSESMENT Tool

From Gordon, M. (1994). Nursing diagnosis: Process and application (3rd ed.). St.
Louis: Mosby; Gordon, M. (2000). Manual of nursing diagnosis: 1995- 1996. St. Louis:

I. HEALTH PERCEPTION-HEALTH MANAGEMENT 0 full self-care

PATTERN 1 requires use of equipment or device
1. History 2 requires assistance from another person
a. How has general health been? 3 requires assistance both person and equipment or
b. Any illnesses in past year? When appropriate: absences from device
work? 4 totally dependent
c. Most important things you do to keep healthy?
Use of cigarettes, alcohol, drugs? Breast self-examination? IV. SLEEP-REST PATTERN
d. In past, been easy to find ways to follow suggestions from a. Generally rested and ready for daily activities after sleep?
physicians or nurses? b. Sleep onset problems? Aids? Dreams (nightmares)? Early
awakening?
2. Examination—general health appearance c. Rest-relaxation periods?
II. NUTRITIONAL-METABOLIC PATTERN V. COGNITIVE-PERCEPTUAL PATTERN
1. History 1. History
a. Typical daily food intake? a. Hearing difficulty? Hearing aid?
b. Typical daily fluid intake? b. Vision? Wear glasses? Last checked? When last changed?
c. Weight and height loss or gain? c. Any change in memory lately?
d. Appetite? d. Important decision easy or difficult to make?
e. Food or eating: Discomfort? Swallowing? Diet restrictions? e. Easiest way for you to learn things? Any difficulty?
f. Skin problems: Lesions? Dryness? f. Any discomfort? Pain?

2. Examination VI. SELF-PERCEPTION - SELF-CONCEPT PATTERN

a. Skin: Bony prominences? Lesions? Color changes? 1. History
Moistness? a. How describe self? Most of the time, feel good (not so good)
b. Oral mucous membranes: Color? Moistness? Lesions? about self?
c. Teeth: General appearance and alignment? Dentures? b. Changes in body or things you can’t do? Problem to you?
Cavities? Missing teeth? c. Changes in way you feel about self or body
d. Actual weight, height. d. Things frequently make you angry? Annoyed? Fearful?
e. Temperature. Anxious?
e. Ever feel you lose hope?
III. ELIMINATION PATTERN
1. History VII. ROLES-RELATIONSHIPS PATTERN
a. Bowel elimination pattern? Frequency? Character? 1. History
Discomfort? Problem in control? Laxatives? a. Live alone? Family?
b. Urinary elimination pattern? Frequency? Problem in control? b. Any family problems you have difficulty handling?
c. Excessive perspiration? Odor problems? c. Family or others depend on you for things? How managing?
d. Belong to social groups? Close friends? Feel lonely
2. Examination—when indicated: examine excreta or drainage (frequency)?
color and consistency. g. Things generally go well at work? (School?)
IV. ACTIVITY-EXERCISE PATTERN VIII. SEXUALITY-REPRODUCTIVE PATTERN
1. History 1. History
a. Sufficient energy for desired or required activities? a. When appropriate to age and situations: Sexual relationships
b. Exercise pattern? Type? Regularity? satisfying? Changes? Problems?
c. Spare-time (leisure) activities? b. When appropriate: Use of contraceptives? Problems?
d. Perceived ability c. Female: When menstruation started? Last
menstrual period? Menstrual problems? Para? Gravida?
Feeding
Dressing IX. COPING-STRESS TOLERANCE PATTERN
Cooking 1. History
Bathing __________ a. Any big changes in your life in the last year or two? Crisis?
Grooming _____ b. Who’s most helpful in talking things over? Available to you
Shopping ______ now?
Toileting ______ c. Tense or relaxed most of the time? When tense, what helps?
General mobility______ d. Use any medicines, drugs, alcohol?
Bed mobility _______ e. When (if) have big problems (any problems) in your life, how
Home maintenance _____ do you handle them?
f. Most of the time is this (are these) way(s) successful?

X. VALUES-BELIEFS PATTERN
 11 Gordon’s Functional Health Patterns
1. Health Perception Health Management Pattern
2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity Exercise Pattern
5. Sleep Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self-Concept Pattern
8. Role-Relationship Pattern
9. Sexuality-Reproductive
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern

1. Health Perception and Health Management. It’s 2. Nutritional Metabolic Pattern it’s focused on the
focused on the person’s perceived level of health and pattern of food and fluid consumption relative to
well-being, and on practices for maintaining health. metabolic need. Is evaluated the adequacy of local
Also evaluated Habits including smoking and alcohol or nutrient supplies. Actual or potential problems
drug use. related to fluid balance, tissue integrity, and host
Contamination defenses may be identified as well as problems with
Disturbed energy field the gastrointestinal system.
Effective therapeutic regimen management
Health-seeking behaviors (specify) Adult failure to thrive
Ineffective community therapeutic regimen Deficient fluid volume: [isotonic]
management [Deficient fluid volume: hyper/hypotonic]
Ineffective family therapeutic regimen Effective breastfeeding [Learning Need]
management Excess fluid volume
Ineffective health maintenance Hyperthermia
Ineffective protection Hypothermia
Ineffective therapeutic regimen Imbalanced nutrition: more than body
management requirements
Noncompliance (ineffective Adherence) Imbalanced nutrition: less than body
Readiness for enhanced immunization requirements
status Imbalanced nutrition: risk for more than
Readiness for enhanced therapeutic body requirements
regimen management Impaired dentition
Risk for contamination Impaired oral mucous membrane
Risk for infection Impaired skin integrity
Risk for injury Impaired swallowing
Risk for perioperative positioning injury Impaired tissue integrity
Risk for poisoning Ineffective breastfeeding
Risk for sudden infant death syndrome Ineffective infant feeding pattern
Risk for suffocation Ineffective thermoregulation
Risk for trauma Interrupted breastfeeding
Risk-prone health behavior Latex allergy response
Nausea
 Readiness for enhanced fluid balance Impaired gas exchange
Readiness for enhanced nutrition Impaired home maintenance
Risk for aspiration Impaired physical mobility
Risk for deficient fluid volume Impaired transfer ability
Risk for imbalanced fluid volume Impaired walking
Risk for imbalanced body temperature Impaired wheelchair mobility
Risk for impaired liver function Ineffective airway clearance
Risk for impaired skin integrity Ineffective breathing pattern
Risk for latex allergy response Ineffective tissue perfusion
Risk for unstable blood glucose Readiness for enhanced organized infant
behavior
3. Elimination Pattern. It’s focused on excretory Readiness for enhanced self care
patterns (bowel, bladder, skin). Risk for delayed development
Bowel incontinence Risk for disorganized infant behavior
Constipation Risk for disproportionate growth
Diarrhea Risk for activity intolerance
Functional urinary incontinence Risk for autonomic dysreflexia
Impaired urinary elimination Risk for disuse syndrome
Overflow urinary incontinence Sedentary lifestyle
Perceived constipation Self-care deficit
Readiness for enhanced urinary elimination, Wandering
Reflex urinary incontinence
Risk for constipation 5. Sleep Rest Pattern. It’s focused on the person’s
Risk for urge urinary incontinence sleep, rest, and relaxation practices. To identified
Stress urinary incontinence dysfunctional sleep patterns, fatigue, and responses to
Total urinary incontinence sleep deprivation.
Urge urinary incontinence Insomnia
[acute/chronic] Urinary retention Readiness for enhanced sleep
Sleep deprivation
4. Activity and Exercise Pattern. It’s focused on the
activities of daily living requiring energy expenditure, 6. Cognitive-Perceptual Pattern. It’s focused on the
including self-care activities, exercise, and leisure ability to comprehend and use information and on the
activities. sensory functions. Neurologic functions, Sensory
experiences such as pain and altered sensory input.
Activity intolerance
Autonomic dysreflexia Acute confusion
Decreased cardiac output Acute pain
Decreased intracranial adaptive capacity Chronic confusion
Deficient diversonal activity Chronic pain
Delayed growth and development Decisional conflict
Delayed surgical recovery Deficient knowledge
Disorganized infant behavior Disturbed sensory perception
Dysfunctional ventilatory weaning response Disturbed thought processes
Fatigue Impaired environmental interpretation
Impaired spontaneous ventilation syndrome
Impaired bed mobility Impaired memory
 Readiness for enhanced comfort Readiness for enhanced communication
Readiness for enhanced decision making Readiness for enhanced family processes
Readiness for enhanced knowledge Readiness for enhanced parenting
Risk for acute confusion Relocation stress syndrome
Unilateral neglect Risk for caregiver role strain
Risk for complicated grieving
7. Self-Perception-Self-Concept Pattern its focused on Risk for impaired parent/infant/child
the person’s attitudes toward self, including identity, attachment
body image, and sense of self-worth. Risk for relocation stress syndrome
Anxiety Social isolation
disturbed Body image
Chronic low self-esteem 9. Sexuality and Reproduction. It’s focused on the
Death anxiety person’s satisfaction or dissatisfaction with sexuality
Disturbed personal identity patterns and reproductive functions.
Fear Ineffective sexuality patterns
Hopelessness Rape-trauma syndrome
Powerlessness Sexual dysfunction
Readiness for enhanced hope
Readiness for enhanced power 10. Coping-Stress Tolerance Pattern. its focused on the
Readiness for enhanced self-concept person’s perception of stress and coping strategies
Risk for compromised human dignity Support systems, evaluated symptoms of stress,
Risk for loneliness effectiveness of a person’s coping strategies.
Risk for powerlessness Compromised family coping
Risk for situational low self-esteem Defensive coping
Risk for [/actual] other-directed violence Disabled family coping
Risk for [actual/] self-directed violence Impaired adjustment
Situational low self-esteem Ineffective community coping
Ineffective coping
Ineffective denial
8. Role-Relationship Pattern. It’s focused on the Post-trauma syndrome
person’s roles in the world and relationships with Readiness for enhanced community coping
others. Evaluated Satisfaction with roles, role strain, Readiness for enhanced coping
or dysfunctional relationships. Readiness for enhanced family coping
Risk for self-mutilation
Risk for suicide
Caregiver role strain Risk for post-trauma syndrome
Chronic sorrow Self-mutilation
Complicated grieving Stress overload
Dysfunctional family processes: alcoholism
(substance abuse) 11. Value-Belief Pattern it’s focused on the person’s
Grieving values and beliefs.
Impaired social interaction Impaired religiosity
Impaired verbal communication Moral distress
Ineffective role performance Readiness for enhanced religiosity
Interrupted family processes Readiness for enhanced spiritual well-being
Parental role conflict Risk for impaired religiosity
Risk for spiritual distress
Spiritual distress