Nursing Process

OVERVIEW OF THE NURSING PROCESS

A process is a series of steps or acts that lead to accomplishment of some goal or purpose. The
purpose of the nursing process is to provide care for a client that is individualized, holistic,
effective, and efficient. The steps of the nursing process build upon each other, but they are not
linear. There is overlap of each step with the previous and subsequent steps. The nursing process
is dynamic and requires creativity for its application. The steps remain the same, but the
application and results will be different in each client situation. The nursing process is designed
to be used with clients throughout the life span and in any setting in which a nurse provides care
for clients.
Currently, the steps in the nursing process are:
• Assessment
• Diagnosis
• Outcome identification and planning
• Implementation
• Evaluation

Gordon's functional health patterns is 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.
Contents of Gordon’s functional health pattern approach

1. Health Perception and Management
2. Nutrition and metabolism
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

The following questions pertain to those asked by the nurse 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.
History (subjective data):
Client’s general health? Any colds in past year? If appropriate: any absences from work/school?
Most important things you do to keep healthy? Use of cigarettes, alcohol, drugs? Perform self
exams, i.e. Breast/testicular self-examination? Accidents at home, work, school, driving? In past,
has it been easy to find ways to carry out doctor’s or nurse’s suggestions? (If appropriate) What
do you think caused current illness? What actions have you taken since symptoms started? Have
your actions helped? (If appropriate) What things are most important to your health? How can
we be most helpful? done exercise every what?
1. Nutrition and metabolism
This pattern describes nutrient intake relative to metabolic need.
Typical daily food intake? (Describe) Use of supplements, vitamins, types of snacks? Typical
daily fluid intake? (Describe) Weight loss/gain? Height loss/gain? Appetite? Breastfeeding?
Infant feeding? Food or eating: Discomfort, swallowing difficulties, diet restrictions, able to
follow? Healing – any problems? Skin problems: lesions? Dryness? Dental problems?
Examination (examples of objective data):
Skin assessment, oral mucous membranes, teeth, actual weight/height, temperature. Abdominal
assessment.
3.Elimination
Describes the function of the bowel, bladder and skin. Through this pattern the nurse is able to
determine regularity, quality, and quantity of stool and urine.
Bowel elimination pattern (describe) Frequency, character, discomfort, problem with bowel
control, use of laxatives (i.e. type, frequency), etc.? Urinary elimination pattern (describe)
Frequency, problem with bladder control? Excess perspiration? Odour problems? Body cavity
drainage, suction, etc.?
If indicated, examine excretions or drainage for characteristics, colour, and consistency.

Abdominal assessment.
4.Activity exercise
This pattern centers on activity level, exercise program, and leisure activities.
Sufficient energy for desired and/or required activities? Exercise pattern? Type? regularity?
Spare time (leisure) activities? Child-play activities? Perceived ability for feeding, grooming,
bathing, general mobility, toileting, home maintenance, bed mobility, dressing and shopping?
Assess mobility, respiratory and cardiovascular status
Demonstrate ability for above criteria. Gait. Posture. Absent body part. Range of motion (ROM)
joints. Hand grip - can pick up pencil?(based on the severity of illness a Respiration. Blood
pressure. General appearance. Musculoskeletal, cardiac and respiratory assessments.
5. Sleep and rest pattern
Assesses sleep and rest patterns.
Generally rested and ready for activity after sleep? Sleep onset problems? sleep aids? Dreams
(nightmares), early awakening? Rest / relaxation periods? sleep hour and nap if there…
Observe sleep pattern and rest pattern and note for indicaters of lack of sleep like frequent
yawening.
6. Cognition and perception
Assesses the ability of the individual to understand and follow directions, retain information,
make decisions, and solve problems. Also asesses the five senses.
Assess;
consciousness, attention, concentration, orientation, memory, descision making ability…
Hearing difficulty? Hearing aid? Vision? Wears glasses? Last checked? When last changed? Any
change in memory? Concentration? Important decisions easy/difficult to make? Easiest way for
you to learn things? Any difficulty? Any discomfort? Pain? If appropriate – PQRST questions
Orientation. Hears whispers? Reads newsprint? Grasps ideas and questions (abstract, concrete)?
Language spoken. Vocabulary level. Attention span.
7. Self perception/self concept
How do you describe yourself? Most of the time, feel good (or not so good) about self? Changes
in body or things you can do? Problems for you? Changes in the way you feel about self or body
(generally or since illness started)? Things frequently make you angry? Annoyed? Fearful?
Anxious? Depressed? Not able to control things? What helps? Ever feel you lose hope?
Eye contact. Attention span (distraction?). Voice and speech pattern. Body posture.
8. Role relationship
Live alone? Family? Family structure? Any family problems you have difficulty handling
(nuclear/extended family)? Family or others depend on you for things? clients role in the family,
How well are you managing? If appropriate – How families/others feel about your illness?
Problems with children? Belong to social groups? Close friends? Feel lonely? (Frequency)
Things generally go well at work / school? If appropriate – income sufficient for needs? Feel part
of (or isolated in) your neighbourhood?
Interaction with family members or others if present.
9. Sexuality reproductive
If appropriate to age and situation – Sexual relationships satisfying? Changes? Problems? If

appropriate – Use of contraceptives? Problems? Female – when did menstruation begin? Last
menstrual period (LMP)? Any menstrual problems? (Gravida/Para if appropriate)
None unless a problem is identified or a pelvic examination is warranted as port of full physical
assessment (advanced nursing skill).
10. Coping-stress tolerance
Any big changes in your life in last year or two? Crisis? Who is most helpful in talking things
over? Available to you now? Tense or relaxed most of the time? When tense, what helps? Use
any medications, drugs, alcohol to relax? When (if) there are big problems in your life, how do
you handle them? Most of the time, are these ways successful?
None.
12. Value-Belief Pattern
Generally get things you want from life? Important plans for future? Religion important to you?
If appropriate - Does this help when difficulties arise? If appropriate – will being here interfere
with any religious practices?
Observe while praying, visited by religious leader, religious articles around the client…
References
1. Edelman, C.L., & Mandle, C.L.,(2006)In D. Como, L. Thomas (Eds.), Health Promotion
Throughout the Lifespan St. Louis, Missouri: Mosby, Inc
2. Adapted from: Gordon, M. (1994) Nursing Diagnosis: Process and application, Third
Edition. St. Louis: Mosby

Nursing Process

Uploaded by

Copyright:

Available Formats

Nursing Process

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nursing Process

Uploaded by

Copyright:

Available Formats

OVERVIEW OF THE NURSING PROCESS

Gordon's functional health patterns is a method devised by Marjory Gordon to be used by

Contents of Gordon’s functional health pattern approach

1. Health Perception and Management

1. Nutrition and metabolism

This pattern describes nutrient intake relative to metabolic need.

History (subjective data):

Examination (examples of objective data):

History (subjective data):

Examination (examples of objective data):

If indicated, examine excretions or drainage for characteristics, colour, and consistency.

History (subjective data):

Examination (examples of objective data):

Assess mobility, respiratory and cardiovascular status

5. Sleep and rest pattern

Assesses sleep and rest patterns.

History (subjective data):

Examination (examples of objective data):

6. Cognition and perception

consciousness, attention, concentration, orientation, memory, descision making ability…

History (subjective data):

7. Self perception/self concept

History (subjective data):

Examination (examples of objective data):

History (subjective data):

Examination (examples of objective data):

Interaction with family members or others if present.

History (subjective data):

If appropriate to age and situation – Sexual relationships satisfying? Changes? Problems? If

Examination (examples of objective data):

History (subjective data):

Examination (examples of objective data):

12. Value-Belief Pattern

History (subjective data):

Examination (examples of objective data):

You might also like