Chapter 6

Question 1

What the 5 steps to the Nursing Process?

Answer 1

1. Assess- gather info about the pt’s condition: subjective and objective data
2. Diagnose- identify the pt’s problems: analyse the data gathered and explain why this is happening
3. Plan- set goals of care and desired outcomes and identify appropriate nrsg actions
4. Implement- perform the nrsg actions identified in planning
5. Evaluate- determine if goals and expected outcomes are achieved

Question 2

What are the 11 domains of Gordon’s functional health patterns?

Answer 2

1. Health perception: Individual’s perceived health and well being- affects lifestyle and ability to func; nurse should identify and address reasons for past failures to promote success for interventions
2. Nutrition: Individual’s typical food and fluid consumption in relation to metabolic needs and perceived problems; assess pt’s frequency of eating out and pt’s finances and meal preparation
3. Elimination: Adequacy, control, and regularity of an individual’s bowel, bladder, and skin excretion of waste; closely related to nutritional pattern
4. Activity: Individual’s activity level, exercise, leisure; assess exercise type, frequency, duration, intensity, barriers, modes of transportation, subjective complaints, and objective measures to assess func; assess infant/toddler development
5. Sleep: Adequacy of an individual’s sleep and relaxation; assess pt’s reports of energy level, causes of stress, decreases immune sys, unhealthy relationships, sleep disturbances, quality/ quantity of sleep; advise counseling, bedtime routine, relaxation techniques
6. Cognitive-perceptual: Individual’s ability to understand and follow directions, retain information, make decisions, solve problems, use language appropriately; assess lang capabilities, sensory deficits, use of assistive devices, learning style/ memory changes/ edu, appearance/ hygiene, behavior, attention span, use of assessment tools ie Folstein mini-mental exam
7. Self-perception: Individual’s sense of personal identity, goals, emotional patterns, feelings about self, self-image, self-worth; assess disturbed self-esteem, anxiety, fear, depression
8. Roles-relationships: position(s) assumed by the pt, satisfaction w/ the position(s); relationships affect the whole person; assess pattern of relationships/roles, family, work, communication patterns, decision making skills, stress
9. Sexuality: Related to individual’s satisfaction and dissatisfaction with sexuality and reproduction; self-perception and relationship patterns; Sexual identity linked to body image, self-concept, role, gender identity; assess knowledge of sexual func/ health practices; trusting relationship needed for discussion
10. Coping: General coping and ability to effectively manage stress; assess stress levels and coping behaviors; interventions include replacing unhealthy coping strategies and employ stress management techniques
11. Values: Values, beliefs, and goals, Perceptions of right and wrong; Facilitate effective health promotion