Gordon s Functional Health Pattern. Maj Nusrat Bashir RN,RM,BScN,MScN

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1 Gordon s Functional Health Pattern Maj Nusrat Bashir RN,RM,BScN,MScN

2 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.

3 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

4 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.

5 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.

6 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

7 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

8 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.

9 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

10 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.

11 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

12 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.

13 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.

14 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

15 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.

16 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.

17 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.

18 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.

19 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.

20 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/ Expected outcomes are realistic, achievable, safe, and acceptable from the patient s viewpoint.

21 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

22 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

23 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.

24 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.

25 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.

26 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.

27 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.

28 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

29 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.

30 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.

31 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

32 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.

33 ADMISSION ASSESSMENT OBJECTIVE 1. Mental Status 2. Vision 3. Hearing 4. Taste 5. Touch 6. Smell 7. General appearance

34 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:

35 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.

36 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

37 During: Weight: 41 kg Height: 4 ft and 10 in Normal Body Mass Index; BMI = kg/m 2 Average Body Temperature is 36 0 C Able to fast in preparation for surgical procedure On NPO

38 BEFORE HOSPITALIZATION 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. DURING HOSPITALIZATION Patient were placed on an NPO status. ANALYSIS 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)

39 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.

40 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.

41 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)

42 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).

43 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 wellbeing and

44 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

45 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

46 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

47 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

48 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

49 BEFORE HOSPITALIZATION 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. DURING HOSPITALIZATION Patient can t sleep when the lights are on; she even wakes up once in a while due to the noise at the hallway. ANALYSIS 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)

50 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