Gordon’s
Functional
Health Pattern
Health
Perception
and Health
Management
Nursing History
Subjective
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Nutrition
and
Metabolism
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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
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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
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
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
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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
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
system
Oral Cavity
Abdomen
Thyroid gland
Lymphatic system
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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
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Activity and
Exercise
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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
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Typical activities
Physical fitness
Activity tolerance
Factors contributing to
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Self Care abilities
General
Appearance
Body
System
indicators
of
altered
urinary
elimination
Abdominal
examination
Anal and rectal
examination
General
appearance
Vital signs
Cardiovascular
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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
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Information concerning
the special senses
Symptoms related to
neurological
dysfunction
Pertinent psychological
alterations
and
medications
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Sleep and
Rest
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Usual sleep pattern
Altered sleep pattern
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
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
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Blood test
Radiographic test
Electromyography
EEG
Evoked potentials

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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

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
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
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Role perceptions
Role
satisfaction/dissatisfac
tion
Role strain
Family composition and
structure
Family relationships
Family decision making
process
Discipline patterns
Relationships
with
helping professionals
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Sexuality
and
Reproductive
Function
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Sexual role and gender
identification
Sexuality
and
reproduction
knowledge base
Sexual
performance
and
satisfaction
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
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
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Stressors
Perception of stressors
Coping strategies
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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