Module 02: Gordon's Functional Health Patterns (Part 01) Flashcards
What are the eleven (11) functional health patterns?
(1) Health Perception- Health Management Pattern
(2) Nutritional-Metabolic Pattern
(3) Elimination Pattern
(4) Activity Exercise Pattern
(5) Sleep-Rest Pattern
(6) Cognitive-Perceptual Pattern
(7) Self Perception-Self Concept Pattern
(8) Role Relationship Pattern
(9) Sexuality-Reproductive Pattern
(10) Coping-Stress Tolerance Pattern
(11) Value-Belief Pattern
What are the three (3) ways in which data are used in professional judgement in the nursing process?
(1) Diagnostic Judgement
(2) Therapeutic Judgement
(3) Ethical Judgement
This professional judgement in the nursing process is the identification of an actual or potential health problem.
Diagnostic Judgement (judge and define what the actual problem is being experienced by the client)
This professional judgement in the nursing process refers to the decisions about intervention, outcome projection and evaluation.
Therapeutic Judgement (varies depending on the nursing diagnosis, perceive the overall health status of the patient so that it becomes congruent to their actual needs)
This professional judgement in the nursing process refers to the identification of an actual or potential moral problem.
Ethical Judgment
These are guides which information to collect, in what sequence, and how extensive the assessment should be.
Functional Health Patterns
What do functional health patterns provide?
(1) Items to assess
(2) Structure for organizing assessment data
(3) Purpose and direction to health status evaluation and diagnosis
What are the characteristics of Gordon’s functional health patterns?
(1) Can be used in all nursing specialties, levels of care, age groups and setting
(2) Represent a holistic framework of person-environmental (support system, metaphysical dimensions) interaction
(3) Influenced by age, culture, gender and pathophysiology or mental alterations
What should the nurse do when assessing health patterns?
(1) The nurse should be clear as to what are good clinical data
(2) Remember that the nurse are the sensitive, measuring instrument
(3) Consider the environment to ensure privacy and facilitate information sharing
What is the nurse’s role in health patterns?
(1) Know what cues to pay attention to during assessment
(2) Combines analytic, logical reasoning and intuition to interpret assessment data
(3) Verifies assumptions and intuitive knowing
(4) Uses communication and technical skills to ensure accurate assessments and diagnoses
(6) Demonstrate an empathetic, compassionate manner and establishes therapeutic relationship
(7) Avoid sharing own similar feelings
What should the nurse do to prepare the patient’s environment?
(1) Ensure the physical environment is: 1) adequately lit and comfortable temperature, 2) free of distractions 3)
proper positioning to maximize hearing and sight
(2) Ensure interpersonal environment is: 1) the procedure is explained well 2) establish comfortable rapport 3) unhurried pace of assessment
When should the nurse avoid conducting assessment?
(1) Immediately before or after patient meals
(2) Immediately before or after patient has had medical, diagnostic or therapeutic procedures
(3) When the patient is experiencing pain or discomfort
(4) Immediately after a patient awakens from sleep (at least 30 mins after)
Time so that the patient will give you a good or optimal answer.
This health pattern describes perceived pattern of health and well-being and how health is managed.
Health Perception - Health Management Pattern
This health pattern verifies patient understanding of his or her condition so that misperceptions of illness, treatment, and health-risk management can be clarified.
Health Perception - Health Management Pattern
What does Health Perception - Health Management Pattern identify?
It identifies the client’s nonadherence to therapeutic regimen and the reasons why.
Who are at risk under Health Perception - Health Management Pattern?
(1) Denial of Illness
(2) Perceived low vulnerability
(3) Cognitive impairment
(4) Language barrier
(5) Visual or hearing deficit
(6) Complex therapeutic regimen
(7) Elderly, particularly with sensory deficits
(8) Lack of knowledge of health policies and resources
(9) Nontherapeutic relationship with care provider
What are the families at risk under Health Perception - Health Management Pattern?
(1) History of a pattern of absences from school or work
(2) Low income
(3) No health insurance
(4) High Housing costs or crowding
What should nurses consider under Health Perception - Health Management Pattern?
Consider cultural and religious values and beliefs that influence
health perception and management
What should nurses do under Health Perception - Health Management Pattern?
(1) Always use assessment data rather than cultural stereotypes in judgments.
(2) Use open-ended questions to allow the patient to voice his or her concerns
(3) In a nonjudgmental manner, review compliance with medication prescriptions: “Let’s go over the pills you take. Tell me when you take each one and the dose.”
(4) Use judgment in choosing the time for in-depth assessment of the health management pattern. Determine when the person is ready to think about health promotion. This may or may not be at the admission interview.
(5) Allow the patient to describe his or her illness and treatment. It is the patient’s perception that is needed (Not your own perception of the disease). Then misperceptions can be corrected
Why is it important to use open-ended questions?
Open-ended questions may elicit problems that will be assessed in another pattern. If this occurs, say the concern is important and that you will come back to it. Exceptions to this are emotionally charged concerns that should be talked about when expressed.
This health pattern describes the pattern of food and fluid consumption relative to metabolic need. Also included are pattern indicators of local nutrient supply.
Nutritional Metabolic Pattern
What do deficiencies in the Nutritional Metabolic Pattern imply?
Deficiencies in this pattern can explain problems in other areas, such as constipation, skin breakdown, and fatigue.
Under Nutritional Metabolic Pattern, this is important because metabolism occurs in a fluid medium.
Fluid Intake
What does the Nutritional Metabolic Pattern identify?
(1) Identification of patients at risk for pressure ulcers and detection of any break in the skin are important in preventing infection.
(2) Safe food handling and preparation in the home are important to prevent infections.
(metabolic, fluid, GI, and integument are under the metabolic pattern)
Who are the individuals at risk under the Nutritional Metabolic Pattern?
(1) Impaired swallowing (stroke patients)
(2) Limited food preparation ability
(3) Anorexia
(4) Financial limitations
(5) Dental caries or missing teeth
(6) Chemotherapy with nausea
(7) Sedentary activity level
(8) Dysfunctional eating patterns
(9) Knowledge deficit or nutritional requirements
(10) Life Stress
(11) Immobilization or bedrest
(12) Vitamin deficiencies
Under Nutritional Metabolic Pattern, what should be included under the patient’s individual assessment?
(1) Typical Daily nutrient Intake
(2) Type of Snacks
(3) Eating times
(4) Quantity of food and fluids consumed
(5) Particular food preferences
(6) Use of nutrient, vitamin, and mineral supplements
(7) Condition of skin
What should the nurse do under the Nutritional Metabolic Pattern?
(1) Use the food groups in the pyramid to assess intake. Calculations of specific nutrients can be done later if a problem exists.
(2) Consider that eating is a biopsychosocial-spiritual phenomenon when intake is more or less than body requirements.
(3) Remember that environmental factors influence a nutritional pattern through culture, religion, and availability of resources in a region.
(4) Approach assessment of overweight and obese patients with sensitivity.
(5) Monitor patients who are on bedrest, noting skin condition over bony prominences.
(6) Recognize that complaints of pain or discomfort over a bony prominence when skin is intact can be a sign of deep tissue breakdown.
This is defined as a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear or
friction (prominent among stroke patients or patients on bed rest.)
Pressure Ulcer Staging
What are the stages of pressure ulcer in laymen’s terms?
Stage 01: Skin is broken, but inflamed
Stage 02: Skin is broken to epidermis or dermis
Stage 03: Ulcer extends to the subcutaneous fat layer
Stage 04: Ulcer extends to the muscle or bone (undermining is likely)
In this stage of pressure ulcer, intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage 01
In this stage of pressure ulcer, partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister.
Stage 02
In this stage of pressure ulcer, there is full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage 03
In this stage of pressure ulcer, there is full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling.
Stage 04
This is an indicator of the optimal weight for health.
Body mass index (BMI)
Adults with a BMI between 19 and 24 have what?
Adults with a BMI between 19 and 24 have less risk for illnesses
such as heart disease and diabetes than individuals with a BMI between 25 and 29.
Adults that have a BMI greater than 30 indicates what?
A BMI greater than 30 indicates greatest risk for obesity-related
diseases.
What is the formula for body mass index (BMI)?
Weight (kg)/ height (m)^2
This health pattern describes patterns of excretory function, including bowel, bladder, and skin excretory functions.
Elimination Pattern
Under the elimination pattern, these factors may signal fluid retention.
Intake and output measurements provide information on fluid balance and may signal fluid retention (the intake and the excreted fluid should be equal)
Under the elimination pattern these are often referred to as the “unvoiced symptom”
Anxiety, depression, and social isolation can result from urinary and fecal incontinence. Loss of control is frequently referred to as the “unvoiced symptom.”
What are the effects of Inadequate disposal of wastes?
(1) Infection can spread through a family if there is inadequate disposal of wastes.
(2) Inadequate disposal of wastes in industry can pollute the air or contaminate ground water.
Under the elimination pattern, which individuals are at risk?
(1) Elderly with neuromuscular changes in pelvic floor muscles
(2) Spinal cord injury
(3) Impaired mobility
(4) Cognitive impairment
(5) Diabetes mellitus with neurological changes
(6) Multiple sclerosis
(7) Prostatectomy
(8) Prostate enlargement
(9) Lower abdominal and pelvic surgery
(10) Female who has had multiple births
(11) Radiation cystitis (inflammation of the urinary bladder.)
Under elimination pattern, what should nurses note under assessment?
(1) Think about food and fluid intake (nutritional-metabolic pattern) and activity (activity-exercise pattern) when investigating an elimination problem. Constipation can be caused by lack of activity and food and fluid intake (sedentary lifestyle)
(2) Dehydration can result from too little intake for metabolic need.
(3) The type of urinary incontinence has to be identified to select the correct interventions.
(4) Stress and urge incontinence interfere with life activities. Do a full assessment.
(5) Urinary tract infection is common in women. Be alert for symptoms, such as pain and burning upon urination, frequency, and blood in the urine. Investigate possible
reasons as a basis for referral to physician and patient health education.
(6) Onset of confusion in an elderly patient may signal a urinary tract infection.
(7) Distinguish between the current presence of constipation and the report of episodes of constipation.
What are the different classification of bowel or bladder continence and their following grade?
0 - Continent
1 - Continent with device or bladder program
2 - Usually continent
3 - Occasionally incontinent
4 - Incontinent
in this classification of bowel or bladder continence, the patient has complete control of bladder and bowel. Does not use any type of catheter or other urinary collection device.
Continent
in this classification of bowel or bladder continence, the patient has complete control with use of catheter, urinary collection device, ostomy or toileting program.
Continent with device of bladder program
in this classification of bowel or bladder continence, patient has bladder incontinence episodes once a week or less. Bowel incontinence less than weekly.
Usually continent
in this classification of bowel or bladder continence, patient has bladder incontinence two or more times a week, but not daily. Bowel incontinence once a week.
Occasionally incontinent
in this classification of bowel or bladder continence, patient is unable to control bladder or bowel.
Incontinent
What are the different types of incontinence?
(1) Functional incontinence
(2) Reflex incontinence
(3) Stress incontinence
(4) Urge incontinence
(5) Overflow incontinence
(6) Total incontinence
(7) Mixed incontinence
In this type of incontinence, there is a need to void, unable to get to the toilet quickly, cognitive impairment is sometimes present.
Functional Incontinence
In this type of incontinence, there is specific to spinal cord injury above third sacral. The patient is unaware of bladder fullness; spinal reflex (without higher-level control).
Reflex incontinence
In this type of incontinence, there is sudden loss with increased abdominal pressure due to exertion, laughing, coughing. Also may be dribbling with loss of small amounts.
Stress incontinence
In this type of incontinence, there is sudden overwhelming urge to urinate. Cannot control voiding long enough to reach the toilet. Urine leaker en route to the toilet.
Urge incontinence
In this type of incontinence, bladder overfills and leakage of small amounts. Bladder distention on examination (blockage - cancer patients or BPH patients)
Overflow incontinence
In this type of incontinence, there is an unaware urge to void; continuous, involuntary loss.
Total incontinence
In this type of incontinence, patient may have combination of urge and stress urinary incontinence.
Mixed incontinence
Under Activity-Exercise pattern, this factor brings independence. When challenged by illness, can affect nearly all other health patterns.
Mobility (activity intolerance, impaired bed mobility, impaired physical mobility, impaired transfer mobility)
This health pattern describes exercise and daily activities, which includes:
(a) Mobility
(b) Independent self-care
(c) Exercise and leisure
Activity-Exercise pattern
Under Activity-Exercise pattern, this is one of the major activities of daily living.
Independent Self Care
Under Activity-Exercise pattern, this brings diversion and social
interaction.
Exercise and leisure (deficient diversional activity, impaired walking and impaired wheelchair ability)
Under Activity-Exercise pattern, what else are included?
Problems with perfusion (Autonomic dysplexia, decreased cardiac output, decreased intercranial capacity for patients with stroke, decreased cardiac output for patients with hypertension, impaired spontaneous ventilation, and ineffective airway clearance)
Under Activity-Exercise pattern, which individuals are at risk?
(1) Imbalance between cellular oxygen supply and demand, such as from cardiovascular or pulmonary conditions.
(2) Long-term bedrest or wheelchair usage or deconditioning due to sedentary lifestyle.
(3) Leg cramps with ambulation, indicative of circulatory problems. Decreased sensation to extremities, such as from diabetic neuropathy. Uncompensated paralysis and weakness, such as from cerebrovascular accident, spinal cord injury, or brain tumor.
(4) Cognitive deficit, such as wandering with dementia.
(5) Uncompensated musculoskeletal condition, such as fractures. Confusion, coma.
(6) Environmental barriers to self-care or mobility.
(7) Situational depression.
(8) Conditions resulting in loss of eyesight.
(9) High job or family demands leaving “no time for exercise.”
What are the different types of patient’s perceived ability or functional levels code depending on their activities of daily living or instrumental activities of daily living (shopping, home maintenance)?
0 - Independent
1 - Requires use of equipment or device
2- requires assistance or supervision of another person
3 - Requires assistance or supervision of another person and equipment or device
4 - Is dependent and does not participate
Under Activity-Exercise pattern what is the usual sequence of return function after stroke to be?
(1) Feeding.
(2) Continence.
(3) Toileting.
(4) Bathing.
(5) Dressing.
(6) Cooking.
(7)Shopping.
(8) Home maintenance
3 days to 30 days or a year (physical therapy)
What should the nurse’s note during assessing patients under the Activity-Exercise pattern?
(1) Cardiac and pulmonary medical conditions produce self-care deficits. A clinically useful way of describing this problem is Selfcare deficit (Level 2) related to activity intolerance. The patient learns to compensate through energy conservation.
(2) Cerebrovascular accident may result in self-care deficits and impaired mobility. A clinically useful way of describing this problem for nursing and physical therapy is Self-care deficit (Level 3) related to uncompensated hemiplegia. The patient learns to compensate through rehabilitation.
This level of self care deficit is related to activity intolerance. The patient learns to compensate through energy conservation.
Selfcare deficit (Level 2) - Cardiac and pulmonary medical conditions
This level of self care deficit is related to uncompensated hemiplegia. The patient learns to compensate through rehabilitation.
Self-care deficit (Level 3) - Cerebrovascular accident
This scale is used under Activity-Exercised pattern and is counted from 6 to 20.
Rating of Perceived Exertion (RPE) Category Scale
This scale is used under Activity-Exercised pattern and is counted from 0 to 10. This is subjective to the patient and is used to note the dismiss scale (usually used by the respiratory therapist).
Modified Borg Dyspnoea Scale
This is used to help the patient describe how various activities, weather patterns, or other factors affect his or her breathing. Keeping a diary between clinic or office visits may be helpful to identify needs for learning energy conservation methods
Grading Dyspnea Scale
Under grading dyspnea, this grade shows not troubled by breathlessness except with strenuous exercise.
Grade 0
Under grading dyspnea, this grade shows that patient walks more slowly on a level path because of breathlessness than do people of the same age or has to stop to breathe when walking on a level path at own pace.
Grade 02
Under grading dyspnea, this grade shows that the patient stops to breathe after walking about 100 yards on a level path.
Grade 03
Under grading dyspnea, this grade shows that the patient is too breathless to leave the house or breathless when dressing or undressing.
Grade 04
Under grading dyspnea, this grade shows that the patient is troubled by shortness of breath when hurrying on a level path or walking up a slight hill.
Grade 01
This classification is widely used in cardiac care and is useful for nurses when assessing activity intolerance. It is also useful for before-and- after measures when recommending conditioning exercises or progression in a cardiac rehabilitation program.
Functional Capacity Assessment of Activity Tolerance
Under grading Functional Capacity Assessment of Activity Tolerance, this class indicates ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
Class 01 - No limitation
Under grading Functional Capacity Assessment of Activity Tolerance, this class indicates that the patient is comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
Class 02 - Slight limitation
Under grading Functional Capacity Assessment of Activity Tolerance, this class indicates that the patient Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class 03 - Marked Limitation
Under grading Functional Capacity Assessment of Activity Tolerance, this class indicates that the patient has the
Inability to carry on any physical activity without discomfort. May have symptoms of heart failure or anginal syndrome at rest
Class 04 - Severe Limitation
This patterns describes patterns of sleep, rest and relaxation.
Sleep-Rest Pattern
Fast-paced societies are associated with what?
higher percentages of people with sleep deprivation.
Changes in sleep patterns occur when?
Changes in sleep patterns occur with admission to hospitals and other health-care facilities. Hospitalized patients can experience frequent sleep interruptions that lead to sleep deprivation.
What is the benefit of afternoon naps?
The benefit of the afternoon nap as a response to postprandial (after meals) lethargy is being recognized by some businesses, which are making allowances for power naps of 20 minutes
What are some causes of sleep deprivation?
(1) Pain
(2) Anxiety
(3) Fear
Under the sleep-rest pattern, which individuals are at risk?
(1) Shift work job
(2) Daytime boredom and inactivity
(3) Unrelieved Pain
(4) Restless leg syndrome
(5) Nocturia
(6) Anxiety
(7) Depression
(8) New parents
(9) Teenagers
(10) Cardiac or respiratory patients with dyspnea
(11) Post stroke patient
(12) Working Parents
(13) Home caregivers
What should the nurse note during assessment of sleep-rest pattern?
(1) When there are time pressures, screen this pattern with observation and the question: Do you generally feel rested and ready for daily activities after sleep?
(2) Pain can interfere with sleep, and sleep deprivation can increase the sensitivity to pain.
(3) Snoring may be a sign of sleep apnea and can produce sleep deprivation in the sleep partner. Daytime drowsiness, auto accidents due to falling asleep, and other problems can also be caused by sleep apnea.
(4) Listen when elderly people report insomnia. It is a myth that older people need less sleep.
This may be a sign of sleep apnea and can produce sleep deprivation in the sleep partner
Snoring
What are common problems that can also be caused by sleep apnear
(1) Daytime drowsiness,
(2) auto accidents due to falling asleep, and other problems can also be caused by sleep apnea.
This scale can be used if you suspect problem and to gauge its extent. It can be either be filled out by the patient or read to him or her.
Epworth Daytime Sleepiness Scale (The last two items, when rated as a chance, require counseling and referral. How likely are you to doze off or fall asleep in the following situations, in contrast when you are tired?)
What are the different grades under the Epworth Daytime Sleepiness Scale?
(1) 0 - would never doze off
(2) 1 - slight chance of dozing
(3) 2 - moderate chance of dozing
(4) 3 - high chance of dozing
This pattern describes patterns of perception and cognition.
Cognitive - Perceptual Pattern
What does the cognitive-perceptual pattern include?
(1) Ability to collect and use information from the environment.
(2) Decision-making and other cognitive processes of individuals, families, and communities.
What does the cognitive-perceptual pattern focus?
The cognitive-perceptual pattern focuses on the person’s ability to collect information from the environment and use it in reasoning and other thought processes. Included are:
(1) Adequacy of vision, hearing, taste, touch, kinesthesia, and smell.
(2) Compensations or prostheses currently used, such as glasses and hearing aids.
(3) Pain and how it is managed.
(4) Cognitive functional abilities, such as orientation, memory, reasoning, judgment, and decision making.
Under cognitive-perceptual, who are the individuals at risk?
(1) Familial history of glaucoma.
(2) Age:
(a) Vision: ≥40 years.
(b) Hearing: 260 years.
(c) Smell, touch, kinesthesia: 270 years.
(3) African descent (vision).
(4) Excessive noise exposure, such as in the workplace or loud music.
(5) Circulatory problem.
(6) Trauma or surgical incisional pain.
(7) Cardiac or chest pain.
(8) Arthritis or joint pain.
(9) Burns.
(10) Cancer.
(11) Dementia, Alzheimer’s disease, and other neurological degenerative diseases.
(12) Hypoxia.
(13) Taking medications affecting cerebral function.
What should nurses note when assessing patients under cognitive-perceptual pattern?
(1) Look for a pattern, not isolated behavior. Everyone at times forgets things, makes incorrect statements or poor decisions.
(2) Look for compensations when memory or decision making starts to deteriorate. Many people try to hide early deficits so family and friends will not know.
(3) Self-denial occurs when changes cause anxiety. Recognize that it is very frightening to perceive mental changes in oneself or to recognize the beginning of vision or hearing loss.
(4) Any problem the patient describes during assessment may be used to measure reasoning, judgment, and problem-solving ability.
(5) Disorientation and confusion may occur in the elderly when there is some loss of vision or hearing. Watch for this change, particularly in the evening.
This occurs when changes cause anxiety. Recognize that it is very frightening to perceive mental changes in oneself or to recognize the beginning of vision or hearing loss.
Self-denial
This may occur in the elderly when there is some loss of vision or hearing. Watch for this change, particularly in the evening.
Disorientation and confusion
Memorize areas of identified pain
The data for assessing judgment and decision making may have to be collected over time in some cases. Family may be able to provide information.
Judgment and Decision-Making Scale
Under Judgment and Decision-Making Scale, this shows that client’s decisions are consistent, reasonable, safe.
0 - Independent
Under Judgment and Decision-Making Scale, client finds some difficulty in new situations.
1 - Modified independence
Under Judgment and Decision-Making Scale, in specific situations, decisions become poor or unsafe and cues/supervision necessary at those times.
2 - Minimally impaired
Under Judgment and Decision-Making Scale, client’s decisions consistently poor or unsafe, cues/supervision required at all times.
3 - Moderately impaired (Patients with self-harm)
Under Judgment and Decision-Making Scale, client never or rarely makes decisions.
4 - Severely impaired
This scale is used to determine level of consciousness on the basis of the individual’s best eye, verbal, and motor response to stimuli during an interaction. The following is a method of classifying the assessment data.
Level of Consciousness Classification
Under Level of Consciousness Classification, patient is awake and aware of normal external and internal stimuli. Able to interact in a meaningful way with the nurse.
Alert
Under Level of Consciousness Classification, patient is not fully alert. Tends to drift to sleep when not stimulated, diminished spontaneous physical movement, loses train of thought, ideas wander.
Lethargy or somnolence
Under Level of Consciousness Classification, this is the transitional stage between lethargy and stupor; difficult to arouse, meaningful testing futile, requires constant stimulation to elicit response.
Obtundation
Under Level of Consciousness Classification, patient mumbles or groans in response to persistent and vigorous physical stimulation.
Stupor or semicoma
Under Level of Consciousness Classification, patient cannot be aroused. No behavioral response to stimuli.
Coma
This is a widely used scoring system to quantify level of consciousness after brain injury.
Glasgow Coma Scale
What are the factors tested under the Glasgow Coma Scale?
(1) Eyes open
(2) Best Verbal Response
(3) Best Motor Response
(EVM)
What are the grades to be recorded under eyes in the Glasgow Coma Scale?
4 - Spontaneous
3 - To command
2 - To pain
1 - Unresponsive
What are the grades to be recorded under verbal response in the Glasgow Coma Scale?
5 - Oriented
4 - Confused
3 - Inappropriate
2 - Incomprehensible
1 - Unresponsive
This pattern describes self-concept and perception of self-worth, self competency, body image, and mood state.
Self Perception and Self Concept Pattern
What are the grades to be recorded under motor response in the Glasgow Coma Scale?
6 - Obeys commands
5 - Localizes pain
4 - Withdraws from pain
3 - Abnormal Flexion
(usually found in patients with cortical problems or problems in the brain) - Decorticate Posturing
2 - Abnormal Extension - Decerebrate posturing
1- Unresponsive
This is the body boundary that defines the person, distinguishing the self from non-self. Name is important in identity
Self-identity
These are the thoughts and feelings that comprise self-evaluation, or the self-portrait of oneself.
Self-esteem or self-worth
This is the self-evaluation of capabilities: cognitive, social, and physical.
Self-competency
This is the mental picture of one’s body related to appearance and function.
Body image
What else does the Self-Concept and Self-Perception focus on?
In addition, this pattern is focused on feeling and mood states, such as: Happiness, Anxiety, Hope, Power, Anger, Fear, Depression, Control
What is the GCS of a patient with coma?
3
This describes pattern of role engagements and relationships.
Role-Relationship Pattern
What are different nursing diagnoses under Self Concept and Self Perception pattern?
(1) Anxiety
(2) Chronic self anxiety
(3) Death anxiety
(4) Negative Body Image
(5) Fear, hopelessness, or powerlessness
Under Role-Relationship Pattern, who are the individuals at risk?
(1) Non-elective hospitalization.
(2) Isolation from family and friends during crisis.
(3) Language barrier.
(4) Loss of:
(a) Significant person or pet.
(b) Possession.
(c) Job or status.
(5) Significant home care or dependent needs.
(6) Prolonged caregiving.
(7) History of antisocial violence or abuse. History of drug or alcohol.
(not concerning the patient’s environment)
What should nurses note under Role-Relationship Pattern?
(1) An occupational history can reveal exposure to stress, accidents, or environmental contaminants.
(2) When assessing work stress, use open-ended questions. If warranted, follow with focused questions to obtain specific details.
(3) If a family has recently moved from another country, moved within a country, or left a familiar lifestyle, this may cause feelings of loss and isolation.
(4) Confusion or increased mortality is a risk if elderly moved within and between nursing homes against wishes.
(5) When assessing marital, sibling, parent-child, patient–care provider relationships, observe a few interactions over time before making an inference. This avoids errors. An exception to this rule is when you assess threats of violence or abuse.
If a family has recently moved from another country, moved within a country, or left a familiar lifestyle, this may cause feelings of ________________.
loss and isolation.
This is a risk if elderly moved within and between nursing homes against wishes.
Confusion or increased mortality
In this, men and women may be victims or perpetrators of domestic violence in either heterosexual or same-sex relationships. Only the care provider and patient should be present during assessment, including when screening teens about their dating relationships.
Screening for Domestic Violence
What are some questions to be asked under Screening for Domestic Violence?
(1) How would you describe your relationship?
(2) How do you and your partner settle arguments?
(3) Do you feel safe in your current relationship?
The following is a listing of possible caregiving needs in the home. Assess pre-discharge or at a home visit or a nursing home. Check items requiring either assistance from another person (A) or supervision (S).
Caregiving Needs Checklist
What are the different types of nursing diagnoses under role-relationship pattern?
(1) Caregiver role strain
(2) Chronic Sorrow
(3) Complicated grieving
(4) Dysfunctional family processes
(5) impaired parenting
(6) impaired social interaction
(7) impaired verbal communication
(8) Ineffective role performance
(9) social isolation
This health pattern describes pattern of reproduction and of satisfaction or dissatisfaction with sexuality.
Sexuality-Reproductive Pattern
What does the Sexuality-Reproductive Pattern include?
(1) Perception and feeling of being male or female that develops from bio- psycho-cultural influences starting in early childhood. It is influenced by nature (genetics) and nurture (environment).
(2) Attraction and feelings toward members of the opposite, same, or both genders, also known as sexual orientation.
Under Sexuality-Reproductive Pattern, who are the individuals at risk?
(1) History of sexual abuse.
(2) Multiple sex partners.
(3) Unprotected sex.
(4) Marital conflict.
(5) Domestic violence.
(6) Alcohol abuse (episodic or chronic).
(7) Illness, such as diabetes.
(8) Medications, such as hypertensive medications.
(9) Neurovascular (male) and hormonal (female) changes of aging.
(10) Conflicts (social and peer pressures versus prohibitions and values).
(11) Body or self-image disturbance.
Under Sexuality-Reproductive Pattern, what should the nurse note during assessment?
(1) Ask screening questions in a voice and manner similar to the way other patterns are assessed to let the person know it is all right to discuss sexual concerns.
(2) The nurse chooses the most comfortable communication for her
or his level of expertise:
1. Permission: both verbal and nonverbal message that it is
acceptable to ask questions
2. Limited Information: Information is provided.
3. Specific Suggestions: For the problem.
4. Intensive Therapy: Consult sexuality specialist.
What are the different nursing diagnosis under sexual - reproductive pattern?
(1) Ineffective sexuality pattern
(2) Rape Trauma Syndrome
(3) Sexual dysfunction
This pattern describes pattern of coping and effectiveness of the pattern in terms of stress tolerance.
Coping Stress Tolerance Pattern
This is a process, event, person, or situation that produces a fight-or- flight, psycho-physiological response when a threat to self-integrity is perceived.
Stressor
This is manifested as fear or anxiety, it is an autonomic response to a threatening event.
Psychological Stress
This is a response of body systems to internal or external demands, such as what the heart and circulatory system experience during exercise.
Physiological Stress
These are behaviors used to manage anxiety or fear related to a threatening event. Strategies are effective (adaptive) or ineffective (maladaptive).
Coping Strategies
Effective coping strategies lead to what?
Effective strategies control anxiety and lead to problem solving
Ineffective coping strategies lead to what?
Ineffective strategies can lead to abuse of food, tobacco, drugs, or alcohol
This is the capacity to manage threats to self integrity.
Stress tolerance
Under Coping Stress Tolerance Pattern, who are the individuals at risk?
(1) Uncertainty in diagnosis or prognosis.
(2) Financial problems.
(3) Marital problems.
(4) Interpersonal conflict.
(5) Health-related decisional conflict.
(6) Poor job fit.
(7) High demand/low control jobs.
(8) High job effort/low reward.
(9) Few close friends and family.
What should the nurse note under Coping Stress Tolerance Pattern?
(1) Assess two important factors when a person or family is dealing with illness, disability, or other stressful event: self-esteem and a belief in the ability to cope.
(2) When stress tolerance is exceeded by excessive demands that require action, stress overload occurs. Have the patient rate his or her stress level on a scale of 1 to 10. A score of 7 or above is a diagnostic cue for stress overload.
(3) Avoid superficial assessment and premature closure on a judgment of Ineffective coping when assessing a patient who is not managing his or her disease, medication, or dietary or activity prescription.
(4) Assess coping strategies during the time lapse between tests and diagnostic results, especially if traumatic news is likely.
Under classification of coping strategies, the patient uses realistic appraisal, plans, and actions to deal with a stressor and associated emotional reaction.
Problem solving
Under classification of coping strategies, patient is excelling in one area to overcome a real or imagined deficit in own behavior.
Compensation (naghahanap ng iba)
Under classification of coping strategies, patient is using an excuse to justify behavior.
Rationalization
Under classification of coping strategies, patient is not acknowledging anything that might cause emotional distress.
Denial
Under classification of coping strategies, patient is placing traumatic events out of awareness so they cannot be unconsciously remembered.
Repression (kinakalimutan yung traumatic events)
Under classification of coping strategies, patient is modeling oneself after the behavior or appearance of another person.
Identification (naghahanap ka ng role model)
Under classification of coping strategies, patient is denying feelings by responding with impersonal or theoretical statements
Intellectualization (trying to make it more scientific)
Under classification of coping strategies, patient’s behavior is more appropriate for an earlier developmental period.
Regression
Under classification of coping strategies, patient is redirecting an unacceptable tendency to a more acceptable one.
Sublimation
Under classification of coping strategies, patient is deciding consciously not to act.
Suppression
Under classification of coping strategies, patient is shifting feelings from a less socially acceptable or threatening object or person to one more acceptable.
Displacement
Under classification of coping strategies, patient is losing self identity.
Depersonalization (referring yourself as the third point of view)
This health pattern describes pattern of values, beliefs (including spiritual beliefs), and goals that guide choices and decisions
Values-Belief Pattern
This is something that is accepted as true with an emotional or spiritual sense of certainty.
Belief
This is an accepted principle or standard of an individual or group.
Value
This is a way of living that comes from a set of meanings,
values, and beliefs that are important to the person. Meanings can focus on purpose in life, hope, and suffering.
Spirituality
This is the practice of behavior that furthers the common good and is based in philosophical and theological principles. It is commonly referred to as good
conduct.
Morality
This is an inner knowing about ideas, people, and events.
Faith
This is the belief in a supernatural power that has
created the universe and has involvement in human life. Each religion has a set of practices, beliefs, and a theology
Religion
What are the nursing diagnosis under the Coping Stress Tolerance Pattern?
(1) Compromised Family Coping
(2) Defensive Coping
(3) Ineffective Community Coping
(4) Ineffective Denial
(5) Post Trauma syndrome
(6) Readiness for Enhanced Coping
(7) Risk Prone Health Behaviors
(8) Stress
Under Values-Belief Pattern, which individuals are at risk?
(1) Life transitions, such as maturational transitions and retirement
(2) Cultural barrier to practicing religion.
(3) Terminal illness.
(4) Uncontrolled pain or chronic pain.
(5) Loss of significant person, pet, job, body part, or bodily function.
(6) Decisional conflict, such as choice between equally risky alternatives.
(7) Values conflict.
(8) Lack of social support.
(9) Loneliness.
The purpose of this scale is to help the patient talk about his or her spirituality in a nonthreatening way and to give you a sense of the importance of spirituality in your patient’s life so that you can plan appropriate interventions.
Jarel Spiritual Well-Being Scale
Under Values-Belief Pattern, what should the nurse note during assessment?
(1) Avoid cultural or religious stereotyping of spiritual needs. Assumptions, rather than assessment, can lead to errors because individual differences exist within cultures and religions.
(2) Assessing spiritual needs requires concern, empathy, sensitivity, listening, and time. Listening can be, simultaneously, both diagnostic and therapeutic.
(3) Hospital patient records do not reflect spiritual needs assessment (Cavendish et al., 2003; Byrne, 2002; Broten, 1997).
(4) Limiting assessment to religious preference may miss individuals and families in spiritual distress, such as those patients who are searching for meaning in illness, have lost the will to live or the feeling of connectedness, and who experience feelings of abandonment when dying.
