Chapter 5 Fundamentals of Nursing

Question 1

Gordon’s functional health patterns

Health Perception and Management
● Nutritional metabolic
● Elimination-excretion patterns and problems need to be evaluated (constipation,
incontinence, diarrhea)
● Activity exercise-whether one is able to do daily activities normally without any problem,
self care activities
● Sleep rest-do they have hypersomnia, insomnia, do they have normal sleeping patterns
● Cognitive-perceptual-assessment of neurological function is done to assess, check the
person’s ability to comprehend information
● Self perception/self concept
● Role relationship-This pattern should only be used if it is appropriate for the patient’s age
and specific situation.
● Sexuality reproductive
● Coping-stress tolerance
● Value-Belief Pattern

Answer 1

A method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more
comprehensive nursing assessment of the patient.
The following areas are assessed through questions asked by the nurse and medical examinations
to provide an overview of the individual’s health status and health practices that are used to reach
the current level of health or wellness.[1][2]

Question 2

The Interview
Consists of three basic stages***

Answer 2

The opening, during which rapport is established
with the patient, inform patient of the purpose of
data gathering as well as how the information will
be safeguarded.
The body of the interview, during which necessary
questions are presented
The closing, during which information is
summarized, allow patient to ask questions
especially the interview process.

Question 3

Medical records (chart) review should include:

Answer 3

Face sheet and physician’s orders
Nurses’ notes (at least the past 24 hours)
Physicians’ progress notes and history and physical
examination
Medication administration record
Surgery operative report and pathology report
Diagnostic tests
Nursing admission history and assessment
Fall risk assessment and skin assessment
Nursing care plan or problem list

Question 4

Head-to-Toe Assessment

Answer 4

Initial observation

Breathing
How the patient is feeling
General appearance
Skin color
Affect

Question 5

Head

Answer 5

Level of consciousness
* Awake, alert, and oriented
Ability to communicate
* Language spoken, any communication deficits
Mentation status
* Able to comprehend, form thoughts, alert, oriented.
Appearance of the eyes
* Pupil size, light reaction, eye discharges, any eye
abnormalities, uses glasses, prescription glasses.

Question 6

Vital signs- can be delegated to the nsg asst.

Answer 6

Temperature
Pulse rate
* Rhythm, strength, apical, radial
Respirations
* Rate, pattern, depth; oxygen saturation
Blood pressure
* Within normal limits
* Compare with previous readings

Question 7

Heart and lungs

Answer 7

Heart sounds, normal S1
-S2

⬤ Lungs

Lung sounds
Rales, wheezes, diminished breath sounds

⬤ Abdomen

Shape, hardness, bowel sounds, last bowel
movement, voiding, appetite, nausea

⬤ In the acute care setting, heart, lungs, and abdomen
should be auscultated at least once during a shift. In home
setting, each visit.

Question 8

Extremities

Answer 8

Ability to move all extremities well; For the patient who
cannot follow commands well, spontaneous movements in bed
can be observed and noted in the chart. If the patient guards
one side, or doesn’t move an extremity effectively, some
impairment might be implied.
Ability to move within normal range
Skin turgor, color, temperature
Peripheral pulses; Diminished pulses; pale or cyanotic
coloration, especially distal; decreased temperature;
edema, etc
Edema

Question 9

Tubes and equipment

Answer 9

Oxygen cannula, chest tubes
NG tubes, PEG tubes, jejunostomy tube
IVs, wound suction devices, sequential compression
devices [SCDs], CPM devices, etc
Urinary catheter
Type and amount of drainage
Dressings and drainage
Pulse oximeter
Traction devices
The location of all tubes and equipment attached to the patient
should be noted.
»»»Pain status

Question 10

Assessment in Long-Term Care

Answer 10

Extensive initial assessment performed when
patient enters long-term care facility
⬤ Reassessment at fixed intervals and as the
patient’s condition changes
⬤ Physical assessment, health history,
medication history, and a functional
assessment performed

Question 11

Assessment in Home Health Care

Answer 11

Initial patient assessment in the home is
usually performed by the RN
⬤ The LPN/LVN, when doing private duty in a
home, will need to perform daily assessments
and maintain necessary documentation
⬤ Changes found on assessment should be
reported to the RN supervisor.
⬤ The family is assessed regarding attitude and ability to help with care of the
patient, their ability to provide emotional support for the patient, their ability
to cope with the situation, and teaching that will need to be provided for
them.

Question 12

As part of an assessment, the nurse asks for
information from the patient. This information is
a subjective indication of illness perceived by
the patient and is called a/an:

Answer 12

2) symptom.

Question 13

All of the following components can be found on
the chart except the:

Answer 13

4) patient’s nurse assignment.

Question 14

Linda knows as part of her nursing assignment
that she is to review and update the nursing
care plan on her patients:

Answer 14

⬤ The plan of care should be reviewed and
updated once every 24 hours

Question 15

Theory

Answer 15

Correlate patient problems and wellness issues with
problem statements from the Priority Problem List.

Question 16

Clinical Practice

Answer 16

2) Analyze the data collected to determine patient
needs.
3) Identify appropriate problem statements from the
Priority Problem List for each assigned patient.
4) Prioritize the problem statements.

Question 17

Analysis

Answer 17

⬤ Database analyzed for cues that deviate from
the norm
⬤ Pieces of data are sorted
⬤ Related data are grouped or clustered
⬤ Missing data are identified
⬤ Inferences are made regarding the patient’s
problems

Question 18

Nursing Diagnosis/
Problem Identification

Answer 18

A nursing diagnosis statement indicates the
patient’s actual health status or the risk of a
problem developing, the causative or related
factors, and specific defining characteristics
(signs and symptoms).
❖ The medical diagnosis (i.e., stroke or
cerebrovascular accident) is never included in the
construction of the nursing diagnosis.
❖ The RN formulate problem statements/nursing diagnoses,
but the LPN/LVN is expected to contribute to the plan of care
once the problem statements/diagnoses have been
identified.

Question 19

Etiologic Factors

Answer 19

Causes of the problem
❏ Signs are abnormalities that can be verified by
repeat examination and are objective data
❏ Symptoms are data the patient has said are
occurring that cannot be verified by examination;
symptoms are subjective data.
❏ Subjective data are what the patient tells you;
objective data are what you collect by examining the
patient.

Question 20

Defining Characteristics

Answer 20

Characteristics (signs and symptoms) that
must be present for a particular problem
statement to be appropriate for that patient.
➔ Problem statements and nursing diagnoses differ
from medical diagnoses in that the problem
statement and nursing diagnosis defines the
patient’s response to illness, whereas the medical
diagnosis labels the illness.
➔ Supply the evidence that the problem
statement is valid.

Question 21

Prioritization of Problems

Answer 21

Problems ranked according to their importance
➔ Physiologic needs for basic survival take precedence
(i.e., airway and circulation)
➔ After physiologic needs are met, safety problems take
priority.
➔ Every nurse must attempt to look at each patient
holistically, keeping psychosocial needs in mind while
working on physical problems.
➔ Priorities of care are set so that the nurse will first attend to the most
important interventions for the high-priority problems for each patient.
➔ Order can be guided by the hierarchy of needs adapted from Maslow, by
the patient’s beliefs regarding the level of importance of each problem, and
by what is most life-threatening or problematic for the patient.

Question 22

Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis Risk for infection?

Answer 22

4) Abdominal incision, decreased hemoglobin, and
indwelling catheter present.

Question 23

Theory

Answer 23

Identify appropriate outcome criteria for selected
problem statements.
7) Plan goals for each patient and write outcome
criteria for the chosen problem statements.

Question 24

Clinical Practice

Answer 24

Write specific goal/outcome statements.
6) Plan appropriate nursing interventions to assist
the patient in attaining the goals/expected
outcomes.

Question 25

Planning: Expected Outcomes

Answer 25

Goal: what is to be achieved by nursing
intervention
⬤ Short-term goals

Achievable within 7 to 10 days or before discharge

⬤ Long-term goals

Take many weeks or months to achieve
Often relate to rehabilitation

⬤ Expected outcome: statement of goal patient is
to achieve as a result of nursing intervention
⬤ The patient or significant others should be included in the goal-setting
process.

Question 26

Interventions (Nursing Orders)

Answer 26

Designed to alleviate problems and to achieve
expected outcomes
⬤ Should include giving medications and performing
ordered treatments
⬤ Individualized to the patient’s needs.
⬤ Nursing interventions should give specific steps to be executed, or actions to
be taken, in order for the outcome to be achieved.
⬤ How could you be more specific about an intervention, such as maintaining
skin integrity? For example, reposition patient every 2 hours, use padding to
protect bony prominences, move patient in/out of bed with slide board, etc.
⬤ Examples of nursing interventions include:

Monitoring high-risk problems
Alleviating pain or discomfort
Reducing stress
Maintaining skin integrity

Slide 33

Question 27

Documentation

Answer 27

Planning not complete until plan is
documented and is part of patient’s medical
record
⬤ Plans constructed by LPN/LVNs must be
reviewed by the RN before they are placed in
the chart
⬤ The plan of care should be reviewed and
updated once every 24 hours

Question 28

A nurse has established expected outcomes for
an assigned patient. The nurse carries out this
important activity for the purpose of:

Answer 28

1) evaluating the occurrence of complications.