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    Gordons Functional Health Patterns

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    Kaye Cor
    The document discusses the nursing process of assessment. It involves gathering comprehensive data on a patient's health from multiple sources to understand their overall health status. This includes taking vital signs, a health history, and consulting with the patient and medical records. There are different types of assessments for initial evaluation, focused treatment, monitoring recovery over time, and emergencies. Effective communication and establishing trust are important for obtaining an accurate health history from the patient.

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    Gordons Functional Health Patterns

    Uploaded by

    Kaye Cor
    1K views12 pages
    The document discusses the nursing process of assessment. It involves gathering comprehensive data on a patient's health from multiple sources to understand their overall health status. This includes taking vital signs, a health history, and consulting with the patient and medical records. There are different types of assessments for initial evaluation, focused treatment, monitoring recovery over time, and emergencies. Effective communication and establishing trust are important for obtaining an accurate health history from the patient.

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    The document discusses the nursing process of assessment. It involves gathering comprehensive data on a patient's health from multiple sources to understand their overall health status. This includes taking vital signs, a health history, and consulting with the patient and medical records. There are different types of assessments for initial evaluation, focused treatment, monitoring recovery over time, and emergencies. Effective communication and establishing trust are important for obtaining an accurate health history from the patient.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    1K views12 pages

    Gordons Functional Health Patterns

    Uploaded by

    Kaye Cor
    The document discusses the nursing process of assessment. It involves gathering comprehensive data on a patient's health from multiple sources to understand their overall health status. This includes taking vital signs, a health history, and consulting with the patient and medical records. There are different types of assessments for initial evaluation, focused treatment, monitoring recovery over time, and emergencies. Effective communication and establishing trust are important for obtaining an accurate health history from the patient.

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    ASSESSMENT

     First step in determining


    health status
     Gather information
     Gather all the “puzzle
    pieces” to put together a
    clear picture of health status
     Entire plan is based on data
    collected
     Data needs to be complete
    and accurate, make sense of
    patterns
    Steps in the assessment
    phase of the nursing
    process:
    Establish a data base by
    a. Taking the client’s vital signs
    b. Performing a head to toe
    examination
    c. Taking a complete nursing
    history
    d. Reviewing the client’s chart &
    the literature
    e. Consult with the client, his
    significant others
    4 Types of Assessment
    1. Initial Assessment
     also known as triage, helps to determine the nature of
    the problem and prepares the way for the ensuing
    assessment stages.
     Components may include obtaining a patient's medical
    history or putting him through a physical exam, or
    preparing a psychosocial assessment for a mental
    health patient.
     Other components may include obtaining a patient's
    vital signs and taking subjective statements from the
    patient, as well as double-checking the subjective
    symptoms with the objective signs of the condition.
    4 Types of Assessment
    2. Focused Assessment
     The focused assessment is the stage in which the problem
    is exposed and treated.
     Due to the importance of vital signs and their ever-
    changing nature, they are continuously monitored during
    all parts of the assessment. Depending on the malady,
    initial treatment for pain and long-term treatment for the
    root cause of the malady is administered and monitored.
     Part of the goal of the focused assessment is to diagnose
    and treat the patient in order to stabilize her condition.
    Focused assessments may also include X-rays or other
    types of tests.
    4 Types of Assessment
    3. Time-Lapsed Assessment
     Once treatment has been implemented, a
    time-lapsed assessment must be conducted to
    ensure that the patient is recovering from his
    malady and his condition has stabilized.
     During the time-lapsed assessment, the
    current status of the patient is compared to
    the previous baseline during and prior to
    treatment.
    4 Types of Assessment
    4. Emergency Assessments
     During emergency procedures, a nurse is focused on rapidly
    identifying the root causes of concern for the patient and
    assessing the airway, breathing and circulation (ABCs) of
    the patient.
     Once the ABCs are stabilized, the emergency assessment
    may turn into an initial or focused assessment, depending
    on the situation. If the nurse is not in a health care setting,
    emergency assessments must also include an assessment
    for scene safety so that no other individuals, including the
    nurse himself, are hurt during the rescue and emergency
    response process.

    PROCESS OF DATA
    COLLECTION
     Physiologic: body systems approach that is sometimes
    referred to as a medical model or a head-to-toe
    assessment.
     Functional health patterns: identification of
    behavioural health patterns over time which facilitates
    recognition of functional and dysfunctional patterns.
     Needs models based on Maslow’s hierarchy of needs.
    For a review of Maslow’s hierarchy click on the link
    below.
     Prescribed agency driven formats which are generally
    an adaptation or hybrid of various models.
    TYPES OF DATA
    • S – Subjective -
    What the patient
    tells you;
    Subjective =
    Statements; “I’m
    itching”
    • O – Objective –
    Detectable by an
    observer or can
    be tested; O =
    Objective
    SOURCES OF DATA
     Patient – primary source; best source of
    information
     Family and Significant Others - secondary
    source
     Health Care Team
     Medical Records
    EFFECTIVE
    COMMUNICATION DURING
    INTERVIEW WITH A PATIENT
    Courtesy
    Comfort
    Connection
    confirmation
    PHASES OF INTERVIEW
    Orientation and Setting of the Agenda
    Working Phase
    Terminating phase
    COMPONENTS OF NURSING
    HEALTH HISTORY
    A. Biographical Information
    B. Chief Concern/complaint
    C. History of Present Illness or Health Concerns
    D. Health History (Past)
    E. Family History
    F. Psychosocial History
    G. Spiritual Health
    H. Review of Systems

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