Maj Nusrat Bashir

RN,RM,BScN,MScN

Gordon’s Functional Health Pattern

Nursing process

Alfaro defines the nursing process as ―an

organized, systematic method of giving

individualized nursing care that focuses on

identifying and treating unique responses of

individuals or groups to actual or potential

alterations in health.‖

Nursing process

Basically, the nursing process provides each nurse

a

framework to utilize in working with the patient. The

process begins at the time the patient needs

assistance with

health care, and continues until the patient no

longer needs

assistance to meet health-care maintenance.

The nursing process utilizes the cognitive

(intelligence, critical thinking, and reasoning),

psychomotor (physical), and affective (emotion and

values) skills and abilities a nurse needs to plan

care for a patient.

ROLE IN PLANNING CARE

First, the patient has a right to expect that the

nursing

care received will be complete, safe, and of high

quality. If

planning is not done, then gaps are going to exist in

the care,

impacting patient outcomes.

NURSING PROCESS STEPS

There are five steps, or phases, in the nursing

process: assessment, diagnosis, planning,

implementation, and evaluation.

These steps are not different; rather, they overlap

and build on

each other. To carry out the entire nursing process,

you must

be sure to complete each step accurately and then

build upon

the information in that step to complete the next

one.

ASSESSMENT

The first step, or phase, of the nursing process is

assessment.

During this phase, you are collecting data (factual

information)

from several sources. The collection and

organization

of these data allow you to:

1. Determine the patient’s current health status.

2. Determine the patient’s strengths and problem

areas

(both actual and potential).

3. Prepare for the second step of the process—

diagnosis.

Data Sources and Types The sources for data collection are numerous, but it is essential

to remember that the patient is the primary data source.

No one else can explain as accurately as the patient can the start of the problem, the reason for seeking assistance or the

exact nature of the problem, and the effect of the problem on

the patient.

Other sources include the patient’s family or significant

others; the patient’s admission sheet from the admitting

office; the physician’s history, physical, and orders;

laboratory and x-ray examination results; information from

other caregivers; and current nursing literature.

Assessment data can be further classified as types

of

data. the data types are subjective, objective,

historical, and current.

Subjective data are the facts presented by the

patient

that show his or her perception, understanding,

and interpretation of what is happening. An

example of subjective data is the patient’s

statement, ―The pain begins in my lower back and

runs down my left leg.‖

Objective data are facts that are observable and

measurable by the nurse. These data are gathered

by the

nurse through physical assessment, interviewing,

and observing, and involve the use of the senses of

seeing, hearing,

smelling, and touching. An example of objective

data is the

measurement and recording of vital signs.

Objective data

are also gathered through such diagnostic

examinations as

laboratory tests, x-ray examinations, and other

diagnostic

procedures.

Historical data refer to health events that

happened

prior to this admission or health problem episode.

An example

of historical data is the patient statement, ―The last

time

I was in a hospital was 1996 when I had an

emergency

appendectomy.‖

Current data are facts specifically related to this

admission or health problem episode. An example

of this

type of data is vital signs on admission: T 99.2F, P

78, R 18,

BP 134/86. Please note, that just as there is

overlapping of

the nursing process steps, there is also overlapping

of the

data types. Both historical and current data may be

either

subjective or objective. Historical and current data

assist in

establishing time references and can give an

indication of

the patient’s usual functioning.

First is the overall admission assessment, where

each pattern is assessed through the collection of

objective and subjective data. This assessment

indicates patterns that need further attention, which

requires implementation of the second level of

pattern assessment. The second level of pattern

assessment indicates which nursing diagnoses

within the pattern might be pertinent to this patient,

which leads to the third level of assessment, the

defining characteristics for each individual nursing

diagnosis.

A primary advantage in using this type of

assessment is the validation it gives the nurse that

the resulting nursing diagnosis is the most accurate

diagnosis. Another benefit to using this type of

assessment is that grouping of data is already

accomplished and does not have to be a separate

step.

Data Grouping

Data grouping simply means organizing the

information into

sets or categories that will assist you in identifying

the

patient’s strengths and problem areas. A variety of

organizing

frameworks is available, such as Maslow’s

Hierarchy of

Needs, Roy’s Adaptation Model, Gordon’s

Functional

Health Patterns, and NANDA Taxonomy . Each of

the

nursing theorists (e.g., Roy, Levine, and Orem)

speaks to

assessment within the framework of her theories.

DIAGNOSIS

Diagnosis means reaching a definite conclusion

regarding

the patient’s strengths and human responses. This

diagnostic

process is complex and utilizes aspects of

intelligence, thinking,

and critical thinking.

Nursing Diagnosis

The North American Nursing Diagnosis Association

International (NANDA-I), formerly the National

Conference Group for Classification of Nursing

Diagnosis, has been meeting since 1973 to identify,

develop, and classify nursing diagnoses.

Nursing diagnosis

Nursing diagnosis is a clinical judgment about

individual, family, or community responses to actual

or potential health problems/life processes. Nursing

diagnoses provide the basis for selection of nursing

interventions to achieve outcomes for which the

nurse is accountable.

PLANNING

Planning involves three subsets: setting priorities,

writing

expected outcomes, and establishing target dates.

Planning

sets the stage for writing nursing actions by

establishing

where we are going with our plan of care. Planning

further

assists in the final phase of evaluation by defining

the standard

against which we will measure progress.

Expected Outcomes

Outcomes, goals, and objectives are terms that are

frequently

used interchangeably because all indicate the end

point we will use to measure the effectiveness of

our plan

of care.

Expected outcomes

1. Expected outcomes are clearly stated in terms of

patient

behavior or observable assessment factors.

E X A M P L E

POOR Will increase fluid balance by time of

discharge.

GOOD Will increase oral fluid intake to 1500 mL

per

24 hours by 9/11.

2. Expected outcomes are realistic, achievable,

safe, and

acceptable from the patient’s viewpoint.

E X A M P L E

Mrs. Ahmed is a 28-year-old woman who has delayed

healing of a surgical wound. She is to receive discharge

instructions regarding a high-protein diet. She is a widow

with three children under the age of 10. Her only source

of income is husband pension.

POOR Will eat at least two 8-oz servings of steak

daily. [unrealistic, unachievable, unacceptable,

etc.]

GOOD Will eat at least two servings from the following

list each day:

Lean ground meat, Eggs ,Cheese , beans ,Peanut butter ,Fish ,Chicken

IMPLEMENTATION

Implementation is the action phase of the nursing

process.

Recent literature has introduced the concept of

nursing interventions, which are defined as

treatments based on clinical

judgment and knowledge that a nurse performs to

enhance

patient outcomes.

Nursing action is defined as nursing behavior that

serves to help the patient achieve the expected

outcome.

Nursing actions include both independent and

collaborative

activities.

Independent activities

Independent activities are those actions the nurse

performs, using his or her own optional judgment,

that

require no validation or guidelines from any other

healthcare

practitioner. An example is deciding which

noninvasive

technique to use for pain control or deciding when

to teach

the patient self-care measures.

Collaborative activities

Collaborative activities are those actions that

involve mutual decision making between two or

more health-care practitioners. For example, a

physician and nurse decide which narcotic to use

when meperidine is ineffective in controlling the

patient’s pain, or a physical therapist and nurse

decide on the most beneficial exercise program for

a patient. Implementing a physician’s order and

referral to a dietitian are other common examples of

collaborative actions.

EVALUATION

Evaluation simply means assessing what progress

has been

made toward meeting the expected outcomes; it is

the most

ignored phase of the nursing process. The

evaluation phase

is the feedback and control part of the nursing

process.

Evaluation requires continuation of assessment that

was

begun in the initial assessment phase.

Gordon’s Functional Health Pattern

Marjorie Gordon (1987) proposed functional health

patterns as a guide for establishing a

comprehensive nursing data

base.a method used by nurses in the nursing

process to provide a comprehensive nursing

assessment of the patient.

Taxonomy II of NANDA Nursing Diagnosis

classification is based on Gordon's functional health

patterns.

Gorden's functional health pattern includes 11

categories which is a systematic and standardized

approach to data collection.

These 11 categories make possible a systematic

and standardized approach to data collection, and

enable the nurse to determine the following aspects

of health and human function.

1- Health Perception and Management

2- Nutritional metabolic

3 -Elimination

4- Activity exercise

5 -Sleep rest

6 -Cognitive-perceptual

7 -Self perception/self concept

8 -Role relationship

9 -Sexuality reproductive

10 -Coping-stress tolerance

11 -Value-Belief Pattern

Health Perception and Health

Management

Data collection is focused on the

person's perceived level of health

and well-being, and on practices

for maintaining health.

Health Perception and Health

Management

Habits that may be harmful to health are also

evaluated, including smoking and alcohol or drug

use.

Actual or potential problems r/t

safety & health management

needs for modifications in the home or needs for

continued care in the home.

HEALTH PERCEPTION AND

HEALTH MANAGEMENT PATTERN 1. How has the general health been? How do you rate your own health?

2.What do you consider healthy about you? What are your health goals?

3.What are traditional concepts of health and illness? Beliefs and practices?

4.Do you have routine physical examination? If yes how often?

5.Perform self-breast examination? (female)

6.In the past year how many times have you seen a health care provider? For what reasons?

7.In the past, has it been easy to find ways to follow things nurses/doctors suggest?

8.What safety practices do you follow?

9.Most important things to keep health? You think these things will make a difference to health/ (include family/folk remedies if appropriate).

HEALTH PERCEPTION AND

HEALTH MANAGEMENT PATTERN

10. Personal hygienic practices: Describe how do

you take care of your body? Bath, hand washing,

trimming of fingernails, wearing of slippers, use of

deodorant/cologne, brush teeth, flossing, dental

visits?

11. Substance abuse: Use of cigarette, alcohol,

drugs? Kind, amount, frequency? Reasons? Aware of

effects? Passive smoking?

12. Environmental condition: adequacy of lighting,

and ventilation.

13. Environmental sanitation practices: water supply,

toilet facilities, waste management, food preparation,

presence of vectors, health hazards.

ADMISSION ASSESSMENT

OBJECTIVE

1. Mental Status

2. Vision

3. Hearing

4. Taste

5. Touch

6. Smell

7. General appearance

SUBJECTIVE 1- How would you describe your usual health status?

Good__ Fair__ Poor__

2. Are you satisfied with your usual health status?

Yes__ No__ Source of dissatisfaction: ____________________________

3. Tobacco use? No__ Yes__ Number of packs per day? _______________

4. Alcohol use? No__ Yes__ How much and what kind? ________________

5. Street drug use? No__ Yes__ What and how much? _________________

6. Any history of chronic disease? No__ Yes__ Describe: _______________

___________________________________________________________

Nutrition and Metabolism

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.

B. Nutrition/ Metabolism

Prior:

Eats more of fruits and vegetables

Eats her meals 3x a day with snack in between

Can drink up to 1.5L of water or 4-5 glasses a day

Drinks coffee in the morning and in the afternoon

Claimed to be allergic on shrimps and claimed to

have good appetite

During:

Weight: 41 kg

Height: 4 ft and 10 in

Normal Body Mass Index; BMI = 18.89 kg/m2

Average Body Temperature is 360 C

• Able to fast in preparation for surgical procedure

• On NPO

BEFORE

HOSPITALIZATION

DURING

HOSPITALIZATION

ANALYSIS

Patient usually eats

vegetables, meat and fish

alternately. She’s also fond of

eating native delicacies like

potato and meat. She drinks

an average of 6-8 glasses of

water per day, a cup of tea

with bread at breakfast and 2

glasses of juice during snack

time. She has difficulty in

chewing and swallowing.

Patient were placed on an

NPO status.

Foods and fluids are restricted

6-8 hours prior to surgery.

An individuals health status

greatly affects eating habit

and nutritional status.

(Fundamentals of Nursing by Kozier, pp 1178)

Sleep and Rest

Assessment is focused on the person's sleep, rest,

and relaxation practices. Dysfunctional sleep

patterns,

fatigue, and responses to sleep deprivation may be

identified.

The pattern is based on a 24-hour day and looks

specifically at how an individual rates or judges the

adequacy of his or her sleep, rest, and relaxation in

terms of both quantity and quality. The pattern also

looks at the patient’s energy level in relation to the

amount of sleep, rest, and relaxation described by

the patient as well as any sleep aids the patient

uses.

PATTERN ASSESSMENT 1. Does the patient report a problem falling asleep?

a. Yes (Disturbed Sleep Pattern)

b. No (Readiness for Enhanced Sleep)

2. Does the patient report interrupted sleep?

a. Yes (Disturbed Sleep Pattern)

b. No (Readiness for Enhanced Sleep)

3. Does the patient report long periods without sleep,

resulting in daytime malaise?

a. Yes (Sleep Deprivation Pattern)

b. No (Readiness for Enhanced Sleep)

A person at rest feels mentally relaxed, free from

anxiety,

and physically calm. Rest need not imply inactivity,

and

inactivity does not necessarily afford rest. Rest is a

reduction

in bodily work that results in the person’s feeling

refreshed

and with a sense of readiness to perform activities

of daily

living (ADLs).

Sleep Sleep is a state of rest that occurs for sustained periods

at a deeper level of consciousness. The reduced consciousness

during sleep provides time for essential repair

and recovery of body systems. Sleep is as essential to

our bodies as good nutrition and exercise. Sleep is considered

one of the major components to our health, performance,

safety, and quality of life.

A person who sleeps

has temporarily reduced interaction with the environment.

Sleep restores a person’s energy and sense of well-being and

lets him or her function in a safe, efficient, and effective

manner.

Sleep patterns and characteristics vary and change

over the life cycle. A person’s age, general health

status, culture, and emotional well-being dictate the

amount of sleep

he or she requires. On the whole, older persons

require less

sleep, whereas young infants require the most

sleep. As the

nurse assesses the patient’s needs for sleep and

rest, he or

she makes every effort to individualize the care

according to

this sleep–rest cycle.

Stages 1 through 4 are known as non–rapid eye movement

(NREM) sleep. NREM sleep accounts for 75 percent of an 8-

hounight’s sleep.

After falling asleep, a person passes through a series

of stages that afford rest and recuperation physically, mentally,

and emotionally. In stage 1, the individual is in a

relaxed, dreamy state, and is aware of his or her surroundings.

In stages 2 and 3, there is progression to deeper levels

of sleep in which the individual becomes unaware of his or

her surroundings but wakens easily.

In stage 4, there is profound sleep characterized by little body movement and difficult arousal. Stage 4 restores and allows the body to rest.

Stage 5 is called rapid eye movement

(REM) sleep. REM sleep accounts for 25 percent of

an

8-hour night’s sleep and is the stage in which

dreaming

occurs. Other characteristics of REM sleep are

irregular

pulse, variable blood pressure, muscular twitching,

profound

muscular relaxation, and an increase in gastric

secretions.

2,3 After REM sleep, the individual progresses back

through stages 1, 2, and 3 again.

DEVELOPMENTAL

CONSIDERATIONS In general, as age increases, the amount of sleep per night

decreases. The length of each sleep cycle—active (REM)

and quiet (NREM)—changes with age.

Infant: Awake 7 hours; NREM sleep, 8.5 hours; REM

sleep, 8.5 hours

Age 1: Awake 13 hours; NREM sleep, 7 hours; REM

sleep, 4 hours

Age 10: Awake 15 hours; NREM sleep, 6 hours; REM

sleep, 3 hours

Age 20: Awake 17 hours; NREM sleep, 5 hours; REM

sleep, 2 hours

Age 75: Awake 17 hours; NREM sleep, 6 hours; REM

sleep, 1 hour

SLEEP DEPRIVATION Prolonged periods of time without sleep (sustained, natural,

periodic suspension of relative consciousness).

DEFINING CHARACTERISTICS

1. Daytime drowsiness

2. Decreased ability to function

3. Malaise

4. Tiredness

5. Lethargy

6. Restlessness

7. Irritability

8. Heightened sensitivity to pain

9. Slowed reaction

BEFORE

HOSPITALIZATION

DURING

HOSPITALIZATION

ANALYSIS

Patient gets an average of 6-7 hours of sleep daily with 1-2 hour nap in the afternoon. Patient states of no difficulty of falling asleep.

Patient can’t sleep when the

lights are on; she even wakes

up once in a while due to the

noise at the hallway.

Environmental factors can either enhance or impair sleep. Lighting, temperature, ventilation and noise level can all interact to sleep

process.

(Delaune, Fundamentals of Nursing, p. 1119)

Sleep/Rest

Prior:

Can sleep for 7-9 hours per night

Straight hours of sleep

Her earliest time in going to sleep is at 9:30 PM

Latest time in waking up is at 6:30 AM

She sometimes takes a nap at noon for about 1-3 hours

No difficulties in going to sleep

Doesn’t uses any medication to promote sleep

During:

Sleeps at 8:00 PM

Wakes up at 6:00 AM

Can consume 10 hours of sleep

Sometimes, she is distracted and sleep is interrupted due to pain, administration of medication and visitors

With rest intervals, usually naps for 4 hours