functional assessments

transcript

Functional Assessments

Maria Carmela L. Domocmat, RN ,MSN

Functional Assessments

�Gordon’s Functional Health Patterns�Katz Index of Independence�Barthel Index

GORDON’S FUNCTIONAL HEALTH PATTERNS

�Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base. base.

�These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health determine the following aspects of health and human function:

� 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

�1 Health Perception and Management�2 Nutritional metabolic�3 Elimination�4 Activity exercise�4 Activity exercise�5 Sleep rest�6 Cognitive-perceptual

�7 Self perception/self concept�8 Role relationship�9 Sexuality reproductive�10 Coping-stress tolerance�10 Coping-stress tolerance�11 Value-Belief Pattern

(1) 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

Health Perception and Health Management

�Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use.

�Actual or potential problems r/t �Actual or potential problems r/t � safety & health management� needs for modifications in the home or needs for

continued care in the home.

(2) 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 �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.

(3) Elimination

�Data collection is focused on excretory patterns (bowel, bladder, skin).

�Excretory problems such as incontinence, constipation, diarrhea, and urinary constipation, diarrhea, and urinary retention may be identified.

(4) Activity and Exercise

�Assessment is focused on the �activities of daily living requiring energy

expenditure, including self-care activities, exercise, and leisure activities. exercise, and leisure activities.

�The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.

�Cognition and Perception . Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated.

�Sleep and Rest. Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep fatigue, and responses to sleep deprivation may be identified.

�Self-Perception and Self-Concept. Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified.

�Roles and Relationships. Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional with roles, role strain, or dysfunctional relationships may be further evaluated.

�Sexuality and Reproduction. Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive with sexuality patterns and reproductive functions. Concerns with sexuality may he identified.

�Coping and Stress Tolerance . Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated.

�Values and Belief. Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions.that guide his or her choices or decisions.

Critical Thinking Exercise 2: Clustering of Data

�On a separate piece of paper, cluster the following data according to Gordon’s Functional Health Patterns.

�When you organized these data, you have �When you organized these data, you have found that some categories had no data listed. If this happens to you in the clinical area, what should you do?

Case history

�Age 36�Married, has three small children�Occupation: landscape architect and

homemakerhomemaker�Religion: Baptist

Case history

�Medical diagnosis: Pneumonia�T: 38.3; P: 100; R: 28; :BP: 104/68�States she is concerned about how her

husband is caring for the children, that “it husband is caring for the children, that “it is tough on him.”

�States she feels weak and tired all the time but can’t seem to rest because she keeps coughing all the time.

�Appetite poor. Has eaten less than half of �Appetite poor. Has eaten less than half of regular meals. Is forcing fluids well (1000ml per shift)

�Before illness, she smoked a pack of cigarettes a day but has not smoked since hospitalization

�States she always has been in good �States she always has been in good health and never had to be hospitalized (even gave birth at home)

�States that all of the tests that have to be done make her nervous; she is worried about getting AIDS from needle sticks.

�Lungs have bilateral rhonchi; she coughs �Lungs have bilateral rhonchi; she coughs up thick yellow mucus

�Chest x-ray shows improvement over the last 2 days

�White blood cell count is elevated at 16,000. 16,000.

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