MODULE 1 : NURSING PROCESS PLANNING

NURSING PROCESS DETERMINING HOW TO PREVENT, REDUCE, OR RESOLVE THE IDENTIFIED

PRIORITY CLIENT PROBLEMS; HOW TO SUPPORT CLIENT STRENGTHS; AND
 SYSTEMATIC, RATIONAL METHOD OF PLANNING AND PROVIDING HOW TO IMPLEMENT NURSING INTERVENTIONS IN AN ORGANIZED,
INDIVIDUALIZED NURSING CARE. INDIVIDUALIZED, AND GOAL-DIRECTED MANNER
 CYCLICAL - ITS COMPONENTS FOLLOW A LOGICAL SEQUENCE, BUT
MORE THAN ONE COMPONENT MAY BE INVOLVED AT ONE TIME PURPOSE: TO DEVELOP AN INDIVIDUALIZED CARE PLAN THAT SPECIFIES
 AT THE END OF THE FIRST CYCLE, CARE MAY BE TERMINATED IF GOALS CLIENT GOALS/DESIRED OUTCOMES, AND RELATED NURSING
ARE ACHIEVED, OR INTERVENTIONS
 THE CYCLE MAY CONTINUE WITH REASSESSMENT, OR
ACTIVITIES:
 THE PLAN OF CARE MAY BE MODIFIED.
✓ SET PRIORITIES AND GOALS/OUTCOMES IN COLLABORATION
PURPOSE:
WITH CLIENT.
✓ GOALS/DESIRED OUTCOMES.
IDENTIFY A CLIENT’S HEALTH CARE STATUS, AND ACTUAL OR POTENTIAL
✓ SELECT NURSING STRATEGIES/INTERVENTIONS.
HEALTH PROBLEMS
✓ CONSULT OTHER HEALTH PROFESSIONALS.
ESTABLISH PLANS TO MEET THE IDENTIFIED NEEDS ✓ WRITE NURSING INTERVENTIONS AND NURSING CARE PLAN.
✓ COMMUNICATE CARE PLAN TO RELEVANT HEALTH CARE
DELIVER SPECIFIC NURSING INTERVENTIONS TO ADDRESS THOSE NEEDS. PROVIDERS.

ADPIE

ASSESSMENT IMPLEMENTING

COLLECTING, ORGANIZING, VALIDATING, AND DOCUMENTING CLIENT CARRYING OUT (OR DELEGATING) AND DOCUMENTING THE PLANNED
DATA NURSING INTERVENTIONS

PURPOSE: TO ESTABLISH A DATABASE ABOUT THE CLIENT’S RESPONSE TO PURPOSE: TO ASSIST THE CLIENT TO MEET DESIRED GOALS/ OUTCOMES;
HEALTH CONCERNS OR ILLNESS AND THE ABILITY TO MANAGE HEALTH PROMOTE WELLNESS; PREVENT ILLNESS AND DISEASE; RESTORE HEALTH;
CARE NEEDS AND FACILITATE COPING WITH ALTERED FUNCTIONING

ACTIVITIES: ESTABLISH A DATABASE: ACTIVITIES: REASSESS THE CLIENT TO UPDATE THE DATABASE. DETERMINE
THE NURSE’S NEED FOR ASSISTANCE. PERFORM PLANNED NURSING
✓ OBTAIN A NURSING HEALTH HISTORY. INTERVENTIONS. COMMUNICATE WHAT NURSING ACTIONS WERE
✓ CONDUCT A PHYSICAL ASSESSMENT. IMPLEMENTED:
✓ REVIEW CLIENT RECORDS.
✓ REVIEW NURSING LITERATURE. ✓ DOCUMENT CARE AND CLIENT RESPONSES TO CARE.
✓ CONSULT SUPPORT PERSONS. ✓ GIVE VERBAL REPORTS AS NECESSARY
✓ CONSULT HEALTH PROFESSIONALS.

UPDATE DATA AS NEEDED. ORGANIZE DATA. VALIDATE DATA. EVALUATING

COMMUNICATE/DOCUMENT DATA.
MEASURING THE DEGREE TO WHICH GOALS/OUTCOMES HAVE BEEN
DIAGNOSING ACHIEVED AND IDENTIFYING FACTORS THAT POSITIVELY OR NEGATIVELY
INFLUENCE GOAL ACHIEVEMENT.
ANALYZING AND SYNTHESIZING DATA
PURPOSE: TO DETERMINE WHETHER TO CONTINUE, MODIFY, OR
PURPOSE: TO IDENTIFY CLIENT STRENGTHS AND HEALTH PROBLEMS THAT TERMINATE THE PLAN OF CARE
CAN BE PREVENTED OR RESOLVED BY COLLABORATIVE AND INDEPENDENT
NURSING INTERVENTIONS TO DEVELOP A LIST OF NURSING AND ACTIVTIES:
COLLABORATIVE PROBLEMS
✓ COLLABORATE WITH CLIENT AND COLLECT DATA RELATED TO
ACTIVITIES: INTERPRET AND ANALYZE DATA: DESIRED OUTCOMES.
✓ JUDGE WHETHER GOALS/OUTCOMES HAVE BEEN ACHIEVED.
✓ COMPARE DATA AGAINST STANDARDS. ✓ RELATE NURSING ACTIONS TO CLIENT GOALS/OUTCOMES.
✓ CLUSTER OR GROUP DATA (GENERATE TENTATIVE MAKE DECISIONS ABOUT PROBLEM STATUS.
HYPOTHESES). ✓ REVIEW AND MODIFY THE CARE PLAN AS INDICATED OR
✓ IDENTIFY GAPS AND INCONSISTENCIES. DETERMINE CLIENT’S TERMINATE NURSING CARE.
STRENGTHS, RISKS, AND PROBLEMS. FORMULATE NURSING ✓ DOCUMENT ACHIEVEMENT OF OUTCOMES AND MODIFICATION
DIAGNOSES AND COLLABORATIVE PROBLEM STATEMENTS. OF THE CARE PLAN.
DOCUMENT NURSING DIAGNOSES ON THE CARE PLAN.

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NURSING TYPES OF DATA
THE PROTECTION, PROMOTION, AND OPTIMIZATION OF HEALTH AND SUBJECTIVE
ABILITIES, PREVENTION OF ILLNESS AND INJURY, ALLEVIATION OF
SUFFERING THROUGH THE DIAGNOSIS AND TREATMENT OF HUMAN  CAN BE ELICITED AND VERIFIED ONLY BY THE CLIENT.
RESPONSES AND ADVOCACY IN THE CARE OF INDIVIDUALS, FAMILIES,
 PROVIDE CLUES TO POSSIBLE PHYSIOLOGIC, PSYCHOLOGICAL,
COMMUNITIES AND POPULATIONS.”
AND SOCIOLOGIC PROBLEMS.
EMPHASIS IS PLACED ON “DIAGNOSIS AND TREATMENT OF HUMAN  PROVIDE INFORMATION THAT MAY REVEAL A CLIENT’S RISK
RESPONSES” BASED ON “ACCURATE CLIENT ASSESSMENTS,” INCLUDING FOR A PROBLEM AS WELL AS AREAS OF STRENGTHS FOR THE
HOW EFFECTIVE NURSING INTERVENTIONS ARE “TO PROMOTE HEALTH CLIENT.
AND PREVENT ILLNESS AND INJURY.” (ANA, 2010)
 INFORMATION IS OBTAINED THROUGH INTERVIEWING.
FOCUS OF NURSING DIAGNOSIS: DIAGNOSIS AND TREATMENT OF
HUMAN RESPONSES
SUBJECTIVE DATA CONSIST OF:

✓ SENSATIONS OR SYMPTOMS
SCOPE AND STANDARD OF NURSING PRACTICE ✓ FEELINGS
“THE REGISTERED NURSE COLLECTS COMPREHENSIVE DATA PERTINENT TO ✓ PERCEPTIONS
THE PATIENT’S HEALTH OR SITUATION”. ✓ DESIRES
✓ PREFERENCES
TO ACCOMPLISH THIS PERTINENT AND COMPREHENSIVE DATA
COLLECTION, THE NURSE… ✓ BELIEFS
✓ IDEAS
 COLLECTS DATA IN A SYSTEMATIC AND ONGOING PROCESS
✓ VALUES
 INVOLVES THE PATIENT, FAMILY, OTHER HEALTHCARE PROVIDERS,
AND ENVIRONMENT, AS APPROPRIATE, IN HOLISTIC DATA
✓ PERSONAL INFORMATION
COLLECTION
 PRIORITIZES DATA COLLECTION ACTIVITIES BASED ON THE PATIENT’S
IMMEDIATE CONDITION, OR ANTICIPATED NEEDS OF THE PATIENT OR PURPOSE OF A HEALTH INTERVIEW
SITUATION
 USES APPROPRIATE EVIDENCE-BASED ASSESSMENT TECHNIQUES AND 1. TO GET OR GIVE INFORMATION
INSTRUMENTS IN COLLECTING PERTINENT DATA 2. TO IDENTIFY PROBLEMS OF MUTUAL CONCERN
 USES ANALYTICAL MODELS AND PROBLEM-SOLVING TOOLS 3. TO EVALUATE CHANGE
 SYNTHESIZES AVAILABLE DATA, INFORMATION, AND KNOWLEDGE 4. TO TEACH
RELEVANT TO THE SITUATION TO IDENTIFY PATTERNS AND 5. TO PROVIDE SUPPORT
VARIANCES 6. TO PROVIDE COUNSELLING OR THERAPY
 DOCUMENTS RELEVANT DATA IN A RETRIEVABLE FORMAT
TYPES OF INTERVIEW APPROACHES
UNREGISTERED NURSES CAN ASSIST/HELP THE REGISTERED
NURSES BUT WITH PRECAUTION. UNREGISTERED NURSES DIRECTIVER INTERVIEW
CANNOT BE LEFT ALONE WITH THE PATIENT AND THEY SHOULD
 HIGHLY STRUCTURED AND ELICITS SPECIFIC INFORMATION.
NOT BE ALLOWED TO ADMINISTER MEDICATION.
 THE NURSE ESTABLISHES THE PURPOSE OF THE INTERVIEW
AND CONTROLS THE INTERVIEW, AT LEAST AT THE OUTSET.
HEALTH HISTORY  THE CLIENT RESPONDS TO QUESTIONS BUT MAY HAVE
LIMITED OPPORTUNITY TO ASK QUESTIONS OR DISCUSS
 CONSISTS OF SUBJECTIVE DATA COLLECTED DURING AN CONCERNS.
INTERVIEW.  NURSES FREQUENTLY USE DIRECTIVE INTERVIEWS TO GATHER
 INCLUDES INFORMATION ABOUT PATIENTS’ CURRENT STATE AND TO GIVE INFORMATION WHEN TIME IS LIMITED (E.G., IN
OF HEALTH, MEDICATIONS THEY TAKE, PREVIOUS ILLNESSES AN EMERGENCY SITUATION).
AND SURGERIES, AND FAMILY HISTORY AND A REVIEW OF
SYSTEMS. NON-DIRECTIVE INTERVIEW
 PATIENTS MAY REPORT FEELINGS OR EXPERIENCES
 RAPPORT-BUILDING INTERVIEW.
ASSOCIATED WITH HEALTH PROBLEMS.
 THE NURSE ALLOWS THE CLIENT TO CONTROL THE PURPOSE,
 THESE REPORTS FROM PATIENTS ARE CALLED SYMPTOMS
SUBJECT MATTER, AND PACING.
AND ARE CONSIDERED SUBJECTIVE DATA.
 RAPPORT IS AN UNDERSTANDING BETWEEN TWO OR MORE
 SUBJECTIVE DATA ACQUIRED DIRECTLY FROM THE PATIENT
PEOPLE
ARE CONSIDERED PRIMARY SOURCE DATA.
 IF DATA ARE ACQUIRED FROM ANOTHER INDIVIDUAL (SUCH A COMBINATION OF DIRECTIVE AND NONDIRECTIVE APPROACHES
AS A FAMILY MEMBER), THEY ARE REFERRED TO AS IS USUALLY APPROPRIATE DURING THE INFORMATION-
SECONDARY SOURCE DATA. GATHERING INTERVIEW.

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TYPES OF INTERVIEW QUESTIONS “HOW HAVE YOU BEEN FEELING LATELY?”

CLOSED QUESTIONS “WHAT BROUGHT YOU TO THE HOSPITAL?”

 USED IN THE DIRECTIVE INTERVIEW, ARE RESTRICTIVE AND “HOW DID YOU FEEL IN THAT SITUATION?”
GENERALLY REQUIRE ONLY “YES” OR “NO” OR SHORT
“WOULD YOU DESCRIBE MORE ABOUT HOW YOU RELATE TO
FACTUAL ANSWERS THAT PROVIDE SPECIFIC INFORMATION.
YOUR CHILD?”
 CLOSED QUESTIONS OFTEN BEGIN WITH • “WHEN,” “WHERE,”
“WHO,” “WHAT,” “DO (DID, DOES),” OR “IS (ARE, WAS).” “WHAT WOULD YOU LIKE TO TALK ABOUT TODAY?”
 OFTEN USED WHEN INFORMATION IS NEEDED QUICKLY, SUCH
AS IN AN EMERGENCY SITUATION.
 THE HIGHLY STRESSED PERSON AND THE PERSON WHO HAS
ADVANTAGES:
DIFFICULTY COMMUNICATING WILL FIND CLOSED QUESTIONS
EASIER ✓ THEY LET THE INTERVIEWW DO THE TALKING
 EXAMPLES OF CLOSED QUESTIONS ARE: ✓ THE INTERVIEWER IS ABLE TO LISTEN AND OBSERVE
✓ THER REVEAL WHAT THE INTERVIEWEE’S LACK OF
“WHAT MEDICATION DID YOU TAKE?”
INFORMATION, MISUNDERSTANDING OF WORDS, FRAME OR
“ARE YOU HAVING PAIN NOW? SHOW ME WHERE IT IS.” REDERENDE, PREJUDICES, OR STREOTYPES
✓ THEY CAN PROVIDE INFORMATION THE INTERVIEWER MAY
“HOW OLD ARE YOU?” NOT ASK FOR
✓ THEY CAN REVEAL THE INTERVIEWEE’S DEGREE OF FEELING
“WHEN DID YOU FALL?” ABOUT AN ISSUE
ADVANTAGES: ✓ THEY CAN CONVEY INTEREST AND TRUST BECAUSE OF THE
FREEDOM THEY PROVIDE
✓ QUESTIONS AND ANSWERS CAN BE CONTROLLED MORE
EFFECTIVELY
✓ THEY REQUIRE LESS MORE EFFORT FROM THE DISADVANTAGE:
INTERVIEWEE
✓ THEY MAY BE LESS THREATHENING, SINCE THEY DO NOT ✓ THEY TAKE MORE TIME
REQUIRE EXPLANATIONS OR JUSTIFICATIONS ✓ ONLY BRIEF ANSWERS MAY BE GIVEN
✓ THEY TAKE LESS TIM ✓ VALUABLE INFORMATION MAY BE WITHHELD
✓ INFORMATION CAN BE ASKED FOR SOONER THAT IT ✓ THEY OFTEN ELICIT MORE INFORMATION THAN
WOULD BE VOLUNTEERED NECESSARY
✓ RESPONSES ARE EASILY DOCUMENTED ✓ RESPONSES ARE DIFFICULT TO DOCUMENT AND REQUIRE
✓ QUESTIONS ARE EASY TO USE AND CAN BE HANDLED BY SKILL IN RECORDING
UNSKILLED INTERVIEWERS ✓ INTERVIEWER REQUIRES SKILL IN CONTROLLING AN
OPEN-ENDED INTERVIEW
DISADVANTAGES: ✓ RESPONSES REQUIRE INSIGHT AND SENSITIVITY FROM
✓ THEY MAY PROVIDE TOO LITTLE INFORMATION AND THE INTERVIEWER
REQUIRE FOLLOW-UP QUESTIONS
✓ THEY MAY NOT REVEAL HOW THE INTERVIEWEE FEELS
✓ THEY DO NOT ALLOW THE INTERVIEWEE TO VOLUNTEER NEUTRAL QUESTIONS
POSSIBLE VALUABLE INFORMATION
✓ THEY MAY INHIBIT COMMUNICATION AND CONVEY LACK  IS A QUESTION THE CLIENT CAN ANSWER WITHOUT
OF INTEREST BY THE INTERVIEWER DIRECTION OR PRESSURE FROM THE NURSE,
✓ THE INTERVIEWER MAY DOMINATE THE INTERVIEW  IS OPEN ENDED AND IS USED IN NONDIRECTIVE INTERVIEWS.
WITH QUESTIONS  EXAMPLES:

“HOW DO YOU FEEL ABOUT THAT?” “WHAT DO YOU THINK LED

TO THE OPERATION?”
OPEN-ENDED QUESTIONS

 ASSOCIATED WITH THE NONDIRECTIVE INTERVIEW,

 INVITE CLIENTS TO DISCOVER AND EXPLORE, ELABORATE, LEADING QUESTIONS
CLARIFY, OR ILLUSTRATE THEIR THOUGHTS OR FEELINGS.
 SPECIFIES ONLY THE BROAD TOPIC TO BE DISCUSSED AND  IS USUALLY CLOSED, USED IN A DIRECTIVE INTERVIEW, AND
INVITES ANSWERS LONGER THAN ONE OR TWO WORDS. THUS DIRECTS THE CLIENT’S ANSWER.
 SUCH QUESTIONS GIVE CLIENTS THE FREEDOM TO DIVULGE  THE LEADING QUESTION GIVES THE CLIENT LESS
ONLY THE INFORMATION THAT THEY ARE READY TO DISCLOSE. OPPORTUNITY TO DECIDE WHETHER THE ANSWER IS TRUE
 USEFUL AT THE BEGINNING OF AN INTERVIEW OR TO CHANGE OR NOT.
TOPICS AND TO ELICIT ATTITUDES.  LEADING QUESTIONS CREATE PROBLEMS IF THE CLIENT, IN
 MAY BEGIN WITH “WHAT” OR “HOW.” AN EFFORT TO PLEASE THE NURSE, GIVES INACCURATE
 EXAMPLES OF OPEN-ENDED QUESTIONS: RESPONSES. THIS CAN RESULT IN INACCURATE DATA.
 EXAMPLES:

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“YOU’RE STRESSED ABOUT SURGERY TOMORROW, AREN’T YOU?”  IT CAN BEGIN WITH A GREETING OR A SELF- INTRODUCTION
“YOU WILL TAKE YOUR MEDICINE, WON’T YOU?” ACCOMPANIED BY NONVERBAL GESTURES SUCH AS A SMILE,
A HANDSHAKE, AND A FRIENDLY MANNER.
 THE NURSE MUST BE CAREFUL NOT TO OVERDO THIS STAGE;
PLANNING THE INTERVIEW AND SETTING TOO MUCH SUPERFICIAL TALK CAN AROUSE ANXIETY ABOUT
WHAT IS TO FOLLOW AND MAY APPEAR INSINCERE
✓ TIME  IN ORIENTATION, THE NURSE EXPLAINS THE PURPOSE AND
NATURE OF THE INTERVIEW, FOR EXAMPLE, WHAT
NURSES NEED TO PLAN INTERVIEWS WITH CLIENTS WHEN THE INFORMATION IS NEEDED, HOW LONG IT WILL TAKE, AND
CLIENT IS PHYSICALLY COMFORTABLE AND FREE OF PAIN, AND WHAT IS EXPECTED OF THE CLIENT.
WHEN INTERRUPTIONS BY FRIENDS, FAMILY, AND OTHER  THE NURSE TELLS THE CLIENT HOW THE INFORMATION WILL
HEALTH PROFESSIONALS ARE MINIMAL. NURSES SHOULD BE USED AND USUALLY STATES THAT THE CLIENT HAS THE
SCHEDULE INTERVIEWS WITH CLIENTS IN THEIR HOMES AT A RIGHT NOT TO PROVIDE DATA
TIME SELECTED BY THE CLIENT.
✓ STEP 1: ESTABLISH RAPPORT
✓ PLACE ✓ STEP 2: ORIENTATION
A WELL-LIGHTED, WELL-VENTILATED ROOM THAT IS BODY/DEVELOPMENT
RELATIVELY FREE OF NOISE, MOVEMENTS, AND
DISTRACTIONS ENCOURAGES COMMUNICATION. IN  IN THE BODY OF THE INTERVIEW, THE CLIENT
ADDITION, A PLACE WHERE OTHERS CANNOT OVERHEAR OR COMMUNICATES WHAT HE OR SHE THINKS, FEELS, KNOWS,
SEE THE CLIENT IS DESIRABLE AND PERCEIVES IN RESPONSE TO QUESTIONS FROM THE
NURSE.
✓ SEATING ARRANGEMENT  EFFECTIVE DEVELOPMENT OF THE INTERVIEW DEMANDS
THAT THE NURSE USE COMMUNICATION TECHNIQUES THAT
BY STANDING AND LOOKING DOWN AT A CLIENT WHO IS IN MAKE BOTH PARTIES FEEL COMFORTABLE AND SERVE THE
BED OR IN A CHAIR, THE NURSE RISKS INTIMIDATING THE PURPOSE OF THE INTERVIEW.
CLIENT. WHEN A CLIENT IS IN BED, THE NURSE CAN SIT AT A
GUIDELINES DURING AN INTERVIEW
45-DEGREE ANGLE TO THE BED. THIS POSITION IS LESS
FORMAL THAN SITTING BEHIND A TABLE OR STANDING AT THE ✓ LISTEN ATTENTIVELY, USING ALL YOUR SENSES, AND
FOOT OF THE BED. SITTING ON A CLIENT’S BED HEMS THE SPEAK SLOWLY AND CLEARLY.
CLIENT IN AND MAKES STARING DIFFICULT TO AVOID. ✓ USE LANGUAGE THE CLIENT UNDERSTANDS AND CLARIFY
POINTS THAT ARE NOT UNDERSTOOD.
✓ DISTANCE ✓ PLAN QUESTIONS TO FOLLOW A LOGICAL SEQUENCE.
✓ ASK ONLY ONE QUESTION AT A TIME. MULTIPLE
THE DISTANCE BETWEEN THE INTERVIEWER AND QUESTIONS LIMIT THE CLIENT TO ONE CHOICE AND MAY
INTERVIEWEE SHOULD BE NEITHER TOO SMALL NOR TOO CONFUSE THE CLIENT.
GREAT, BECAUSE PEOPLE FEEL UNCOMFORTABLE WHEN ✓ ACKNOWLEDGE THE CLIENT’S RIGHT TO LOOK AT THINGS
TALKING TO SOMEONE WHO IS TOO CLOSE OR TOO FAR THE WAY THEY APPEAR TO HIM OR HER AND NOT THE
AWAY. MOST PEOPLE FEEL COMFORTABLE MAINTAINING A WAY THEY APPEAR TO THE NURSE OR SOMEONE ELSE.
DISTANCE OF 2 TO 3 FEET DURING AN INTERVIEW. ✓ DO NOT IMPOSE YOUR OWN VALUES ON THE CLIENT.
✓ AVOID USING PERSONAL EXAMPLES, SUCH AS SAYING,
✓ LANGUAGE “IF I WERE YOU ”
✓ NONVERBALLY CONVEY RESPECT, CONCERN, INTEREST,
FAILURE TO COMMUNICATE IN LANGUAGE THE CLIENT CAN AND ACCEPTANCE.
UNDERSTAND IS A FORM OF DISCRIMINATION. THE NURSE ✓ BE AWARE OF THE CLIENT’S AND YOUR OWN BODY
MUST CONVERT COMPLICATED MEDICAL TERMINOLOGY INTO LANGUAGE.
COMMON ENGLISH USAGE. INTERPRETERS OR TRANSLATORS ✓ BE CONSCIOUS OF THE CLIENT’S AND YOUR OWN VOICE
ARE NEEDED IF THE CLIENT AND THE NURSE DO NOT SPEAK INFLECTION, TONE, AND AFFECT.
THE SAME LANGUAGE OR DIALECT. ✓ SIT DOWN TO TALK WITH THE CLIENT (BE AT AN EVEN
LEVEL).
✓ USE AND ACCEPT SILENCE TO HELP THE CLIENT SEARCH
STAGES OF AN INTERVIEW
FOR MORE THOUGHTS OR TO ORGANIZE THEM.
OPENING/INTRODUCTION ✓ USE EYE CONTACT AND BE CALM, UNHURRIED, AND
SYMPATHETIC.
 THE OPENING CAN BE THE MOST IMPORTANT PART OF THE
INTERVIEW BECAUSE WHAT IS SAID AND DONE AT THAT TIME CLOSING
SETS THE TONE FOR THE REMAINDER OF THE INTERVIEW.
 THE NURSE TERMINATES THE INTERVIEW WHEN THE NEEDED
 THE PURPOSES OF THE OPENING ARE TO ESTABLISH RAPPORT
INFORMATION HAS BEEN OBTAINED.
AND ORIENT THE INTERVIEWEE.
 IN SOME CASES, HOWEVER, A CLIENT TERMINATES IT, FOR
 ESTABLISHING RAPPORT IS A PROCESS OF CREATING
EXAMPLE, WHEN DECIDING NOT TO GIVE ANY MORE
GOODWILL AND TRUST.
INFORMATION OR WHEN UNABLE TO OFFER MORE

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INFORMATION FOR SOME OTHER REASON—FATIGUE, FOR CONCEPTUAL MODELS/FRAMEWORKS

EXAMPLE.
 THE CLOSING IS IMPORTANT FOR MAINTAINING RAPPORT 1. GORDON’S FUNCTIONAL HEALTH PATTERN FRAMEWORK
AND TRUST AND FOR FACILITATING FUTURE INTERACTIONS – *THIS IS WHAT WE WILL BE UTILIZING TO ORGANIZE
CLIENT DATA
THE FOLLOWING TECHNIQUES ARE COMMONLY USED TO CLOSE 2. OREM’S SELF-CARE MODEL
AN INTERVIEW: 3. ROY’S ADAPTATION MODEL

➢ OFFER TO ANSWER QUESTIONS: GORDON 11 FUNCTIONAL HEALTH PATTERNS

“DO YOU HAVE ANY QUESTIONS?” 1. HEALTH PERCEPTION AND MANAGEMENT

2. NUTRITIONAL AND METABOLIC
“I WOULD BE GLAD TO ANSWER ANY QUESTIONS YOU HAVE.” BE 3. ELIMINATION
SURE TO ALLOW TIME FOR THE PERSON TO ANSWER, OR THE 4. ACTIVITY AND EXERCISE
OFFER WILL BE REGARDED AS INSINCERE. 5. COGNITION AND PERCEPTION
6. SLEEP AND REST
➢ CONCLUDE BY SAYING:
7. SELF-PERCEPTION AND SELF-CONCEPT
“WELL, THAT’S ALL I NEED TO KNOW FOR NOW” OR 8. ROLES AND RELATIONSHIPS
9. SEXUALITY AND REPRODUCTION
“WELL, THOSE ARE ALL THE QUESTIONS I HAVE FOR NOW.” 10. COPING AND STRESS TOLERANCE
PRECEDING A REMARK WITH THE WORD “WELL” GENERALLY 11. VALUES AND BELIEF
SIGNALS THAT THE END OF THE INTERACTION IS NEAR.
MARJORIE GORDON (1931-2015) PROPOSED FUNCTIONAL HEALTH
➢ THANK THE CLIENT: PATTERNS AS A GUIDE FOR ESTABLISHING A COMPREHENSIVE
NURSING DATA BASE. THESE 11 CATEGORIES MAKE POSSIBLE A
“THANK YOU FOR YOUR TIME AND HELP. THE QUESTIONS YOU SYSTEMATIC AND STANDARDIZED APPROACH TO DATA
HAVE ANSWERED WILL BE HELPFUL IN PLANNING YOUR NURSING COLLECTION, AND ENABLE THE NURSE TO DETERMINE THE
CARE.” YOU MAY ALSO SHAKE THE CLIENT’S HAND. FOLLOWING ASPECTS OF HEALTH AND HUMAN FUNCTION:
➢ EXPRESS CONCERN FOR THE PERSON’S WELFARE AND FUTURE: 1. HEALTH PERCEPTION AND MANAGEMENT
- DESCRIBES THE CLIENT’S PERCEIVED HEALTH & WELL-
“I HOPE ALL GOES WELL FOR YOU.”
BEING AND HOW HEALTH IS MANAGED.
➢ PLAN FOR THE NEXT MEETING, IF THERE IS TO BE ONE, OR STATE
WHAT WILL HAPPEN NEXT. INCLUDE THE DAY, TIME, PLACE, TOPIC, ✓ CLIENT’S GENERAL HEALTH?
AND PURPOSE: ✓ ANY COLDS IN PAST YEAR?
✓ IF APPROPRIATE: ANY ABSENCES FROM
“LET’S GET TOGETHER AGAIN HERE ON THE FIFTEENTH AT NINE WORK/SCHOOL?
A.M. TO SEE HOW YOU ARE MANAGING THEN.” OR “MS.
✓ MOST IMPORTANT THINGS YOU DO TO KEEP HEALTHY?
GOODWIN, I WILL BE RESPONSIBLE FOR GIVING YOU CARE THREE
✓ USE OF CIGARETTES, ALCOHOL, DRUGS?
MORNINGS PER WEEK WHILE YOU ARE HERE. I WILL BE HERE
EACH MONDAY, TUESDAY, AND WEDNESDAY BETWEEN EIGHT ✓ PERFORM SELF-EXAMS, I.E., BREAST/TESTICULAR SELF-
O’CLOCK AND NOON. AT THOSE TIMES, WE CAN ADJUST YOUR EXAMINATION?
CARE AS NEEDED.” ✓ ACCIDENTS AT HOME, WORK, SCHOOL, DRIVING?
✓ IN PAST, HAS IT BEEN EASY TO FIND WAYS TO CARRY
➢ PROVIDE A SUMMARY TO VERIFY ACCURACY AND AGREEMENT. OUT DOCTOR’S OR NURSE’S SUGGESTIONS?
✓ (IF APPROPRIATE) WHAT DO YOU THINK CAUSED
SUMMARIZING SERVES SEVERAL PURPOSES: IT HELPS TO
CURRENT ILLNESS?
TERMINATE THE INTERVIEW, IT REASSURES THE CLIENT THAT THE
✓ WHAT ACTIONS HAVE YOU TAKEN SINCE SYMPTOMS
NURSE HAS LISTENED, IT CHECKS THE ACCURACY OF THE NURSE’S
PERCEPTIONS, IT CLEARS THE WAY FOR NEW IDEAS, AND IT HELPS STARTED?
THE CLIENT TO NOTE PROGRESS AND A FORWARD DIRECTION. ✓ HAVE YOUR ACTIONS HELPED?
✓ (IF APPROPRIATE) WHAT THINGS ARE MOST
IMPORTANT TO YOUR HEALTH?
✓ HOW CAN WE BE MOST HELPFUL? DONE EXERCISE
ORGANIZING DATA
EVERY WHAT?
• THE NURSE USES A WRITTEN (OR ELECTRONIC) FORMAT THAT
ORGANIZES THE ASSESSMENT DATA SYSTEMATICALLY. 2. NUTRITIONAL AND METABOLIC
- THIS PATTERN DESCRIBES FOOD AND FLUID
• THIS IS OFTEN REFERRED TO AS A NURSING HEALTH HISTORY, CONSUMPTION RELATIVE TO METABOLIC NEED &
NURSING ASSESSMENT, OR NURSING DATABASE FORM. PATTERN INDICATORS OF LOCAL NUTRIENT SUPPLY
HISTORY (SUBJECTIVE DATA):
• THE FORMAT MAY BE MODIFIED ACCORDING TO THE CLIENT’S
PHYSICAL STATUS SUCH AS ONE FOCUSED ON MUSCULOSKELETAL
DATA FOR ORTHOPEDIC CLIENTS. ✓ TYPICAL DAILY FOOD INTAKE INCLUDING SNACKS?
✓ USE OF SUPPLEMENTS, VITAMINS?
✓ TYPICAL DAILY FLUID INTAKE?

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✓ WEIGHT LOSS/GAIN? HEIGHT LOSS/GAIN? 4. ACTIVITY AND EXERCISE

✓ APPETITE? - THIS PATTERN DESCRIBES ACTIVITY LEVEL, EXERCISE
✓ BREASTFEEDING? INFANT FEEDING? PROGRAM, AND LEISURE ACTIVITIES. HISTORY
(SUBJECTIVE DATA):
✓ FOOD OR EATING: DISCOMFORT, SWALLOWING
DIFFICULTIES, DIET RESTRICTIONS, ABLE TO FOLLOW?
✓ SUFFICIENT ENERGY FOR DESIRED AND/OR REQUIRED
✓ HEALING – ANY PROBLEMS? SKIN PROBLEMS:
ACTIVITIES?
LESIONS? DRYNESS? DENTAL PROBLEMS? EXAMINATION
(EXAMPLES OF OBJECTIVE DATA): ✓ EXERCISE PATTERN? TYPE? REGULARITY?
✓ SKIN ASSESSMENT, ORAL MUCOUS MEMBRANES, ✓ SPARE TIME (LEISURE) ACTIVITIES?
TEETH, ACTUAL WEIGHT/HEIGHT, TEMPERATURE. ✓ CHILD-PLAY ACTIVITIES?
ABDOMINAL ASSESSMENT. ✓ PERCEIVED ABILITY FOR FEEDING, GROOMING,
BATHING, GENERAL MOBILITY, TOILETING, HOME
MAINTENANCE, BED MOBILITY, DRESSING AND
SHOPPING?

EXAMINATION (EXAMPLES OF OBJECTIVE DATA):

✓ DEMONSTRATE ABILITY FOR THE FOLLOWING

CRITERIA:
✓ GAIT. POSTURE. ABSENT BODY PART. RANGE OF
MOTION (ROM) JOINTS. HAND GRIP - CAN PICK UP
PENCIL?
✓ RESPIRATION. BLOOD PRESSURE. GENERAL
APPEARANCE.
✓ MUSCULOSKELETAL, CARDIAC, AND RESPIRATORY
ASSESSMENTS.

5. SLEEP AND REST

3. ELIMINATION DESCRIBES THE PATTERN OF EXCRETORY - DESCRIBES PATTERNS OF SLEEP, REST, AND RELAXATION.
FUNCTION (BOWEL, BLADDER, SKIN). HISTORY (SUBJECTIVE DATA):
- THROUGH THIS PATTERN THE NURSE IS ABLE TO
DETERMINE REGULARITY, QUALITY, AND QUANTITY OF ✓ GENERALLY RESTED AND READY FOR ACTIVITY AFTER
STOOL AND URINE. HISTORY (SUBJECTIVE DATA): SLEEP?
✓ SLEEP ONSET PROBLEMS? AIDS? DREAMS
✓ BOWEL ELIMINATION PATTERN (DESCRIBE) (NIGHTMARES), EARLY AWAKENING?
FREQUENCY, CHARACTER, DISCOMFORT, PROBLEM WITH ✓ REST / RELAXATION PERIODS?
BOWEL CONTROL, USE OF LAXATIVES (I.E., TYPE,
FREQUENCY), ETC.?
✓ URINARY ELIMINATION PATTERN (DESCRIBE)
EXAMINATION (EXAMPLES OF OBJECTIVE DATA):
FREQUENCY, PROBLEM WITH BLADDER CONTROL?
✓ EXCESS PERSPIRATION? ODOR PROBLEMS? BODY ✓ OBSERVE SLEEP PATTERN AND REST PATTERN IF
CAVITY DRAINAGE, SUCTION, ETC.? EXAMINATION APPLICABLE
(EXAMPLES OF OBJECTIVE DATA): ✓ DARK CIRCLES AROUND THE EYES, EYE BAGS,
✓ IF INDICATED, EXAMINE EXCRETIONS OR DRAINAGE YAWNING, INABILITY TO CONCENTRATE, ETC.
FOR CHARACTERISTICS, COLOR, AND CONSISTENCY.
ABDOMINAL ASSESSMENT.

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EXAMINATION (EXAMPLES OF OBJECTIVE DATA):

✓ EYE CONTACT. ATTENTION SPAN (DISTRACTION?). ✓

VOICE AND SPEECH PATTERN.
✓ BODY POSTURE.
✓ CLIENT NERVOUS (5) OR RELAXED (1) (RATE SCALE 1-5)
CLIENT ASSERTIVE (5) OR PASSIVE (1) (RATE SCALE 1-5)

8. ROLES AND RELATIONSHIPS HISTORY (SUBJECTIVE DATA):

✓ LIVE ALONE?
✓ FAMILY? FAMILY STRUCTURE? ANY FAMILY PROBLEMS
YOU HAVE DIFFICULTY HANDLING (NUCLEAR/EXTENDED
FAMILY)? FAMILY OR OTHERS DEPEND ON YOU FOR
THINGS? HOW WELL ARE YOU MANAGING?
6. COGNITIVE/ PERCEPTUAL PATTERN
✓ IF APPROPRIATE – HOW FAMILIES/OTHERS FEEL
- DESCRIBES THE ABILITY OF THE INDIVIDUAL TO
ABOUT YOUR ILLNESS?
UNDERSTAND AND FOLLOW DIRECTIONS, RETAIN
✓ PROBLEMS WITH CHILDREN?
INFORMATION, MAKE DECISIONS, AND SOLVE
PROBLEMS. ALSO ASSESSES THE FIVE SENSES. HISTORY ✓ BELONG TO SOCIAL GROUPS?
(SUBJECTIVE DATA): ✓ CLOSE FRIENDS? FEEL LONELY? (FREQUENCY)
✓ THINGS GENERALLY GO WELL AT WORK / SCHOOL?
✓ HEARING DIFFICULTY? HEARING AID? ✓ IF APPROPRIATE – INCOME SUFFICIENT FOR NEEDS?
✓ VISION? WEARS GLASSES? LAST CHECKED? WHEN LAST ✓ FEEL PART OF (OR ISOLATED IN) YOUR
CHANGED? NEIGHBORHOOD?
✓ ANY CHANGE IN MEMORY? CONCENTRATION? EXAMINATION (EXAMPLES OF OBJECTIVE DATA):
✓ IMPORTANT DECISIONS EASY/DIFFICULT TO MAKE?
✓ EASIEST WAY FOR YOU TO LEARN THINGS? ANY ✓ INTERACTION WITH FAMILY MEMBERS OR OTHERS IF
DIFFICULTY? PRESENT.
✓ ANY DISCOMFORT? PAIN? COLDSPA
✓ C – CHARACTER, O – ONSET, L – LOCATION, D – 9. SEXUALITY AND REPRODUCTION HISTORY (SUBJECTIVE
DATA):
DURATION, S – SEVERITY, ✓ P – PATTERN, A -
ASSOCIATED FACTORS
✓ IF APPROPRIATE TO AGE AND SITUATION – SEXUAL
EXAMINATION (EXAMPLES OF OBJECTIVE DATA): RELATIONSHIPS SATISFYING? CHANGES? PROBLEMS?
✓ IF APPROPRIATE – USE OF CONTRACEPTIVES?
✓ ✓ ORIENTATION. PROBLEMS?
✓ ✓ HEARS WHISPERS? READS NEWSPRINT? ✓ FEMALE – WHEN DID MENSTRUATION BEGIN? LAST
✓ ✓ GRASPS IDEAS AND QUESTIONS (ABSTRACT, MENSTRUAL PERIOD (LMP)? ANY MENSTRUAL
CONCRETE)? PROBLEMS?
✓ ✓ LANGUAGE SPOKEN. VOCABULARY LEVEL. ✓ (GRAVIDA/PARA IF APPROPRIATE)
✓ ✓ ATTENTION SPAN.
EXAMINATION (EXAMPLES OF OBJECTIVE DATA):
7. SELF-PERCEPTION AND SELF-CONCEPT
✓ NONE UNLESS A PROBLEM IS IDENTIFIED OR A PELVIC
- DESCRIBES CLIENT’S SELF-WORTH, COMFORT, BODY
EXAMINATION IS WARRANTED AS PART OF FULL
IMAGE, FEELING STATE HISTORY (SUBJECTIVE DATA):
PHYSICAL ASSESSMENT (ADVANCED NURSING
✓ HOW DO YOU DESCRIBE YOURSELF?
✓ MOST OF THE TIME, FEEL GOOD (OR NOT SO GOOD) 10. COPING AND STRESS TOLERANCE HISTORY (SUBJECTIVE
ABOUT SELF? DATA):
✓ CHANGES IN BODY OR THINGS YOU CAN DO?
PROBLEMS FOR YOU? ✓ ANY BIG CHANGES IN YOUR LIFE IN LAST YEAR OR
✓ CHANGES IN THE WAY YOU FEEL ABOUT SELF OR BODY TWO? CRISIS?
(GENERALLY OR SINCE ILLNESS STARTED)? ✓ WHO IS MOST HELPFUL IN TALKING THINGS OVER?
✓ THINGS FREQUENTLY MAKE YOU ANGRY? ANNOYED? AVAILABLE TO YOU NOW?
FEARFUL? ANXIOUS? DEPRESSED? ✓ TENSE OR RELAXED MOST OF THE TIME? WHEN TENSE,
✓ NOT ABLE TO CONTROL THINGS? WHAT HELPS? WHAT HELPS?
✓ EVER FEEL YOU LOSE HOPE? ✓ 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?

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11. VALUES AND BELIEF DESCRIBES THE PATTERNS OF VALUES,

BELIEFS (INCLUDING SPIRITUAL), AND GOALS THAT GUIDES
THE CLIENT’S CHOICES OR DECISIONS. HISTORY (SUBJECTIVE
DATA):

✓ DO YOU 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?
✓ HEALTH BELIEFS/VALUES?

8 SECTIONS OF A COMPLETE HEALTH HISTORY

1. BIOGRAPHIC DATA
2. REASONS FOR SEEKING HEALTH CARE (CHIEF
COMPLAINT)
3. HISTORY OF PRESENT HEALTH CONCERN
4. PAST HEALTH HISTORY
5. FAMILY HEALTH HISTORY (GENOGRAM)
6. REVIEW OF SYSTEMS FOR CURRENT HEALTH PROBLEMS
7. LIFESTYLE AND PRACTICES PROFILE (PATTERNS OF
LIVING)
8. DEVELOPMENTAL LEVEL

TAKE NOTE: HOSPITALIZATION ≠ SURGERY

ALMEÑANA, JOHN RENDEW | BSNR 2026 pg. 8