Gordon’s Functional Health Pattern Health Perception and Health Management Nursing History Subjective Nutrition and Metabolism Health perception General Information on factors influencing health management and adherence behavior Risk factors Preventive health screening activities Dietary intake Factors that influence diet Metabolic needs Nutrition knowledge PE Objective Gen appearance, including dress and speech patterns Body structures, incl. height/weight proportions Mental status Validation of disease/ Condition skills Assessment of environment for possible hazards General Appearance Anthropometric measurements Integumentary Laboratory Nursing Diagnosis Energy Field, Disturbed Health Maintenance, Ineffective Health-Seeking Behaviors (Specify) Infection, Risk for Injury, Risk for Risk for injury, Suffocation Risk for injury, Poisoning Risk for injury, Trauma Latex Allergy Response, Risk for and Actual Management of Therapeutic Regimen Effective Management of Therapeutic Regimen (Individual, Family, Community), Ineffective Management of Therapeutic Regimen Readiness for Enhanced Noncompliance (Specify) Perioperative-Positioning Injury, Risk Protection, Ineffective Surgical Recovery, Delayed Serum Albumin Serum transferrin Total Lymphocyte count Urine Urea nitrogen Adult Failure to Thrive Aspiration, Risk for Body Temperature, Imbalanced, Risk Factors related to nutritional problems system Oral Cavity Abdomen Thyroid gland Lymphatic system Nitrogen Balance Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Dentition, Impaired Fluid Balance, Readiness for Enhance Fluid Volume, Deficient, Risk for and Actual Fluid Volume, Excess Fluid Volume, Imbalanced, Risk for Hyperthermia Hypothermia Infant Feeding Pattern, Ineffective Nausea Nutrition, Imbalanced, Less Than Bod Requirements Nutrition, Imbalanced, More Than Bo Requirements, Risk for and Actual Nutrition, Readiness for Enhanced Swallowing, Impaired Thermoregulation, Ineffective Tissue Integrity, Impaired Skin Integrity, Impaired, Risk for and Actual Oral Mucous Membrane, Impaired Elimination Activity and Exercise Usual voiding and defecation patterns Self care practices related to bowel and urinary elimination Factors influencing bowel and urinary elimination Altered bowel and urinary elimination Typical activities Physical fitness Activity tolerance Factors contributing to Self Care abilities General Appearance Body System indicators of altered urinary elimination Abdominal examination Anal and rectal examination General appearance Vital signs Cardiovascular Stool Urine Barium Enema Proctosigmoidoscopy Colonoscopy Intravenous pyelogram Cystometrogram Electromyography Bulbocavernous reflex Bowel Incontinence Constipation, Risk for, Actual, and Perceived Diarrhea Urinary Elimination, Readiness for Enhanced Urinary Incontinence Functional Urinary Incontinence Reflex Urinary Incontinence Stress Urinary Incontinence Total Urinary Incontinence Urge Urinary Incontinence, Risk for a Actual Urinary Retention Activity Intolerance, Risk for and Actual Airway Clearance, Ineffective Autonomic Dysreflexia, Risk for and activity problems system Respiratory system Musculoskeletal system Neurologic system Actual Bed Mobility, Impaired Breathing Pattern, Ineffective Cardiac Output, Decreased Disuse Syndrome, Risk for Diversional Activity, Deficient Dysfunctional Ventilatory Weaning Response Falls, Risk for Fatigue Gas Exchange, Impaired Growth and Development, Delayed Development, Risk for Delayed Growth, Risk for Disproportionate Home Maintenance, Impaired Infant Behavior, Disorganized, Risk fo and Actual, and Readiness for Enhanced Organized Peripheral Neurovascular Dysfunction, Risk for Physical Mobility, Impaired Sedentary Lifestyle Self-Care Deficit Feeding Bathing-Hygiene Dressing-Grooming Toileting Spontaneous Ventilation, Impaired Tissue Perfusion, Ineffective (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) Transfer Ability, Impaired Walking, Impaired Wandering Wheelchair Mobility, Impaired Cognition and Perception Information concerning the special senses Symptoms related to neurological dysfunction Pertinent psychological alterations and medications Sleep and Rest Usual sleep pattern Altered sleep pattern General appearance Eye and vision examination Ears and hearing examination Cranial nerve examination Motor function and reflex examination Sensory and cerebellar function examination Examination of cognitive functions Examination of pain Facial appearance Speech patterns Blood test Radiographic test Electromyography EEG Evoked potentials EEG EOG Adaptive Capacity, Intracranial, Decreased Confusion, Acute and Chronic Decisional Conflict (Specify) Environmental Interpretation Syndrome, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced (Specify) Memory, Impaired Pain, Acute and Chronic Sensory Perception, Disturbed (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) Thought Processes, Disturbed Unilateral Neglect Sleep, Readiness for Enhanced Sleep Sleep and bedtime rituals Sleep environment Sleep position Factors that influence sleep Sleep pattern disturbance symptoms The person’s thoughts and feelings about self Factors influencing the development of self concept Threats to self concept A person’s responses to self concept or low self esteem Self Concept Gross motor movements and posture Cognitive functions Sleep patterns EMG Deprivation Respiratory patterns Sleep Pattern, Disturbed analysis ECG Arterial hemoglobin saturation analysis Anxiety Body Image, Disturbed Death Anxiety Fear Helplessness Loneliness, Risk for Personal Identity, Disturbed Powerlessness, Risk for and Actual Self-Concept, Readiness for Enhance Self-Esteem, Chronic Low, Situational Low, and Risk for Situational Low Self-Mutilation, Risk for and Actual Roles and Relationship Role perceptions Role satisfaction/dissatisfac tion Role strain Family composition and structure Family relationships Family decision making process Discipline patterns Relationships with helping professionals Sexuality and Reproductive Function Sexual role and gender identification Sexuality and reproduction knowledge base Sexual performance and satisfaction Signs of role strain Signs of family violence Interaction patterns between client and family members Discipline and decision making process if observable Relationship with nurse Communication patterns Social relationships Interactions with significant others Breast examination Female genital and pelvic examination or Caregiver Role Strain, Risk for and Actual Communication, Readiness for Enhanced Family Process, Interrupted, and Family Process, Dysfunctional: Alcoholism Family Process, Readiness for Enhanc Grieving, Anticipatory Grieving, Dysfunctional, Risk for and Actual Parent, Infant, and Child Attachment, Impaired, Risk for Parenting, Impaired, Risk for and Actual, and Parental Role Conflict Parenting, Readiness for Enhanced Relocation Stress Syndrome, Risk for Actual Role Performance, Ineffective Social Interaction, Impaired Social Isolation Sorrow, Chronic Verbal Communication, Impaired Violence, Self-Directed and OtherDirected, Risk for Rape-Trauma Syndrome: Compound Reaction And Silent Reaction Sexual Dysfunction Sexuality Patterns, Ineffective Stress and Stress Response Values and Beliefs concers Reproductive history Stressors Perception of stressors Coping strategies Spiritual beliefs and rituals and related dietary habits, if any Identification of cultural heritage, including beliefs about health and acceptable treatment of illness Possible perceived conflict between prescribed health male genital examination Rectal examination Use of Assessment tools Social readjustment rating scale Everyday hassles scale The stress audit Nursing observations Body system indicators of stress Behavioral responses Affective responses Assessment of dress, accent , language and presence of religious or spiritual articles Observation of consistency between stated cultural membership and Adjustment, Impaired Community Coping, Ineffective and Readiness for Enhanced Coping, Readiness for Enhanced Family Coping, Compromised and Disabled Family Coping, Readiness for Enhanced Individual Coping, Ineffect Coping, Defensive Denial, Ineffective Post-Trauma Syndrome, Risk for and Actual Suicide, Risk for Impaired Religiosity, Risk for and Actual Spiritual Distress, Risk for and Actual Spiritual Well-Being, Readiness for Enhanced illness regimens and belief Expressed disturbance of belief system behavior Observation of spiritual practices