Gordon’s Functional Health Patterns Assessment, Nursing Process & NANDA Approved
Prepared by Gebremichael Reta Mengistu (BSc.)
Nursing Diagnoses 2015- 2017
By Gebremichael Reta Mengistu
June 2018 Arba Minch, Ethiopia
Prepared by Gebremichael Reta Mengistu (BSc.)
Antenatal Care History and Physical Examination History 1. Identification Name Religion Age Occupation Sex Educational Status Address Date of visit Medical Registration Marital status Number OPD, Ward, Bed or Ethnicity Unit 2. Source of referral: Self, Health center, Health post/HEWs, etc. 3. Source of history: Herself, husband, etc. 4. Mode of arrival: Public transport, Ambulance 5. Pervious history of visit/admission with case: If Yes with case/No 6. Chief complaints: Patients may have come for routine antenatal care follow up or may come with one or more specific complaints. Note the duration of each complaint. 7. History of present pregnancy: Get information on the following points: Gravidity: all forms of pregnancy whether it is term, live births, still birth, abortion, ectopic pregnancy or molar pregnancy. Parity: fetus delivered after 28 weeks of gestation for Ethiopia and United kingdom and greater than or equal to 20 weeks – according to WHO Abortion: Loss of pregnancy before 28 weeks of gestation for Ethiopia and UK and less than 20 weeks according to WHO Last normal menstrual period (LNMP) Expected date of delivery (EDD)- which could be calculated by: 1- Ethiopian calendars LNMP+ 9 months +10 days if pagume is not passed LNMP+ 9 months + 5/4 days if pagume is passed 2- Naegale’s rule (using European calendar) LNMP- 3 months + 7 days Gestational age: Calculate gestational age in completed weeks and days by using LNMP. Date of quickening: the first time the mother felt fetal movement In primigravida it is around 18-20 weeks and in multigravida at 16-18 weeks of gestational age. Used to date pregnancy if LNMP is unknown Presence of ANC elsewhere, place and number of visits Elaboration of chief complaints Sign and symptoms of pregnancy(if early)
Prepared by Gebremichael Reta Mengistu (BSc.)
Danger symptoms of pregnancy: vaginal bleeding, severe headache, blurring of vision, epigastric or severe abdominal pain, profuse vaginal discharge, absence or reduction of fetal movement, fever and persistent vomiting.
Prepared by Gebremichael Reta Mengistu (BSc.)
Pregnancy facts: planned or unplanned pregnancy, wanted or unwanted, supported or unsupported Any client concern or complaints Ask positive and negative statement according to the patient complaints 8. Past obstetric history The following should be asked for all previous pregnancies in chronologic order: Date, month and year of gestation for example first delivery in June 2017 Length of gestation - abortion (< 28 weeks), preterm (<37 completed weeks), term (>37 completed to 42 completed weeks), post term (greater than 42 completed weeks) Onset of labor (spontaneous or induced) Fetal presentation Duration of labor Mode of delivery (spontaneous vaginal, instrumental, caesarian section, destructive delivery) Place of delivery Fetal outcome (alive or dead, sex of the newborn, weight of the newborn, malformations, current condition) Complications which can recur or have an impact on current pregnancy Complications/health problems during previous pregnancy: Pre-term labor, APH, pre-eclampsia, PROM, uterine rupture, PPH, infections, early neonatal deaths, etc. 9. Past gynecology history Family planning methods - use , type , duration and side effects Sexual history- assess risk of sexually transmitted infections and HIV/AIDS Gynecology operations- Female genital mutilation , laparatomy, dilatation and curettage ,evacuation and curettage, manual vacuum aspiration Menstrual history ( age of menarche, interval of period 21-36 days, amount of flow 10 –80 ml, duration of flow 1-8 days, normally dark red and non-clotting). 10. Past medical and surgical history History of diabetes mellitus, hypertension, hypo or hyper thyroidism which may the affect pregnancy or get aggravated by pregnancy Blood transfusion important in hemolytic disease of new born Drugs risk of teratogenicity or allergic reactions Maternal infection – TORCH Syndrome. 11. Personal, family and social history Childhood development Educational status Habits like alcohol , smoking and elicit drugs Occupation- exposure to radiation, anesthesia- halothane, chemical factory and others Income- low socio-economic status associated with obstetric problems like preeclampsia ,preterm labor Family history- diabetes mellitus, hypertension, multiple pregnancy, genetic disorders
Prepared by Gebremichael Reta Mengistu (BSc.)
12. Review of Systems/Functional inquiry General condition HEENT Check all systems Physical examination 1. General appearance 2. Vital signs and anthropometric measurements Blood pressure: positions include left lateral with 300 tilt to the left to avoid supine hypotensive syndrome or sitting position in ambulatory patient. Pulse rate: increases 10-15 beats/minute in pregnancy Respiratory rate: increases 1-4 breath /minute in pregnancy Temperature Weight: pregnancy and pre-pregnancy weight. Increment of more than 1kg/week is abnormal Height: less than 150 centimeters could be constitutional but may be a risk factor. Strikingly short for every society is risk factor. 3. HEENT Emphasis on conjunctiva, sclera, teeth and buccal mucus membrane to see pallor, jaundice, edema, mucosal congestion and dental carries. 4. Lympho glandular System Thyroid gland for hyper or hypo thyroidism signs. Breast for nipple refraction, pigmentation, lumps, discharge, colour change 5. Respiratory and cardiovascular system Steps in examination are essentially same as non-pregnant patient. Note that the following are normal findings in pregnancy. Decreased diaphragmatic excursion due to diaphragm elevation by gravid uterus PMI deviation to left is possible in pregnancy S3 gallop may be heard Functional systolic murmur may be heard 6. Abdomen i. Inspection( 5s)-size, shape, scar, striae and skin Linea nigra- midline hyper pigmentation due to melanocyte stimulating hormone Striae gravidarum – purplish in new striae and white in old striae. In both cases is due to distension, which causes stretching. Umbilicus may be inverted, flat or everted Surgical or non-surgical scar Distended veins, flank fullness, fetal movement ii. Palpation Superficial palpation – checks for rigidity, tenderness, superficial mass and characterize it, abdominal wall defects. Deep palpation – palpate for mass, organomegally and characterize the mass Obstetric palpation or Leopold’s maneuver A. The first Leopold maneuver or fundal palpation Prepared by Gebremichael Reta Mengistu (BSc.) 3
Prepared by Gebremichael Reta Mengistu (BSc.)
I. Fundal height measurement: first correct for asymmetry before measurement. Then use one of the following methods: 1- Finger method – one finger above umbilicus is equal to two weeks and below umbilicus one finger is equal to one week. Uterus felt at symphysis corresponds to 12 weeks. At the umbilicus it is 20 weeks and at xiphysternum it is 38 weeks. 2- Tape measurement: symphysis to funded height in centimeter with tape meter between 18-34 weeks is accurate to within two weeks of actual gestational age. II. Determine what occupies the fundus. If soft, irregular bulky mass is found it is the breech. If hard round ballotable mass is found, it is the head. B. The second Leopold maneuver or lateral palpation I. Determines the lie of the fetus which could be longitudinal, transverse or oblique lie. . II.In longitudinal lie it determines on which side of the abdomen is the fetal back. The back of the fetus is linear, rigid and smooth in outline. The extremities are felt as small irregular and bulky masses. The fetal heart beat is best heard on back side. C.The third Leopold maneuver or Pelvic palpation I. Determines what part of the fetus occupies the lower uterine pole which is also called the presentation. The possibilities are the head (cephalic presentation), the breech (breech presentation), and the shoulder (shoulder presentation). II. In cephalic presentations it determines the descent by using rule of fifth which measures the distance between upper border of the symphysis to anterior shoulder. 5/5 is floating head, 4/5 is fixed head, 2/5 denotes engaged head. III. In conjunction of the findings of the second maneuver it determines the attitude of the fetus (relation of head to the trunk). In extended attitude the cephalic prominence is on the same side of the back. In flexed attitude the cephalic prominence is on the opposite side of the back. In military attitude the cephalic prominence is felt on both sides at the same level. D. The fourth Leopold maneuver or Pawlik grip It is the only maneuver that is done with one hand. It assesses presentation of the fetus. iii. Percussion Shifting and flank dullness Fluid thrill iv. Auscultation
Prepared by Gebremichael Reta Mengistu (BSc.)
Fetal heart beat is first heard in the back side at16-18 weeks in multiparas and 18-20 weeks in primigravida. In complete breech it is heard above umbilicus. In cephalic presentations it is below umbilicus. In occipito posterior it is heard in the flanks. . 7. Genitourinary system Costovertebral and suprapubic tenderness Pelvic examination- to be done two times in pregnancy except in cases of complications and if labor is suspected
Prepared by Gebremichael Reta Mengistu (BSc.)
I. First trimester (early) – To diagnose pregnancy, for dating of the pregnancy by measuring uterine size and to diagnose pelvic problems II. Late in pregnancy greater than 37 weeks A. To diagnose contracted pelvis (refer chapter on) B. To assess Bishop Score (refer to chapter on induction) III. In labor assess cervical dilatation and effacement, status of the membranes and color of liquor, presenting part, station of presenting part and position, molding, caput, clinical pelvimetry. 8. Integumentary system Hyper pigmentation on breast, lower and mid line abdomen genitalia are normally seen in pregnancy Vascular Changes- Spider angiomata and palmar erythema 9. Extremities Check for edema, dilated vessels and calf tenderness. Dependent edema (pretibial and pedal), seen in 80% of normal pregnancies. Pathological edema (non -dependent) involves the face, fingers or the whole body. 10. Central nervous system As non-pregnant Laboratory Examination: Hct/Hgb Blood group and Rh U/A for: proteinuria, glucose, ketone, infection Serology examination for syphilis, HBSAg PTIC Other investigation as indicated
Prepared by Gebremichael Reta Mengistu (BSc.)
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Prepared by Gebremichael Reta Mengistu (BSc.)
Obstetrics History & Physical Examination History 1. Identification Name Religion Age Occupation Sex Educational Status Address Date of admission Medical Registration Marital status Number Ethnicity Ward and bed number 2. Source of Referral: Self, Health center, Health post, etc. 3. Source of History: Herself, husband, etc. 4. Mode of Arrival: Public transport, Ambulance 5. Pervious History of Admission with Case: If Yes with case/No 6. Chief complaints: Patients may have come for routine antenatal care follow up or may come with one or more specific complaints. Note the duration of each complaint. 7. History of present pregnancy: Get information on the following points Gravidity: all forms of pregnancy whether it is term, live births, still birth, abortion, ectopic pregnancy or molar pregnancy. Parity: fetus delivered after 28 weeks of gestation for Ethiopia and United kingdom and greater than or equal to 20 weeks – according to WHO Abortion Last normal menstrual period (LNMP) Expected date of delivery (EDD) which could be calculated by 1. Naegale’s rule (using European calendar) LNMP- 3 months + 7 days 2. Ethiopian calendars LNMP+ 9 months +10 days if pagume is not passed LNMP+ 9 months + 5/4 if pagume is passed Calculate gestational age in completed weeks and days by using LNMP If the mother doesn’t know her LNMP use developmental milestones for pregnancy: a. Date of quickening: the first time the mother felt fetal movement - In primigravida it is around 18-20 weeks and in multigravida at 16-18 weeks of gestational age. +20wk b. The date when first HCG test positive+36wk c. Ultrasound result up to 20 week +19wk Prepared by Gebremichael Reta Mengistu (BSc.) d. Doppler ultrasound of FHR at 10 wk+29wk e. Fetal heart rate from 18-20wk up to 36 wk Presence of antenatal care elsewhere: Place and Number of visits. Elaboration of chief complaints
Prepared by Gebremichael Reta Mengistu (BSc.)
Danger symptoms of pregnancy: vaginal bleeding, severe headache, blurring of vision, epigastric or severe abdominal pain, profuse vaginal discharge, absence or reduction of fetal movement, fever, persistent vomiting. Common complaints in pregnancy (like nausea, vomiting, weakness etc. Pregnancy - unplanned , unwanted and unsupported Ask positive and negative statement according to the patient complaints 8. Past obstetric history The following should be asked for all previous pregnancies in chronologic order Date, month and year of gestation for example first delivery in July 2017 Length of gestation - abortion (< 28 weeks), preterm (<37 completed weeks), term (>37 completed to 42 completed weeks), post term (greater than 42 completed weeks) Significant antenatal medical problems like hypertension, ante partum hemorrhage, diabetes Onset of labor (spontaneous or induced) Fetal presentation Duration of labor Mode of delivery (spontaneous vaginal, instrumental, caesarian section, destructive delivery) Place of delivery Fetal outcome (alive or dead, sex of the newborn, weight of the newborn, malformations, current condition) Post- partum complications: postpartum hemorrhage, postpartum psychosis, etc. 9. Past gynecology history Family planning methods - use , type , duration and side effects Sexual history- assess risk of sexually transmitted infections and HIV/AIDS Gynecology operations- Female genital mutilation, laparotomy, dilatation and curettage ,evacuation and curettage, manual vacuum aspiration Menstrual history ( age of menarche, interval of period 21-36 days, amount of flow 10 –80 ml, duration of flow 1-8 days, normally dark red and non-clotting). 10. Past medical and surgical history History of diabetes mellitus, hypertension, hypo or hyper thyroidism which may the affect pregnancy or get aggravated by pregnancy Blood transfusion important in hemolytic disease of new born Drugs risk of teratogenicity or allergic reactions Maternal infection – TORCH Syndrome. 11. Personal, family and social history Childhood development Educational status Habits like alcohol , smoking and elicit drugs Occupation- exposure to radiation, anesthesia- halothane, chemical factory and others Income- low socio-economic status associated with obstetric problems like preeclampsia ,preterm labor
Prepared by Gebremichael Reta Mengistu (BSc.)
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Prepared by Gebremichael Reta Mengistu (BSc.)
Family history- diabetes mellitus, hypertension, multiple pregnancy, genetic disorders 12. Review of Systems/Functional inquiry General condition HEENT Check all systems Physical examination Examination must be done in a private room in the presence of a chaperone. Proper explanation must be offered to the patient before during and after the examination. Bladder should be emptied and the patient properly positioned on the couch. Warm hands and instruments must be used. Adequate light, appropriate gloves and swabs should be prepared. Always keep eye contact throughout the examination. 1. General appearance 2. Vital signs and anthropometric measurements Blood pressure: positions include left lateral with 300 tilt to the left to avoid supine hypotensive syndrome or sitting position in ambulatory patient. Pulse rate: increases 10-15 beats/minute in pregnancy Respiratory rate: increases 1-4 breath /minute in pregnancy Temperature Weight: pregnancy and pre-pregnancy weight. Increment of more than 1kg/week is abnormal Height: less than 150 centimeters could be constitutional but may be a risk factor. Strikingly short for every society is risk factor. 3. HEENT Emphasis on conjunctiva, sclera, teeth and buccal mucus membrane to see pallor, jaundice, edema, mucosal congestion and dental carries. 4. Lymphoglandular System Thyroid gland for hyper or hypo thyroidism signs. Breast for nipple refraction, pigmentation, lumps, discharge, colour change 5. Respiratory and cardiovascular system Steps in examination are essentially same as non-pregnant patient. Note that the following are normal findings in pregnancy. Decreased diaphragmatic excursion due to diaphragm elevation by gravid uterus PMI deviation to left is possible in pregnancy S3 gallop may be heard Functional systolic murmur may be heard 6. Abdomen A. Inspection (5s) Linea nigra- midline hyper pigmentation due to melanocyte stimulating hormone
Prepared by Gebremichael Reta Mengistu (BSc.)
Striae gravidarum – purplish in new striae and white in old striae. In both cases is due to distension, which causes stretching. Umbilicus may be inverted, flat or everted Surgical or non-surgical scar
Prepared by Gebremichael Reta Mengistu (BSc.)
Distended veins, flank fullness, fetal movement B. Palpation Superficial palpation – checks for rigidity, tenderness, superficial mass and characterize it, abdominal wall defects. Deep palpation – palpate for mass, organomegally and characterize the mass Obstetric palpation or Leopold’s maneuver a. The first Leopold maneuver or fundal palpation I. Fundal height measurement: first correct for asymmetry before measurement. Then use one of the following methods: 3- Finger method – one finger above umbilicus is equal to two weeks and below umbilicus one finger is equal to one week. Uterus felt at symphysis corresponds to 12 weeks. At the umbilicus it is 20 weeks and at xiphysternum it is 38 weeks. 4- Tape measurement: symphysis to funded height in centimeter with tape meter between 18-34 weeks is accurate to within two weeks of actual gestational age. II. Determine what occupies the fundus. If soft, irregular bulky mass is found it is the breech. If hard round ballotable mass is found, it is the head. b. The second Leopold maneuver or lateral palpation I. Determines the lie of the fetus which could be longitudinal, transverse or oblique lie. . II.In longitudinal lie it determines on which side of the abdomen is the fetal back. The back of the fetus is linear, rigid and smooth in outline. The extremities are felt as small irregular and bulky masses. The fetal heart beat is best heard on back side. c.The third Leopold maneuver or Pelvic palpation I. Determines what part of the fetus occupies the lower uterine pole which is also called the presentation. The possibilities are the head (cephalic presentation), the breech (breech presentation), and the shoulder (shoulder presentation). II. In cephalic presentations it determines the descent by using rule of fifth which measures the distance between upper border of the symphysis to anterior shoulder. 5/5 is floating head, 4/5 is fixed head, 2/5 denotes engaged head. III. In conjunction of the findings of the second maneuver it determines the attitude of the fetus (relation of head to the trunk). In extended attitude the cephalic prominence is on the same side of the back. In flexed attitude the cephalic prominence is on the opposite side of the back. In military attitude the cephalic prominence is felt on both sides at the same level. Prepared by Gebremichael Reta Mengistu (BSc.) d.The fourth Leopold maneuver or Pawlik grip It is the only maneuver that is done with one hand. It assesses presentation of the fetus. C. Percussion Shifting and flank dullness Fluid thrill D. Auscultation
Prepared by Gebremichael Reta Mengistu (BSc.)
Fetal heart beat is first heard in the back side at16-18 weeks in multiparas and 18-20 weeks in primigravida. In complete breech it is heard above umbilicus. In cephalic presentations it is below umbilicus .IN occipito posterior it is heard in the flanks. . 7. Genitourinary system Costovertebral and suprapubic tenderness Pelvic examination- to be done two times in pregnancy except in cases of complications and if labor is suspected I. First trimester (early) – To diagnose pregnancy, for dating of the pregnancy by measuring uterine size and to diagnose pelvic problems II. Late in pregnancy greater than 37 weeks A. To diagnose contracted pelvis (refer chapter on) - B. To assess Bishop score- (refer to chapter on induction) III. In labor assess cervical dilatation and effacement, status of the membranes and color of liquor, presenting part, station of presenting part and position, molding, caput, clinical pelvimetry. 8. Intgumentary system Hyper pigmentation on breast, lower and mid line abdomen genitalia are normally seen in pregnancy Vascular Changes- Spider angiomata and palmar erythema 9. Extremities Check for edema, dilated vessels and calf tenderness. Dependent edema (pretibial and pedal), seen in 80% of normal pregnancies. Pathological edema (non-dependent) involves the face, fingers or the whole body. 10. Central nervous system As non- pregnant Laboratory Investigation
Prepared by Gebremichael Reta Mengistu (BSc.)
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Prepared by Gebremichael Reta Mengistu (BSc.)
Gynecology History and Physical Examination History 1. Identification As obstetric history 2. Source of Referral: Self, Health center, Health post, etc. 3. Source of History: Herself, husband 4. Mode of Arrival: Public transport, Ambulance 5. Pervious History of Admission with Case: If Yes with case/No 6. Chief complaints: Patient comes with the following gynecologic complaints. The common complaints are cessation of menses, vaginal bleeding and discharge, lower abdominal pain or deep pelvic pain, pain during intercourse (dysparunia), pain during menstruation (dysmenorrhea), protruding mass out of the introitus, genital ulcer, urinary incontinence and others. 7. History of present illness Gravidity, parity and abortion Detail of each complaint (localization, duration, date and time of onset, aggravating and relieving factors, sequence of symptoms, evolution with time, effect on life style, relation to menstrual cycle and others) LMP should be included details of menstrual history if pertinent to the complaints Negative and positive statements pertinent to the presenting complaint Treatment received 8. Menstrual history Age of menarche Interval between period Duration of flow Amount & character of flow Dysmenorrhea , premenstrual symptoms Age of menopause 9. Past gynecologic history As obstetric history 10. Past obstetric history As obstetric history 11. Past medical and surgical history As obstetric history 12. Personal social family, history As obstetric history 13. Review of systems/Functional inquiry As obstetrics history
Prepared by Gebremichael Reta Mengistu (BSc.)
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Prepared by Gebremichael Reta Mengistu (BSc.)
Physical examination Preparation for examination is similar to obstetric examination. In addition slides, applicator, test tube, gloves, speculum and fixative are needed. 1. General appearance 2. Vital signs Blood pressure, pulse rate, respiratory rate, temperature 3. HEENT As non-pregnant 4. Lymphoglandular system Lymph nodes- to see for metastatic cancer check mainly supraclavicular and axillary nodes. Thyroid gland- hypo and hyper thyroidism affects reproductive function Breast examination- inspection and palpation 5. Chest and cardiovascular system As non-pregnant 6. Abdomen As non-pregnant (Inspection, auscultation, palpation and percussion) 7. Genitourinary system Costovertebral and suprapubic tenderness Pelvic examination I. Examination of external genitalia: Pubic hair- diamond shaped in male and inverted triangle in female.
II. Speculum Examination
Vagina- note color (normally pink), vaginal septum, rugae folds, fornices, discharge, scar, laceration Cervix – note color (normally pink) pink, cervical os (pin- pointed in nulliparous and slit-like in multiparous), dilatation, effacement and bleeding, mass III. Digital vaginal & bimanual pelvic examination Vagina- mass and tenderness Cervix- Closed normally, moves 2- 4cm without discomfort, smooth surface and like tip of nose inconsistency. Uterus- normally non-tender, mobile, 9 cm in length, pear shaped smooth and firm. Adnexa (tubes, ovaries, parametrium and broad ligaments): normally adenexal structure not palpable except in thin women with soft abdomen, description of masses. Rectal and recto vaginal IV. examination Rectal examination- In virgin and children Rectovaginal examination- For uterosacr ligam Prepared by Gebremichael Reta Mengistu (BSc.) rectovaginal and al ent nodularity or malignant infiltration To differentiate rectocele from enterocele
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Prepared by Gebremichael Reta Mengistu (BSc.)
8. Intgumentary As non-pregnant 9. Extremities As non-pregnant 10. Central nervous system As non- pregnant Laboratory Investigation
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Prepared by Gebremichael Reta Mengistu (BSc.)
Gordon’s Functional Health Patterns Assessment Identification Name Religion Age Occupation Sex Educational Status Address Date of admission Medical Registration Marital status Number Ethnicity Ward and bed number Chief complaints: One or more specific complaints and duration of each complaint+ some pertinent positive symptoms Medical Diagnosis: 1. Health Perception -Health Management Pattern History/Subjective date a. How has general health been? b. Any colds in past year? When appropriate: absences from work/school? c. Most important things you do to keep healthy? Think these things make a difference to health? (Include family folk remedies when appropriate.) Use of cigarettes, alcohol, drugs? Perform self-exams? i.e. Breast self-examination. d. Accidents (home, work, school, driving)? e. In past, been easy to find ways to follow suggestions from physicians or nurses? f. When appropriate: what do you think caused this illness? Actions taken when symptoms perceived? Results of action? g. When appropriate: things important to you in your health care? How can we be most helpful? How often do you exercise? Examination/Objective date: general health appearance 2. Nutritional-Metabolic Pattern History/Subjective date a. Typical daily food intake? (Describe.) Supplements (vitamins, type of snacks)? b. Typical daily fluid intake? (Describe.) c. Weight loss or gain? (Amount) Height loss or gain? (Amount) d. Appetite? e. Food or eating: Discomfort? Swallowing? Diet restrictions? f. Heal well or poorly? g. Skin problems: Lesions? Dryness? h. Dental problems? Examination/Objective date Prepared by Gebremichael Reta Mengistu (BSc.) a. Skin: Bony prominences? Lesions? Color changes? Moistness? b. Oral mucous membranes: Color? Moistness? Lesions? c. Teeth: General appearance and alignment? Dentures? Cavities? Missing teeth? d. Actual weight, height. e. Temperature.
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Prepared by Gebremichael Reta Mengistu (BSc.)
f. Intravenous feeding–parenteral feeding (specify)? 3. Elimination Pattern History/Subjective data a. Bowel elimination pattern? (Describe) Frequency? Character? Discomfort? Problem in control? Laxatives? b. Urinary elimination pattern? (Describe.) Frequency? Problem in control? c. Excessive perspiration? Odor problems? d. Body cavity drainage, suction, and so on? (Specify.) Examination/Objective data: when indicated: examine excreta or drain- age color and consistency. 4. Activity-Exercise Pattern History/Subjective data a. Sufficient energy for desired or required activities? b. Exercise pattern? Type? Regularity? c. Spare-time (leisure) activities? Child: play activities? d. Perceived ability (code for level) for: Feeding _________________________ Dressing _________________________ Cooking _________________________ Bathing _________________________ Grooming _______________________ Shopping ________________________ Toileting ________________________ General mobility______________________ Bed mobility______________________ Home maintenance __________________ Functional Level Codes: Level 0: full self-care • Level I: requires use of equipment or device • Level II: requires assistance or supervision from another person • Level III: requires assistance or supervision from another person and equipment or device • Level IV: is dependent and does not participate Examination/Objective data a. Demonstrated ability (code listed above) for: Feeding_________________________ Dressing________________________ Cooking___________________________Bathing_________________________ Grooming________________________ Shopping__________________________ Toileting________________________ General mobility___________________ b. Gait_____________________________ Posture__________________________ Absent body part? __________________(Specify)_________________________ c. Range of motion (joints)________________Muscle________________Firmness_____________ ____ d. Hand grip ___________________Can pick up a pencil? ________________________ e. Pulse (rate) _______________________ (rhythm) ______________________ Breath sounds___________________ f. Respirations (rate) __________________ (rhythm) ______________________ Breath sounds____________________ g. Blood pressure ______________________ Prepared by Gebremichael Reta Mengistu (BSc.) h. General appearance (grooming, hygiene, and energy level) 5. SLEEP-REST PATTERN History/Subjective data a. Generally rested and ready for daily activities after sleep? b. Sleep onset problems? Aids? Dreams (nightmares)? Early awakening?
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Prepared by Gebremichael Reta Mengistu (BSc.)
c. Rest-relaxation periods? Examination/Objective data a. When appropriate: Observe sleep pattern. 6. Cognitive-Perceptual Pattern History/Subjective data a. Hearing difficulty? Hearing aid? b. Vision? Wear glasses? Last checked? When last changed? c. Any change in memory lately? d. Important decision easy or difficult to make? e. Easiest way for you to learn things? Any difficulty? f. Any discomfort? Pain? When appropriate: How do you manage it? Examination/Objective data a. Orientation? b. Hears whisper? c. Reads newsprint? d. Grasps ideas and questions (abstract, concrete)? e. Language spoken. f. Vocabulary level. Attention span. 7. Self-Perception-Self- Concept Pattern History/Subjective data a. How describe self? Most of the time, feel good (not so good) about self? b. Changes in body or things you can’t do? Problem to you? c. Changes in way you feel about self or body (since ill- ness started)? d. Things frequently make you angry? Annoyed? Fearful? Anxious? e. Ever feel you lose hope? Examination/Objective data a. Eye contact. Attention span (distraction) b. Voice and speech pattern. Body posture c. Nervous (5) or relaxed (1); rate from 1 to 5. d. Assertive (5) or passive (1); rate from 1 to 5. 8. Roles-Relationships Pattern History/Subjective data a. Live alone? Family? Family structure (diagram)? b. Any family problems you have difficulty handling (nu- clear or extended)? c. Family or others depend on you for things? How managing? d. When appropriate: How family or others feel about ill- ness or hospitalization? e. When appropriate: Problems with children? Difficulty handling? f. Belong to social groups? Close friends? Feel lonely (frequency)? g. Things generally go well at work? (School?) h. When appropriate: Income sufficient for needs? i. Feel part of (or isolated in) neighborhood where living? Examination/Objective data a. Interaction with family member(s) or others (if present). 9. Sexuality-Reproductive Pattern History/Subjective data
Prepared by Gebremichael Reta Mengistu (BSc.)
a. When appropriate to age and situations: Sexual relationships satisfying? Changes? Problems?
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Prepared by Gebremichael Reta Mengistu (BSc.)
b. When appropriate: Use of contraceptives? Problems? c. Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? Examination/Objective data a. None unless problem identified or pelvic examination is part of full physical assessment. 10. Coping-Stress Tolerance Pattern History/Subjective data a. Any big changes in your life in the last year or two? Crisis? b. Who’s most helpful in talking things over? Available to you now? c. Tense or relaxed most of the time? When tense, what helps? d. Use any medicines, drugs, alcohol? e. When (if) have big problems (any problems) in your life, how do you handle them? f. Most of the time is this (are these) way(s) successful? Examination/Objective data: None. 11. Values-Beliefs Pattern History/Subjective data a. Generally get things you want from life? Important plans for the future? b. Religion important in life? When appropriate: Does this help when difficulties arise? c. When appropriate: Will being here interfere with any religious practices? Examination/Objective: None. 12. Other concerns (This is not part of functional health pattern but it is very important and it must be asked after completing the 11 approaches) a. Any other things we haven’t talked about that you would like to mention? b. Any questions?
Prepared by Gebremichael Reta Mengistu (BSc.)
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Prepared by Gebremichael Reta Mengistu (BSc.)
Nursing Process Identificat ion Name Religion Age Occupation Sex Educational Status Address Date of admission Medical Registration Marital status Number Ethnicity Ward and bed number Chief complaints: One or more specific complaints and duration of each complaint+ some pertinent positive symptoms Medical Diagnosis: 1. Assessment (what data is collected?) Subjective data: a. Information from the client’s point of view. OR b. Symptoms or covert data Objective data: a. Signs or overt cues are observable and measurable (quantitative) data that are obtained through observation. OR b. Standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing. 2. Nursing Diagnosis (what is the problem?) a. Clinical judgment about individual, family or community response to actual or potential health problem. b. Parts of Nursing Diagnosis:*Problem; statement that describe the health problem of the patient clearly & concisely.*Etiology; The reason (etiology) that identifies the physiological, psychological, social, spiritual & environmental factors related to the problem. *Defining characteristics of manifestations (signs or symptoms). c. Components of a nursing diagnosis: Two statement nursing diagnosis (the first component is problem statement or diagnostic label which is listed in NANDA and the second component is etiology or reason which connected by Related to (RT) by problem) and three statement (Problem RT Etiology AEB by manifestation or sign and symptoms). d. Types of nursing diagnosis: Actual Nursing Diagnosis; represent a problem that has been validated by the presence of its characteristics. Risk Nursing Diagnosis; it’s a clinical judgment that an individual, family, or community is more vulnerable (able) to develop the problem. Possible Nursing Diagnosis; are statements describing a suspected problem. Wellness Diagnosis; it’s a clinical judgment about individual, group, or community in transition from specific level of wellness to a higher level. Syndrome nursing Diagnosis; a cluster of an actual or risk nursing diagnosis suspected to be present according to certain events. Prepared by Gebremichael Reta Mengistu (BSc.) 3. Outcome Identification: (was originally a part of the planning phase, but has recently been added as a new step in the complete process). a. Establish client’s goals and outcome criteria. b. It must be SMART
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Prepared by Gebremichael Reta Mengistu (BSc.)
4. Planning (how to manage the problem) a. Establish/Set priorities b. Plan nursing interventions (plan to action) c. Write a Nursing Care Plan/documentation 5. Implementation (putting plan into action) 6. Rationale (Scientific reason of the implementations) 7. Evaluation (did the plan work)
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Prepared by Gebremichael Reta Mengistu (BSc.)
NANDA Approved Nursing Diagnoses 2015-2017 Indicates new diagnosis for 2015-2017—25 total Indicates revised diagnosis for 2015- 2017- 14 total (Retired Diagnoses at bottom of list— 7 total) 1 3 . Activity Intolerance 8. Constipation, Perceived 2 3 . Activity Intolerance, Risk for 9. Constipation, Risk for 3 40. Constipation, Chronic . Activity Planning, Ineffective Functional 4 Activity Planning, Risk for 4 Constipation, Risk for Chronic . Ineffective 1. Functional 5 Adaptive Capacity, Decreased 4 . Intracranial 2. Contamination 6 4 . Airway Clearance, Ineffective 3. Contamination, Risk for 7 4 . Allergy Response, Risk for 4. Coping, Compromised Family 8 4 . Anxiety 5. Coping, Defensive 9 4 . Aspiration, Risk for 6. Coping, Disabled Family 1 4 0. Attachment, Risk for Impaired 7. Coping, Ineffective 1 4 1. Autonomic Dysreflexia 8. Coping, Ineffective Community 1 4 Coping, Readiness for 2. Autonomic Dysreflexia, Risk for 9. Enhanced 1 5 Coping, Readiness for 3. Behavior, Disorganized Infant 0. Enhanced 1 4. Behavior, Readiness for Enhanced Community 5 Coping, Readiness for Organized Infant 1. Enhanced Family 1 Behavior, Risk for Disorganized 5 5. Infant 2. Death Anxiety 1 5 Decision-Making, Readiness for 6. Bleeding, Risk for 3. Enhanced 1 Blood Glucose Level, Risk for 5 7. Unstable 4. Decisional Conflict 1 5 8. Body Image, Disturbed 5. Denial, Ineffective 1 Body Temperature, Risk for 5 9. Imbalanced 6. Dentition, Impaired Prepared by Gebremichael Reta Mengistu (BSc.) 2 Breastfeeding, Readiness for 5 0. enhanced 7. Development, Risk for Delayed 2 Breastfeeding, 5 1. Ineffective 8. Diarrhea 2 5 2. Breastfeeding, Interrupted 9. Disuse Syndrome, Risk for 2 Breast Milk, 6 3. Insufficient 0. Diversional Activity, Deficient 2 6 4. Breathing Pattern, Ineffective 1. Dry Eye, Risk for 2 6 5. Cardiac Output, Decreased 2. Electrolyte Imbalance, Risk for 26. Cardiac Output, Risk for 6 Decreased 3. Elimination, Impaired Urinary 27. Cardiovascular Function, Risk 6 Elimination, Readiness for for 4. Enhanced Impaired Urinary 2 65. Emancipated Decision 8. Childbearing Process, Ineffective Making, 2 Childbearing Process, Readiness 9. for Impaired 66. Emancipated Decision Enhanced Making, 3 Childbearing Process, Risk for 0. Ineffective Readiness for Enhanced 3 67. Emancipated Decision 1. Comfort, Impaired Making, Risk 3 2. Comfort, Readiness for Enhanced for Impaired 3 Communication, Readiness for 3. Enhanced 68. Emotional Control, Labile 3 6 4. Confusion, Acute 9. Falls, Risk for 3 7 5. Confusion, Chronic 0. Family Processes, Dysfunctional 3 7 6. Confusion, Risk for Acute 1. Family Processes, Interrupted 3 7 Family Processes, Readiness for 7. Constipation 2. Enhanced
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Prepared by Gebremichael Reta Mengistu (BSc.)
73. Fatigue 104. Hypothermia, Risk for 74. Fear Perioperative 75. Feeding Pattern, Ineffective 105. Impulse Control, Ineffective Infant 106. Incontinence, Functional 76. Fluid Balance, Readiness for Urinary Enhanced 107. Incontinence, Overflow 77. Fluid Volume, Deficient Urinary 78. Fluid Volume, Excess 108. Incontinence, Reflex Urinary 79. Fluid Volume, Risk for 109. Incontinence, Risk for Urge Deficient Urinary 80. Fluid Volume, Risk for 110. Incontinence, Stress Urinary Imbalanced 111. Incontinence, Urge Urinary 81. Frail Elderly Syndrome 112. Incontinence, Bowel 82. Frail Elderly Syndrome, 113. Infection, Risk for Risk for 114. Injury, Risk for 83. Gas Exchange, Impaired 115. Injury, Risk for Corneal 84. Gastrointestinal Motility, 116. Injury, Risk for Perioperative- Dysfunctional Positioning 85. Gastrointestinal 117. Injury, Risk for Thermal Motility, Risk for Dysfunctional 86. Gastrointestinal Perfusion, Risk for Ineffective 87. Grieving 88. Grieving, Complicated 89. Grieving, Risk for Complicated 90. Growth, Risk for Disproportionate 91. Health, Deficient Community 92. Health Behavior, Risk-Prone 93. Health Maintenance, Ineffective 94. Health Management, Ineffective 95. Health Management, Readiness for Enhanced 96. Health Management, Ineffective Family 97. Home Maintenance, Impaired 98. Hope, Readiness for Enhanced 99. Hopelessness 100. Human Dignity, Risk for Compromised 101. Hyperthermia 102. Hypothermia 103. Hypothermia, Risk for
Prepared by Gebremichael Reta Mengistu (BSc.)
118. Injury, Risk for Urinary 141. Oral Mucous Membrane, Tract Impaired 119. Insomnia 142. Oral Mucous 120. Jaundice, Neonatal Membrane, Risk for 121. Jaundice, Risk for Neonatal Impaired 122. Knowledge, Deficient 143. Other-Directed Violence, 123. Knowledge, Readiness for Risk for Enhanced 144. Overweight 124. Latex Allergy Response 145. Overweight, Risk for 125. Latex Allergy Response, Risk 146. Pain, Acute for 147. Pain, Chronic 126. Lifestyle, Sedentary 148. Pain, Labor 127. Liver Function, Risk for 149. Pain Syndrome, Chronic Impaired 150. Parenting, Impaired 128. Loneliness, Risk for 151. Parenting, Readiness for 129. Maternal/Fetal Dyad, Risk for Enhanced Disturbed 152. Parenting, Risk for Impaired 130. Memory, Impaired 153. Peripheral Neurovascular 131. Mobility, Impaired Bed Dysfunction, Risk for 132. Mobility, Impaired Physical 154. Personal Identity, Disturbed 133. Mobility, Impaired 155. Personal Identity, Risk for Wheelchair Disturbed 134. Mood Regulation, 156. Poisoning, Risk for Impaired 157. Post-Trauma Syndrome 135. Moral Distress 158. Post-Trauma Syndrome, Risk 136. Nausea for 137. Noncompliance 159. Power, Readiness for 138. Nutrition, Imbalanced: Enhanced Less than Body Requirements 160. Powerlessness 139. Nutrition, Readiness for 161. Powerlessness, Risk for Enhanced 162. Pressure Ulcer, Risk for 140. Obesity
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Prepared by Gebremichael Reta Mengistu (BSc.)
163. Protection, Ineffective 195. Self-Neglect 164. Rape-Trauma Syndrome 196. Sexual Dysfunction 165. Reaction to Iodinated 197. Sexuality Pattern, Ineffective Contrast Media, Risk for 198. Shock, Risk for 166. Relationship, Ineffective 199. Sitting, Impaired 167. Relationship, Risk for 200. Skin Integrity, Impaired Ineffective 201. Skin Integrity, Risk for Impaired 168. Relationship, Readiness 202. Sleep, Readiness for Enhanced for Enhanced 203. Sleep Deprivation 169. Religiosity, Impaired 204. Sleep Pattern, Disturbed 170. Religiosity, Readiness for 205. Social Interaction, Impaired Enhanced 206. Social Isolation 171. Religiosity, Risk for 207. Sorrow, Chronic Impaired 172. Relocation Stress Syndrome 173. Relocation Stress Syndrome, Risk for 174. Renal Perfusion, Risk for Ineffective 175. Resilience, Impaired 176. Resilience, Readiness for Enhanced 177. Resilience, Risk for Impaired 178. Role Conflict, Parental 179. Role Performance, Ineffective 180. Role Strain, Caregiver 181. Role Strain, Risk for Caregiver 182. Self-Care, Readiness for Enhanced 183. Self-Care Deficit, Bathing 184. Self-Care Deficit, Dressing 185. Self-Care Deficit, Feeding 186. Self-Care Deficit, Toileting 187. Self-Concept, Readiness for Enhanced 188. Self-Directed Violence, Risk For 189. Self-Esteem, Chronic Low 190. Self-Esteem, Risk for Chronic Low 191. Self-Esteem, Situational Low 192. Self-Esteem, Risk for Situational Low 193. Self-Mutilation 194. Self-Mutilation, Risk for 208. Spiritual Distress 233. Verbal Communication, 209. Spiritual Distress, Impaired Risk for 234. Walking, Impaired 210. Spiritual Well- 235. Wandering Being, Readiness for Enhanced Retired Diagnoses Energy Field, Disturbed 211. Spontaneous Failure to Thrive, Adult Ventilation, Impaired Immunization Status, Readiness 212. Standing, for Enhanced Nutrition, Impaired Imbalanced: More than Body 213. Stress Overload Requirements 214. Sudden Infant Death Nutrition, Risk for Imbalanced: Syndrome, Risk for More than Body Requirements 215. Suffocation, Risk for Environmental Interpretation 216. Suicide, Risk for Syndrome, Impaired 217. Surgical Recovery, Growth and Development, Delayed Delayed 218. Surgical Recovery, Risk for Delayed 219. Swallowing, Impaired 220. Thermoregulation, Ineffective 22 221. Tissue Integrity, Impaired 222. Tissue Integrity, Risk for Impaired 223. Tissue Perfusion, Ineffective Peripheral 224. Tissue Perfusion, Risk for Ineffective Peripheral 225. Tissue Perfusion, Risk for Decreased Cardiac 226. Tissue Perfusion, Risk for Ineffective Cerebral 227. Transfer Ability, Impaired 228. Trauma, Risk for 229. Vascular Trauma, Risk for 230. Unilateral Neglect 231. Urinary Retention 232. Ventilatory Weaning Response, Dysfunctional