Patients’ information:
Pt 1: Primary Diagnosis (PD): Non–Non-ST-Elevation Myocardial Infarction (NSTEMI)
Comorbidities: AKI, Asthma, COPD, seizure, Depression, Anxiety, CAD, Caffeine abuse, and hypercholesterolemia
Pt 2: Primary Diagnosis (PD): Suspected conversion disorder
Comorbidities: Bilateral lower extremity weakness, PTSD, and ADH
Please, for the Gordon assessment, use patient 1, who is a male in a mental health unit. “Please use U.S.A. base sources, and make it detail.
You can also use these books.
Huether, S. E., McCance, K. L., & Brashers, V. L. (2020a).
Understanding pathophysiology (7th ed.). Elsevier.
Ignatavicius, D. D., Rebar, C. R., & Heimgartner, N. M. (2024).
Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care (11th ed.). Elsevier.
Treas, L. S., Barnett, K. L., Smith, M. H., & Wilkinson, J. M. (2024a).
Davis Advantage for Wilkinson’s fundamentals of nursing: Theory, concepts, and applications (5th ed., Vol. 1). F.A. Davis Company.
Varcarolis, E. M., & Halter, M. J. (2022).
Varcarolis’ foundations of Psychiatric Mental Health Nursing: A clinical approach. Elsevier.
Please, from here below is the assignment
Required to meet SLO
Clinical Packet must be completed for all patients cared for during the clinical day.
1. Describe how you prioritized care for the patient with consideration to patient/family requests.
2. Explain how you valued the ideas of the patient/family in the development of your plan of care.
3. Give one example of how you empowered the health care team through recognition of contributions to safe quality care.
4. Diversity: Create a care plan on ONE of your patients, that meets the needs of your patient using data from the Gordons assessment and your patient assessment.
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GORDON’S FUNCTIONAL ASSESSMENT Document all data gathered from the patient Use the document below as a resource |
NURSING CARE YOU PROVIDED Document all the interventions you performed |
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Health Perception/Health Management: |
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Nutritional-Metabolic: |
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Elimination: |
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Activity-Exercise: |
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Cognitive-Perceptual: |
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Sleep-Rest: |
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Self-Perception/Self-Concept: |
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Role-Relationship: |
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Sexuality-Reproductive: |
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Coping/Stress Tolerance: |
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Value-Belief: |
Nursing Plan of Care
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Recognize Cues: Client problems (list both subjective and objective cues) |
Analyze Data & Prioritize Hypotheses: Write a complete nursing diagnosis statement including R/T factor, secondary to and AEB (as appropriate) |
Generate Solutions: Write a client-centered SMART goal |
Take Actions: List at least 5 nursing interventions that you completed this Clinical day. Then list what team member could perform each task (RN, LPN, CNA, etc.) |
Evaluate Outcomes: Write an evaluation statement (example: the RN will evaluate….), then include real client data to determine if the goal was met or not met. |
image1.emf
Microsoft_Word_97_-_2003_Document.doc
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Organizing Data According to Gordon’s 11 Functional Health Patterns |
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Functional Health Pattern |
Pattern Describes |
Examples |
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Health Perception/ Health Management |
Client’s perceived pattern of health and well-being and how health is managed. |
Compliance with medication regimen, use of health-promotion activities such as regular exercise, annual check-ups. |
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Nutritional-Metabolic |
Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply. |
Condition of skin, teeth, hair, nails, mucous membranes; height and weight. |
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Elimination |
Patterns of excretory function (bowel, bladder, and skin). Includes client’s perception of normal” function. |
Frequency of bowel movements, voiding pattern, pain on urination, appearance of urine and stool. |
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Activity – Exercise |
Patterns of exercise, activity, leisure, and recreation. |
Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and activities of daily living. |
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Cognitive-Perceptual |
Sensory-perceptual and cognitive patterns. |
Vision, hearing, taste, touch, smell, pain perception and management; cognitive functions such as language, memory, and decision making. |
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Sleep-Rest |
Patterns of sleep, rest, and relaxation. |
Client’s perception of quality and quantity of sleep and energy, sleep aids, routines client uses. |
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Self-Perception/ Self Concept |
Client’s self-concept pattern and perceptions of self. |
Body comfort, body image, feeling state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone. |
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Role-Relationship |
Client’s pattern of role engagements and relationships. |
Perception of current major roles sand responsibilities (e.g., father, husband, salesman); satisfaction with family, work, or social relationships. |
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Sexuality-Reproductive |
Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern. |
Number and histories of pregnancy and childbirth; difficulties with sexual functioning; satisfaction with sexual relationship. |
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Coping / Stress Tolerance |
General coping pattern and effective of the pattern in terms of stress tolerance. |
Client’s usual manner of handling stress, available support systems, perceived ability to control or manage situations. |
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Value – Belief |
Patterns of values, beliefs (including spiritual), and goals that guide client’s choices or decisions. |
Religious affiliation, what client perceives as important in life, value-belief conflicts related to health, special religious practices. |
Nursing\Nursing Forms\Gordon’s 11 Functional Health Patterns
D Ladd 7-16-02
