First step of the nursing process. Activities required in the first step are the data collection, validation, sorting, and documentation. The process is to gather info for health problem identification.

1. Collection of info from a primary source (the patient) and secondary sources (family members, health professionals, medical record)

2. The interpretation and validation of data to ensure a complete database

Critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness 

1. Assessment 

2. Diagnosis

3. Planning 

4. Implementation 

5. Evaluation 

Nursing Process

1. Asses 

Nursing Process

2. Diagnosis 

Nursing Process

3. Plan

Nursing Process 

4. Implement 

Nursing Process 

5. Evaluate 

Health-perception

health management

Gordon’s Functional Health Patterns

Gordon’s Functional Health Pattern

Describes patients self report of health and well being; how patient manages health knowledge of preventive health practices 

Nutritional-metabolic pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patients daily/weekly pattern of food and fluid intake; actual weight; weight loss or gain

Elimination pattern 

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patterns of excretory function (bowel, bladder, and skin) 

Activity - excercise pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patterns of excercise, activity leisure, and recreation; ability to perform activities of daily living

Self perception- self concept pattern 

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patients self concept pattern and perceptions of self (self concept/ worth, emotional patterns, body images) 

Sleep rest pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patterns of sleep rest and relaxation

Cognitive perceptual pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes sensory perceptual patterns; launguage adequacy, memory, decision-making ability

Role -relationship pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patients patterns of role engagement and relationships

Sexually- reproductive pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes Patients patterns of satisfaction and dissatisfaction w sexuality pattern; patients reproductive patterns; premenopausal and post menopausal problems

Coping -stress tolerance Pattern 

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patient's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance

Value belief pattern

Gordon’s Functional Health Pattern

Gordon’s Functional Health Pattern

Describes patterns of values, beliefs (including spiritual practices) and goals that guide patients choices or decisions

-Listen patiently

-allow for pauses and time for patient to tell their story.

-recognize normal changes associated with aging these changes might be considered abnormal in a younger adult.

-If a person has a proxy (person who legally represents patient), gather history information from that individual.

-If patient has limited hearing or visual deficits use nonverbal communication when conducting a patient -centered interview.

-Patient directed eye gaze:  this allows the nurse or patient who ever is speaking to check whether information is understood. 

- Affirmative head nodding: This has in important social function it helps to regulate an interaction, supports spoken language and allows for comment On the interaction concerning rapport and content of he communication

-smiling: Smiling is positive and considered as a sign of good humor warmth and immediacy. it is most important one first establishing the nurse- patient Relationship

- Forward leaning: This shows awareness attention an immediacy. during an interaction it is also clearly suggests interest in that Person.

Does not presuppose a specific answer.

Prompts patient to describe a situation in more than one or two words. This method leads to discusssion

Examples of questions:

- Tell me how you are feeling.

-Tell me how your health has been.

-Give me an example of how you get relief from your pain at home.

This approach takes the information provided in the patient story and more fully describes and identifies specific problem areas. Limit answers to one or two words. Requires short answers and clarify previous information or provide additional information. 

Examples: 

-Do you think the medication is helping you? 

- Who helps you at home?

-Do you understand why you are having the x-ray examination?

-Are you having pain now?

-On a scale of 0 to 10' how would you rate your pain?

- Location: Where is the symptom located?

- Precipitating factors: What make symptoms worse are there activities that affect the symptoms?

-Relieving factors: What does the patient do to become more comfortable or relieve the symptom?

-Quality- Have the patient describe what symptom feels like.

-Severity: Have the patient rate the severity a scale of 0 to 10. This gives you a baseline with which to compare in follow-up assessments.

- concomitant symtoms: Does the patient experience other symptoms along with the primary symptom? For example, does nausea accompany pain?

Emotional

social

physical and developmental

intellectual

spiritual

Patient's health history

-emotional

Patient's health history

-Behavioral and emotional status

-support system

-self-concept

-body image

-mood

-sexuality

-coping mechanisms

Patient's health history

-social

Patient's health history

-Financial status

-recreational activities

-primary language

-cultural heritage

-cultural influences

-community resources

-environmental risk factors

-social relationships

-family structure and support

Patient's health history

-physical and developmental

Patient's health history

-Perception of health status

-Past health problems and therapies

- present health therapies

-Risk factors

-Activity and coordination

-Review of symptoms

-Developmental stage

-Members of household marital problems

-Growth and maturation

-occupation

-ability to complete activities of daily living

Patients health history

Intellectual

Patient's health history 

-Problem solving

-Educational level

-Communication patterns

-attention span

-Long term and recent memory 

Patient health history

spiritual 

Patient's health history

-Belief and meaning 

-religious experiences

-fellowship 

-courage

Determine the presence of abnormal findings, recognize that further observations are needed to clarify info, and begin to identify the patients health problems.

The comparison of data with another source to determine data accuracy.

A visual representation that allows you to graphically show the connections between a patient's health problems. Effective learning strategy to understand the relationships that exist among patient problems.

Step 1: Organize the assessment data you collect for your patient. Placing all the cues together into clusters that form patterns. 

Step 2: Nursing diagnosis. Obtain a holistic perspective of your patients healthcare needs which ultimately leads you to make a better clinical decisions.

Concept map example

Primary health problem: radical prostatectomy 

Priority assessments: Condition of wound, level of comfort, knowledge of care requirements when discharged, Ability to manage homecare, And emotional response to changes from surgery

Potential pattern: comfortable problem

• Winces when incision is palpated
• Acknowledges pain over incision
• Rates discomfort a 7 on a scale of 0 to 10
• Asks if pain medicine is available

Potential pattern: mobility restriction 

• Has not turned since some time last night
• Lays flat in bed with muscles tensed
• Reports discomfort over incision

Potential pattern: Request information about postoperative care

• Has no knowledge about Postoprative wound care
• Ask questions

Potential pattern: Concern over affects surgery will have on relationship with wife

• States " I am worried about me and my wife"
• States "Dr. told me surgery could change our ability to have sex"
• Have been married for 32 years