Gordon's Health Assessment

AssessmentUsingFunctionalHealth Patterns

23

Refer to Chapter 2 Assessment, p. 64: Care Plans Developed after usingFunctional Health Patterns Assessment ModelClients name: Mrs. Mary AcostaAge: 55Are there differences between the Body Systems Model and the FunctionalHealth Pattern Model?Document Includes: Student Activities 13, Pathoflow sheet, Scenario withClient Assessment, and 4 Care Plans

Activity 1Compare the Functional Health Pattern Model with the Body Systems Model.Note the areas that lend themselves specifically to nursing assessment such asHealth Perception/Health Management Pattern. When using this model be sureto address all the component parts.

Activity 2Note the scenario for aid in proper identification of the client, the pathoflowsheet for the likely pathophysiological sequencing of events of the diseaseprocess, the complete assessment format, and the four prioritorized nursing careplans.

B2

Appendix

Age Ethnicity

Hyperinsulinemia

Beta cell exhaustion

Hypoinsulinemia

Release of epinephrine

Diabetes mellitus type II

Heredity Virus exposure Idiopathic ObesityLack of exercise

Tissue Resistance to Insulin

Increased insulin

Decreased blood sugar

Release of epinephrine

Body reacts tothis as starvation

Polyphagia

Increased blood glucose that cannotenter the body cells

Hyperglycemia

B-Cellglucosetoxicity

Excessive hepatic glucose production

GlycosuriaSolutediuresis

Plasmahyperosmolarity

OsmoreceptorsDehydration

Polyuria

Activation of thehypothalamictrist center

Increased glucose in kidney acts as osmotic diureticRelease of glucagon

Release of glycogen mobilization of fatty acids

Hyperglycemia Inhibition of water reabsorption

Client: Mrs. Mary Acosta

Hemoconcentration

Hyperviscosity

Anuria

Decreasedrenal

perfusion

Hypovolemia

MI

Retinopathy

Microvasculardamage and

occlusion of rentinalcapillaries

Microaneurysmin capillary

walls

Capillary fluidleaks

Retinal edema

Hard exudateintraretinal

hemorrhageVision changes

Renal failure

Basement membraneof kidney thickened

and leaky

Diffuse/nodularglomerulosclerosis

Nephropathy

Microangiopathy

Neuropathy

Gluconeogenesis

Free fatty acidsand proteins

Inhibition ofperipheral

glucose use

Polydipsia

Release ofadenocorticotrophic

hormone

Release of growth hormone

Release of corticosteroids

Liver

Gluconeogenesisand glycogenolysis

Parenthesis

Loss ofsensation

Amputation Gangrene

Thrombosis

Decrease immune function

Infection

Increase inWBC

Easyhemorrhaging

Bleeding invitreous cavity

Maculainvolvement

Blindness

Hypotension

Tissue Anoxia

Macroanogiopathy

Athereosclerosis

Cardiovasculardisease

Cerebrovasculardisease

PVD

Infection

Hyperglycemia

Dehydration

Oliguria

Electrolyte imbalance

Decreased protein

Decreasedpotassium

Fluid volume deficit

Osmotic diuresis

Decreased sodium

Neovascularization

FIGURE B21 Diabetes Mellitus Type II Pathoflow Sheet (relates to functional health pattern).

Activity 3Use the guidelines in Appendix A to determine if each of the four care plansare individually sequenced and if the goals are met.

HEALTH HISTORY

Client Assessment According to Functional Health Pattern

The scenario: Mrs. Mary Acosta is a 55-year-old female who was admitted to thehospital with a medical diagnosis of diabetes Type-II and hyperglycemia (bloodsugar 400) and vomiting; states she was diagnosed with diabetes 5 years ago.

1. Client ProfileMA is a 55-year-old white female born in New York. She grew up inAustin Texas where she lives with her husband of 30 years. Her major rea-son for seeking health care is extreme weakness, nausea, and vomiting.Source of history is the client who seems reliable.

2. Treatment/Medications(a) Glucophage: 10 mg in morning at breakfast and 5 mg after dinner

(antidiabetic agent)(b) Over the counter drugs: None

3. Past Illnesses/HospitalizationsDiabetes mellitus type-II for 5 yearsPeripheral vascular disease

4. Allergies(a) Codeine, generalized rash(b) Denies any food and environmental allergies

5. Developmental HistoryDevelopmental level: Integrity vs. despairDescribes self as one of eight children who never had enough to eathence she was sent to an uncle in Texas. This she regrets because shewas never allowed to return to visit her family until she was grown.States I smoked heavily (two packs a day) but stopped when I was diag-nosed with diabetes. MA has been married for 30 years and attends aBaptist church with her husband periodically.

6. Health Perception/Health Management Pattern Clients rating of health scale: (1worst, 10best)

5 years ago rated at 7.

26 Appendix B2

Now rates health at 5; states Not so good, too much vomiting5 years from now, hopes to rate at 7, Hopefully healthier

Denies use of tobacco, drugs, or alcohol Understands that she has diabetes but does not know how to care

for the disease Expects vomiting to stop, diabetes to be controlled and to be dis-

charged from hospital in two days Noncompliance with diet and diabetic medication, forgets to take

Glucophage.7. Nutritional/Metabolic

Height: 5 3 Weight: 190 lbs Ideal body weight: 125130 lbs Usual eating pattern: Good appetite eats three meals a day and

many snacks, has not eaten today, vomited all day Oral temperature 98F Signs of dehydrationdecreased skin turgor Does not wear dentures, last dental exam was two years ago Nails hard and smooth. No recent hair loss or change in texture. No

complaint of itching or nonhealing sores (has small discolored spoton left great toe). No excessive dryness or moisture, rash, or otherlesions. Voices intolerance to heat, I prefer the winter.

8. Elimination Pattern Bowel habits: States I have at least two bowel movements a day

(soft and brown) no mucus, blood, or tarry stool. No rectal bleed-ing, change in color or consistency of stool.

Bladder habits: Has been voiding very frequently for the past threedays (frequency with nocturia)

9. Activity Exercise Pattern States she arises at 0630, does her chores around the house and eats

breakfast with her husband at 0700 and eats her own breakfast atabout 0900. Sometimes she either forgets to take the Glucophage orher supply is depleted.

Extreme weakness for the past three days; has been in bed Has no regular exercise regimen, watches soap operas most of the day

10. Sexuality Reproductive Pattern Obstetric History: gravida 5, para 5, Abortions 0 Children living, five all adults, three reside in close proximity to

patient

Appendix B2 27

11. Sleep/Rest Pattern Goes to bed at 2200 and awaken at 0630. States she often has trou-

ble falling asleep because of discomfort in her legs. Sometimes shedoes not feel rested when she awakens. No use of sleep aids. Sleepswith one pillow, has no difficulty breathing at night.

12. Sensory/Perceptual Pattern Vision: wears glasses for reading but sometimes her vision is blurred.

Denies itching, excessive tearing, discharge, redness, or trauma to eyes. Hearing: Does not wear hearing aids. Does not ask for questions to

be repeated at normal hearing level. Smell: States she has no decrease in smell. Denies pain, allergies,

nosebleeds, or discharge. Touch: States her feet often feel numb. States she has been adding more salt to her diet because her food

never tastes good. Pain: admits pain in both legs, sometimes the pain radiates down

my legs.13. Cognitive Pattern

Speech clear without stutter. Word choice appropriate to educationand culture. Follows verbal cues.

Examines ideas clearly and concisely. Recalls past events withoutdifficulty, orientated to time, place, and person.

14. Role/Relationship Pattern Married for 30 years. Lives with husband. Has five grown children,

three of whom live very close to her. They are very caring and visitoften. When she is well she sometimes babysits her grandchildren.Has a total of ten. The two children that are away call very often.She is the fourth of eight children.

15 Value Belief Pattern Religious orientation is Catholic but is now nonpracticing

16. Coping/Stress Tolerance Pattern States the overweight creates great stress. Facial muscles tense.

NURSING PHYSICAL ASSESSMENT

General Physical Survey

Height: 5 3, weight: 190 lbs., ideal weight: 125130 lbs. Temperature: oral98.0F, pulse100, respirations26, blood

pressure130/86 lying, client attentive and cooperative. Lying in

28 Appendix B2

low Fowlers position muscles on face tense, dressed appropriatelyfor the occasion (wearing hospital gown).

17. Assessment of Skin, Hair and Nails Skin: light brown color, consistent throughout body. Temperature

cool on hands, arms, legs, and feet. Skin smooth, slightly dry (dehydration). Skin turgor poor (skin remains tented for several sec-onds over clavicle), small discolored spot on left great toe. Noedema.

18. Assessment of Head and Neck Hair: Shoulder length, graying, straight, and full. No hair on back,

legs or face. Nails: Fingernails short, thick, and clear. No clubbing or Beaus lines.

Capillary refill reflects pallor (poor capillary refill) bilaterally. Blood profile: Hbg9.0 (normal: 1216 g/dl), HCT29.0 (normal:

3747 %), RBC3.1 (normal: 4.24.8 million/cu)19. Assessment of Eye

Head symmetrically rounded, neck with full ROM, and nontender.No scars, masses or pulsation. Trachea midline. Carotid pulse2 bilaterally without bruits, can raise eyebrows, puff cheeks, frown,and smile (CN VII intact).

20. Assessment of Ear Equal size and shape bilaterally. No swelling, redness, or thickening.

Skin color consistent with color of skin on face. No lumps orlesions. Pinna firm and nontender bilaterally. Mastoid process pal-pation painless. Voice test positive (heard words as whispered bilat-erally CN VIII). Webersound heard in both ears (negative),Rinnes test ACBC (Positive Rinne).

21. Assessment of Nose and Sinuses Nares patent. Nasal septum: midline without bleeding or perfora-

tion, no inflammation on skin lesions. Frontal and maxillary si-nuses nontender bilaterally.

22. Assessment of Mouth and Pharynx Lips moist and pink. No lesions or ulcerations. Buccal mucosa pink and moist, no discoloration, increased pigmen-

tation, bleeding, or discoloration. Hard palate smooth without lesions and masses. Tongue midline when protruded, no fasciculation (CN XII) intact,

no masses or lesions.23. Assessment of the Heart

No visible pulsation, heaves, lifts, or vibrations.

Appendix B2 29

S1, S2 sounds, heard no splitting sounds, murmurs, gallops, or rubs. Point of maximum impulse at 5th intercostal space, left mid-clavicular line (PMI 5th ICS at LMCL).

24. Assessment of Peripheral Vascular System Arms: equal in size and symmetry, cool and dry to touch bilaterally,

no edema or lesions. Radial pulse100, and regular Amplitude of radial and brachial pulses 1 bilaterally. Epitrochlear nodes unpalpable. Capillary refill does not return immediately (3 seconds). Legs: equal in size and symmetry. Small discolored area on left great toe, skin cool to touch, dry, no edema. Pedal and posterior tibial pulses 1 bilaterally. Homans sign negative bilaterally. Toenails fairly soft. Capillary refill 3 seconds.

25. Assessment of Thorax and Lungs No visible pulsation or lesions present. No use of accessory muscles

of respiration, no nasal flaring, tenderness, or masses Respirations24 per minute and regular. Neither cough nor adven-

titious sounds. Tactile fremitus equal bilaterally. Resonance throughout lung fields.

26. Assessment of Breast Breasts symmetrical in size. No masses, lesions, tenderness on pal-

pation bilaterally. No dimpling or inverted nipples.27. Assessment of Abdomen

Abdomen: No distention, symmetrical without masses or lesions. Umbilicus midline without swelling or discoloration. Bowel sounds present in all four quadrants (hyperactive). Vomiting

for one day. No tenderness on light and deep palpation.28. Genitourinary Assessment External Assessment

Pubic hairs sparse, labia flattened, vula atrophied.29. Musculoskeletal Assessment

Walks to bathroom, gait steady, upper extremities have full range ofmotion, muscles strong.

Lower extremities: cool to touch, complained of radiating pain,pulses diminished.

Discolored area on left great toe. Shrugs shoulders and moves headto right and left against resistance without weakness (CN XI intact).

30 Appendix B2

30. Neurological Assessment Neurological status: Orientated to time, place, person, and events. Facial expression correlates with state of health and topic being dis-

cussed (appears somewhat sad and anxious). Speech clear, coherent. Questions answered appropriately Long-term and short-term memory intact. Cooperative throughout interview, vocabulary correlates to educa-

tion level. Asked appropriate questions relevant to illness and answered all

questions posed. CN I-XII intact and integrated

Appendix B2 31

Subjective data:Client states I havebeen vomiting for awhole day.I am very weak, I amstill nauseated, I am nothungry, and I cant stoprunning to thebathroom.

Objective data:Skin cool and dryDisplays moderate tohigh level of anxiety(anxious look)No engagement inactivities of daily livingVomited twice withinlast 3 hours (clear andwatery)Blood sugar400 mg/dlon admission Lost 8 lbs. in 3 daysTongue somewhat dryand mildly coatedSkin fold returns tooriginal state in > 3seconds (over clavicle)HGB 9.0 g/dl (normal1216)

Nutrition imbalanced, lessthan body requirements asevidenced by prolongedvomiting for 24 hours, dryskin and frequency ofmicturition (fluid volumedeficit)

Defining characteristics: Decreased oral intake Anorexia Nausea Weakness Fatigue Weight loss Inadequate food intake Lack of interest in food Change in blood profile

RBCHCTHGB

Short term:Client will deny nausea.Client will demonstrate nofurther vomiting.Clients skin will be moist and warm.Client will void lessfrequently and smalleramounts (secretes at least 30cc of urine per hour).Skin fold will return tooriginal state in less than 3 seconds (over clavicle).

Long term:Client will ingestappropriate amounts ofcalories/nutrients.Client will display usualenergy level.Weight will be stabilized.Blood profile will return tonormal range.RBCHCTHGB

Independent: Client Teaching: Inform client that vomiting

and frequent voiding are dueto diabetes out of control.

Diabetics develop complica-tions by non-compliance(diabetic keto acidosis). Theseare temporary conditions andcan be prevented.

Give client tools to controlnausea and vomiting: Oral care after each episode. Cool damp cloth to forehead,

neck, and wrist. Relaxation techniquesdeep

breathing and imagery. Rest before meals. Pleasant relaxed atmosphere

before meal times (no emesis basin, bedpans, orwash basins in view duringmeal time).

Sit up for about two hours. Provide small meals initially,

consistent with diabetic diet(food not too cold or hot).

Knowledge of cause andeffect relationship anddisease prognosis createshope and encourages self-involvement in treatmentregimen.

Knowledge of cause andeffect relationship anddisease prognosis createshope and encourages self-involvement in treatmentregimen.

Removes unpleasant taste. Provides comfort.

May decrease anorexia andpromote desire for more fluids.

Increases energy. Prevents nausea.

Prevents overdistention andregurgitation.

Prevents irritation of thegastrointestinal mucosa.

Short-term goal met:Care plan implementedas written. Client compliant.Vomiting subsided,output approximatedintake.

Long-term goal met:Tolerating food andfluids. Dehydrated stateimproved.Will access blood profileat later date.

continues

CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 1AGE: 55 Relates to Functional Health Pattern Assessment

Ordered &Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation

32

HCT29% (normal3747)RBC3.1 million/cu(normal 4.24.8)

Instruct client to avoiddrinking while eating.

Maintain semi-Fowlersposition.

As nausea subsides, providehigher caloric/proteins inportions (consistent withdiabetic diet).

Consider food idiosyncrasies/culture and provide foodexchanges according toclients food likes and dislikes.

Include iron-rich foods(consistent with diabetic diet)to control low RBC, HCT, HGB.

Administer intravenous fluidsas ordered.

When nausea subsides, offeroral fluids (68 eight-ounceglasses of water per day).

Monitor blood glucose(Normal 90120 mg/dl) levelsat least every four hoursbefore meals and administeranti-diabetic medication asordered according to bloodglucose levels.

Dependent: Administer antiemic

medication one half hourbefore meals.

Enhances digestion (liquidsmust be absorbed beforedigestion begins).

Decreases chance ofregurgitation.

Provides additionalnutritients.

Food preferences and cultureoften influences foodchoices.

Foods rich in iron willimprove blood profile.

Prevents dehydration andmaintains electrolyte balance.

Enhances hydration.

Aids in carbohydratemetabolism.

Relieves vomiting.

CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 1 (continued)AGE: 55 Relates to Functional Health Pattern Assessment

Ordered &Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation

References: Doenges, M., Moorhouse, M., & Geissler-Murr, A. (2002). Nursing care plans: Guidelines for individualizing patient care. Philadelphia: F.A. Davis. Kozier, B., Erb, G., Berman, A., & Burke,K. (2002). Fundamentals of nusing: Concepts, process, and practice. Upper saddle River, NJ: Prentice Hall health. Gulanic, M., Klopp, A., & Galanes, S. (Eds.) (1998). Nursing care plans: Nursingdiagnosis and nursing intervention. St. Louis, MO: Mosby.

Subjective data: Client states I feelextremely weak.

Objective data:Lying in bedVomited twice inthree hoursRequested help tobathroomMarked weakness,tends to lie in onepositionFeet cold to touch.Peripheral pulsesdiminished in lowerextremitiesDarkened spot on leftgreat toe

Risk for injuryrelated toweakness fromprolongedvomiting, probablydehydration andaltered tissue perfusion.

Defining characteristics: Altered mobility Fatigue Weakness Altered peripheral

tissue perfusion

Short term:Client will discussimportance ofseeking help toambulate on06/09/03.

Long term:Client will be injuryfree on 06/19/03.

Independent: Assess orientation. Assess muscle strength, share

findings with client.

Allow client to express ownfeelings.

Correlate clients statementwith objective findings.

Instruct client to use call bell to ask for assistance in allactivities of daily living untilstrength is regained.

Keep environment safe: siderails up when client is in bed.

Bed in lowest position.

Room well lighted anduncluttered, includingbathroom, and use a nightlight.

Assist with ambulation.

Determines cognitive ability. Determines amount of

activity that can betolerated.

Develop clients awarenessof state of illness.

Establish clientsknowledge about thisparticular condition.

Promotes safety.

Promotes safety andgenerates confidence aboutcare given during theclients dependency state.

Promotes safety andprevents accidents (rollingout of bed).

Reduces trauma if clientgets up without assistance.

Reduces incidence ofslipping, sliding, and falling.

Short-term goals met:Client stated she feltweaker than beforeand will seek helpgetting up.

Long-term goal met:Client sustained noinjury.

continues


Ordered & Nursing Selected Data Diagnosis Goals Interventions Rationale Evaluation

34

Answer call bell promptly.

Meet needs as soon asidentified.

Provide nonskid slippers. Assess for orthostatic

hypotension. Assess vital signs before

ambulation.

Assess peripheral pulses andassess for Homans sign beforeambulation.

Examine lower extremities forbruits, color change, and pain.

Allow private time while clientis in bathroom.

Stay in close proximity. Check clients condition and

needs frequently while inbathroom.

Do not forget client inbathroom.

Reassess client afterambulation.

Dependent: Provide assistive device

(walker) when ambulating

Enhances security andbuilds trust.

Same as above.

Promotes safety. Determines if client is able

to tolerate ambulation. Determines circulation

status (oxygenation totissues).

Same as above.

Same as above.

Provides privacy and timefor concentration andreflection.

Promotes safety. Same as above.

Demonstrates caring.

Provides cues regardingfurther ambulation.

Decreases chances of fallsand provides stability.



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Subjective data:Client eats threemeals a day alsomany snacksthroughout the day. Isometimes forget totake the Glucophageand sometimes I donot have themedication. I reallydont know how todeal with thisdiabetes.

Objective data:Client is obese (190 lbs.), approxi-mately 60 lbs. overweight.Blood sugar out ofcontrol (400mg/dl) atpresent. Ordered 1800 ADAdiet.

Nutrition morethan bodyrequirementprobably related to: Erratic eating Noncompliance Knowledge

deficit aboutdiabetes

Defining characteristics: Food intake

exceedsmetabolic needs

Weight morethan 20% ofoptimum bodyweight

Dysfunctionaleating pattern

Short term:Client will identifyways to effectivelycontrol her diabetes.Client will verbalizeknowledge about therelationship betweendiabetes, diet,exercise andmedication.

Long term:Client will achieve ahigh level ofwellness:Client will contributeto her own and herfamilys welfare.Client will makecontributions tosociety.Client will achieveweight only 20%above ideal bodyweight (130160 lbs.).

Independent: Teach client that:Diabetes can be controlled.People can lead a normal life

and lose weight when thereis compliance with themedical regimen.

To control diabetes one mustcomply with ordered diet,medications, exercise, anddoctors visit.

Perform a 24-hour diet recall,point out foods that areallowed on ADA diet.

Discern food idiosyncrasies Identify food exchanges that

are being consumed currentlydue to idiosyncrasies.

Inform client to take allmedication (Glucophage).

Walking is the best form ofexercise.

Teaching the benefits ofadherence will createinterest in learning.

Concentration on foodpreferences and cultureidentification will enhancecompliance

Same as above Same as above

Understanding the benefitsof medication shouldenhance compliance.

Comprehensive instructionon the diabetic plan ofcare provides client with aregimen to follow and aidsin weight loss.

Short-term goal met:Client verbalizedunderstanding of theinformation given,stated she wishedshe knew this longago, my healthwould be better.

Long-term goal met:Daughter came toteaching session.Assisted mother withmeal planning andinsulin administra-tion. Stated that bothwould work with thewhole family toimprove their diet.

continues



36

She should walk at least threetimes a week and avoid fatigue.

She should eat lavishly of fruitsand vegetables.

Decrease fat and red meat andshellfish.

Should eat three times a dayapproximately at the sametime each day.

Diabetic medication should betaken at the same time each dayas ordered by doctor (AC meals).

Client is now being regulated on insulin. Encourage client to involve her

daughter in her diabeticeducation.

Discuss equipment/ supplies/teach insulin administration:

Syringes and needles.Insulin type cleaning agent.Infection control.Demonstrate giving injection

using substitute (orange).Repeat until client is

comfortable with technique.Have client administer

several injections beforedischarge. Tell client insulintreatment may be temporarytherapy.

Same as above

Same as above

Same as above

Same as above

Stimulates secretions ofinsulin thus aids indigestion.

Assistance from caregiverscan help the client achievethe desired outcome.

Same as above



37

Subjective data:Client complained ofnumbness in legswith radiating pain.

Objective data:Lower extremitiescool to touch.Pulses diminished.Capillary refillprolonged (>3seconds).Darkened area on leftgreat toe.

Tissue perfusion,ineffective,evidenced by (seeordered andselected data).Risk for infectionrelated to darkenedarea on left greattoe.

Defining characteristics:Skin cool to touchBlanching of skinCapillary refillmore than 3secondsComplaints ofnumbness inextremitiesDiscoloration ofskin

Short term:Client will discussways to improvecirculation andprevent infection.

Long term:Client will reportcapillary refill >3seconds.Lower extremitieswill be warm totouch.Darkened area onleft great toe willshow no signs ofinfection, redness,warmth, pain, ordrainage.

Independent:Give instructions about foot care: Wash feet in warm to cool

water (avoid hot water). Dry feet thoroughly after

each wash. Use lotion lavishly, dry feet

after application Use gentle approach with feet.

Use only emory boards to carefor nails.

Do not wear tight-fitting shoes. Report all cuts and bruises to

doctor immediately.

Adhere to diet.

Keep feet warm when weatheris cold.

Dependant: Carry out doctors and

dieticians orders as prescribed:DietAntidiabetic medication.Exercise regimen.

Poor foot care promotesthe growth of organisms.

Same as above.

Same as above.

Ischemia in lowerextremities predisposesthe diabetic client tobruises and breaks in theskin that may lead togangrene.

Same as above.

Same as above. Prompt reporting

facilitates early treatmentand should reducecomplications.

Diet enhances balancebetween insulin andcarbohydrates, improvesanabolism and circulation.

Facilitates circulation.

Collaborative careproduces positiveoutcome.

Short-term goal met:Client demonstratedreadiness to learnand verbalizedunderstanding andwillingness tocomply.

Long-term goal met:Lower extremities,circulation improved.Capillary refill 2+.



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Gordon's Health Assessment