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UNIT II-Overview of NANDA and Overview of
Functional Health Patterns
BY
SEHRISH NAZ
RN, Post RN, MSN
Lecturer, Institute of Nursing Sciences, Khyber Medical University
Subject: Adult Health Nursing
At the end of the unit, students will be able to:
• Define NANDA
• Formulate nursing diagnosis
• Define Functional health patterns
• Discuss the purpose of utilizing FHP as a tool for
assessment for patients
• Enumerate the Functional health patterns and their basic
concepts
• Obtain history taking and physical examination of the
client through utilizing
• FHP Formulate nursing diagnosis based on FHP
assessment tool Identify altered physiological functions
based on FHP.
2/8/2020 Post RN semester 1 AHN 2
Definition of (NANDA)
The North American Nursing Diagnosis
Association (NANAD 1994) defines a nursing
diagnosis as “A clinical judgments about
individual, family or community response to
actual and potential health problems and life
responses”
2/8/2020 Post RN semester 1 AHN 3
Functional health pattern (NANDA)
1- Health Perception-Health Management Pattern
2- Nutritional—Metabolic Pattern
3- Elimination Pattern
4- Activity—Exercise Pattern
5- Sexuality—Reproduction Pattern
6- Sleep—Rest Pattern
7- Sensory—Perceptual Pattern
8- Cognitive Pattern
9- Role—Relationship Pattern
10- Self-Perception-Self-Concept Pattern
11- Coping-Stress Tolerance Pattern
12- Value—Belief Pattern
2/8/2020 Post RN semester 1 AHN 4
Health Perception-Health Management
Pattern
1- Determine how the client perceives and
manages his or her health.
2- Compliance with current and past nursing
and, medical recommendations.
3- The client's ability to perceive the
relationship between activities of daily
living and health.
2/8/2020 Post RN semester 1 AHN 5
Subjective Data
 Client's Perception of Health:
Describe your health.
 Client's Perception of Illness
Describe your illness or current health problem.
 Health Management and Habits
Tell me what you do when you have a health problem.
 Compliance with Prescribed Medications and Treatments
Have you been able to take your prescribed medications?
If not, what caused your inability to do so?
2/8/2020 Post RN semester 1 AHN 6
Objective Data
Refer to General Physical Survey
Associated Nursing Diagnoses
 Wellness Diagnoses
Effective Management of Therapeutic Regimen
 Risk Diagnoses
Risk for Injury
Risk for Suffocation
Risk for Trauma
 Actual Diagnoses
Altered Growth and Development
Ineffective Management of Therapeutic Regimen: Individual
Ineffective Management of Therapeutic Regimen: Family
Ineffective Management of Therapeutic Regimen: Community
Noncompliance
2/8/2020 Post RN semester 1 AHN 7
Nutritional-Metabolic Pattern
Assessing the client's nutritional-metabolic pattern
is to determine the client's dietary habits and
metabolic needs. The conditions of hair, skin,
nails, teeth and mucous membranes are assessed.
Subjective Data
 Dietary and Fluid Intake
Describe the type and amount of food you eat at breakfast, lunch,
and supper on an average day.
Do-you take any vitamin supplements? Describe.
Do you find it difficult to tolerate certain foods? Specify.
Do you ever experience nausea and vomiting? Describe.
Do you ever experience abdominal pains? Describe.
2/8/2020 Post RN semester 1 AHN 8
Condition of Skin
Describe the condition of your skin.
How well and how quickly does your skin heal?
Do you have any skin lesions? Describe.
Do you have any itching? What do you do for relief?
Condition of Hair and Nails
Have you had difficulty with scalp itching or sores?
Do you use any special hair or scalp care products?
Have you noticed any changes in your nails? Color
Cracking? Shape? Lines?
2/8/2020 Post RN semester 1 AHN 9
Metabolism
What would you consider to be your "ideal weight"?
Have you had any recent weight gains or losses?
Do you have any intolerance to heat or cold?
Have you noted any changes in your eating or
drinking habits? Explain.
Have you noticed any voice changes?
2/8/2020 Post RN semester 1 AHN 10
Objective Data
Assess the client's temperature, pulse, respirations, and height
and weight.
Wellness Diagnoses
Opportunity to enhance nutritional metabolic pattern
Opportunity to enhance effective breastfeeding
Opportunity to enhance skin integrity
Risk Diagnoses
Risk for Altered Body Temperature
Hypothermia
Risk for Infection
Risk for altered nutrition less than body requirements .
Risk for Aspiration
2/8/2020 Post RN semester 1 AHN 11
Actual Diagnoses
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body requirements
Altered Nutrition: More than body requirements
Ineffective Breastfeeding
Altered Oral Mucous Membrane
Impaired Skin Integrity.
2/8/2020 Post RN semester 1 AHN 12
Elimination Pattern
Adequacy of the client's bowel and bladder.
The client's bowel and urinary habits.
Bowel or urinary problems.
Use of urinary or bowel elimination devices.
2/8/2020 Post RN semester 1 AHN 13
Subjective Data
Bowel Habits
How frequent are your bowel movements?
Do you use laxatives? What kind and how often do you use
them?
Do you use enemas or suppositories? How often and what
kind?
Do you have any discomfort with your bowel movements?
Describe.
2/8/2020 Post RN semester 1 AHN 14
Bladder Habits
How frequently do you urinate?
What is the amount and color of your urine?
Do you have any of the following problems with urinating:
 Pain? Blood in urine? Difficulty starting a stream?
Incontinence? Voiding frequently at night? Voiding
frequently during day? Bladder infections?
 Have you ever had a urinary catheter? Describe. When?
How long?
Objective Data
Refer to abdominal assessment, and the rectal assessment.
2/8/2020 Post RN semester 1 AHN 15
Associated nursing-Diagnoses
Wellness Diagnoses
Opportunity to enhance adequate bowel elimination pattern
Opportunity to enhance adequate urinary elimination pattern
Risk Diagnoses
Risk for constipation
Risk for altered urinary elimination
2/8/2020 Post RN semester 1 AHN 16
Actual Diagnoses
Altered Bowel Elimination Constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary
Retention
Total Incontinence
Stress Incontinence
2/8/2020 Post RN semester 1 AHN 17
Activity-Exercise Pattern
Activities of daily living, including routines of exercise,
leisure, and recreation.
Activities necessary for personal hygiene, cooking,
shopping, eating, maintaining the home, and working.
An assessment is made of any factors that affect or interfere
with the client's routine activities of daily living.
2/8/2020 Post RN semester 1 AHN 18
Subjective Data
 Describe your activities on a normal day (Including hygiene activities, eating
activities).
 Do you have difficulty with any of these self-care activities? Explain.
 Does anyone help you with these activities? How?
 Do you use any special devices to help you with your activities?
 Does your current physical health affect any of these activities e.g. dyspnea,
shortness of breath, palpations, chest pain. pain, stiffness, weakness)? Explain.
Occupational Activities
 Describe what you do to make a living.
 Do you feel it has affected your health?
 How has your health affected your ability to work?
2/8/2020 Post RN semester 1 AHN 19
Objective Data
Refer to Thoracic and Lung Assessment
Cardiac Assessment
Peripheral Vascular Assessment
Musculoskeletal Assessment
Associated Nursing Diagnoses
Wellness Diagnoses
Opportunity to enhance effective cardiac output
Opportunity to enhance effective self-care activities
Opportunity to enhance adequate tissue perfusion
Opportunity to enhance effective breathing pattern
2/8/2020 Post RN semester 1 AHN 20
Risk Diagnoses
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
Actual Diagnoses
 Activity Intolerance
 Impaired Gas Exchange
 Ineffective Airway Clearance
 Ineffective Breathing Pattern
 Disuse syndrome
 Impaired Physical Mobility
 Inability to Sustain Spontaneous Ventilation
 Altered Tissue Perfusion
2/8/2020 Post RN semester 1 AHN 21
Sexuality-Reproduction Pattern
Subjective Data
1- Female
Menstrual history:
Last cycle begin?
Duration ?
Any change or abnormality ?
Describe any mood changes or discomfort
before, during, or after your cycle
2/8/2020 Post RN semester 1 AHN 22
Obstetric history
 How many times have you been pregnant?
 Describe the outcome of each of your pregnancies.
 If you have children, what are the ages and sex of each?
 Explain any health problems or concerns you had with
each pregnancy. If pregnant now .
Contraception
 What do you or your partner do to prevent pregnancy?
 Describe any discomfort or undesirable effects this method
produces.
 Have you had any difficulty with fertility? Explain
2/8/2020 Post RN semester 1 AHN 23
Special problems
Do you have or have you ever had a sexually
transmitted disease? Describe.
Describe any pain, burning, or discomfort you
have while voiding.
Objective Data
Refer to Breast Assessment, d Abdominal
Assessment, and urinary-Reproductive
Assessment
2/8/2020 Post RN semester 1 AHN 24
Associated nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance sexuality patterns
Risk-Diagnosis
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
2/8/2020 Post RN semester 1 AHN 25
Sleep-Rest Pattern
Subjective data
Sleep Habits:
How would you rate the quality of your sleep?
Special Problems
Do you ever experience difficulty with falling asleep?
Remaining asleep? Do you ever feel fatigued after a sleep
period?
Sleep Aids
What helps you to fall asleep? medications? reading?
relaxation technique? Watching TV? Listening to music?
2/8/2020 Post RN semester 1 AHN 26
Objective Data
1. Observe appearance
a. Pale b. Puffy eyes with dark circles
2. Observe behavior
a. Yawning
b. Dozing during day
c. Irritability
d. Short attention span
2/8/2020 Post RN semester 1 AHN 27
Associated nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance sleep
Risk Diagnosis
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleep Pattern Disturbance.
2/8/2020 Post RN semester 1 AHN 28
Sensory-Perceptual Pattern
Subjective Data
Describe your ability to see, hear, feel, taste, and smell.
Describe any difficulty you have with your vision, hearing,
and ability to feel (e.g., touch, pain, heat, cold), taste
(salty, sweet, bitter, sour), or smell.
Pain Assessment
Complete Symptom Analysis
Special Aids:
What devices (e.g., glasses, contact lenses, hearing aids)
Describe any medications you take to help you with these
problems.
Objective Data
Refer to the section on Nose and Sinus Assessment, Eye
Assessment, and Ear Assessment.
2/8/2020 Post RN semester 1 AHN 29
Associated Nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses
Risk for pain
Actual Diagnoses
Pain
2/8/2020 Post RN semester 1 AHN 30
Cognitive Pattern
Subjective Data
Ability to Understand:
Explain what your doctor has told you about your health.
Ability to Communicate:
Can you tell me how you feel about your current state of
health?
Ability to Remember:
Are you able to remember recent events and events of
long ago? Explain.
Ability to Make Decisions:
Describe how you feel when faced with a decision.
2/8/2020 Post RN semester 1 AHN 31
Objective Data
Refer to the Mental Status Assessment (GCS)
Associated nursing Diagnoses
Wellness Diagnosis: Opportunity to enhance cognition
Risk Diagnosis: Risk for altered thought processes
Actual Diagnoses:
Acute confusion
Chronic Confusion
Knowledge Deficit (Specify)
Impaired Memory
2/8/2020 Post RN semester 1 AHN 32
Role-Relationship Pattern
Subjective Data
Perception of Major Roles and Responsibilities in Family
Describe your family.
Are there any major problems now?
Perception of Major Roles and Responsibilities at Work
Describe your occupation.
What is your major responsibility at work?
Perception of Major Social Roles and Responsibilities
Describe your neighborhood and the community in which
you live.
2/8/2020 Post RN semester 1 AHN 33
Objective Data
1. Outline a family genogram for your client.
2. Observe your client's family members.
Associated Nursing Diagnoses
Wellness Diagnoses:
Opportunity to enhance effective relationships
Opportunity to enhance effective communication
Risk Diagnoses:
High risk for Loneliness
Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
Impaired Verbal Communication
Impaired Social Interaction: Social Isolation
2/8/2020 Post RN semester 1 AHN 34
Coping-Stress Tolerance Pattern
Subjective Data
Perception of Stress and Problems in Life
Describe what you believe to be the most stressful
situation in your Life.
How has your illness affected the stress you feel?
Coping Methods and Support Systems:
What do you usually do first when faced with a problem?
What helps you to relieve stress and tension?
Do you use medication, drugs, or alcohol to help relieve
stress? Explain.
Objective Data
Refer to the Mental Status Assessment.
2/8/2020 Post RN semester 1 AHN 35
Associated nursing Diagnoses
Wellness Diagnoses
Opportunity to enhance effective individual coping.
Opportunity to enhance family coping
Risk Diagnoses:
Risk for self-harm
Risk for suicide
Actual Diagnoses:
Ineffective Individual Coping
Ineffective Family Coping: Disabling
2/8/2020 Post RN semester 1 AHN 36
Value-Belief Pattern
Subjective Data
Values, Goals, and Philosophical Beliefs
Religious and Spiritual Beliefs:
Are there certain health practices or restrictions that
are important for you to follow while you are ill or
hospitalized? Explain.
Objective Data
Observe religious practices
Bible , clergy
Observe client's behavior for signs of spiritual distress
Anxiety, Anger , Depression , Doubt, Hopelessness and
Powerlessness
2/8/2020 Post RN semester 1 AHN 37
Associated Nursing Diagnoses
Wellness Diagnosis:
Potential for Enhanced Spiritual Well-Being
Risk diagnosis:
Risk for spiritual distress
Actual Diagnosis:
Spiritual disturbance (distress of the human spirit).
2/8/2020 Post RN semester 1 AHN 38
References
1. Dillon PM., Nursing Health Assessment; A Critical
Thinking, Case Studies Approach, 2nd ed. Copyright
© 2007 by F. A. Davis.
2. Kozier & Erb, G. K., (2015). Fundamentals of
Nursing: Concept, process and practice (10th ed.).
Addison.
3. Wesley.Bruner, L.S., & Suddarth, D.S. (2015). Text
book of Medical-Surgical Nursing (14 Ed.).
Philadelphia: Lippincott.
2/8/2020 39Post RN semester one
Thanks for
Attention
2/8/2020 Post RN semester 1 AHN 40

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Unit 2 Adult Health Nursing

  • 1. UNIT II-Overview of NANDA and Overview of Functional Health Patterns BY SEHRISH NAZ RN, Post RN, MSN Lecturer, Institute of Nursing Sciences, Khyber Medical University Subject: Adult Health Nursing
  • 2. At the end of the unit, students will be able to: • Define NANDA • Formulate nursing diagnosis • Define Functional health patterns • Discuss the purpose of utilizing FHP as a tool for assessment for patients • Enumerate the Functional health patterns and their basic concepts • Obtain history taking and physical examination of the client through utilizing • FHP Formulate nursing diagnosis based on FHP assessment tool Identify altered physiological functions based on FHP. 2/8/2020 Post RN semester 1 AHN 2
  • 3. Definition of (NANDA) The North American Nursing Diagnosis Association (NANAD 1994) defines a nursing diagnosis as “A clinical judgments about individual, family or community response to actual and potential health problems and life responses” 2/8/2020 Post RN semester 1 AHN 3
  • 4. Functional health pattern (NANDA) 1- Health Perception-Health Management Pattern 2- Nutritional—Metabolic Pattern 3- Elimination Pattern 4- Activity—Exercise Pattern 5- Sexuality—Reproduction Pattern 6- Sleep—Rest Pattern 7- Sensory—Perceptual Pattern 8- Cognitive Pattern 9- Role—Relationship Pattern 10- Self-Perception-Self-Concept Pattern 11- Coping-Stress Tolerance Pattern 12- Value—Belief Pattern 2/8/2020 Post RN semester 1 AHN 4
  • 5. Health Perception-Health Management Pattern 1- Determine how the client perceives and manages his or her health. 2- Compliance with current and past nursing and, medical recommendations. 3- The client's ability to perceive the relationship between activities of daily living and health. 2/8/2020 Post RN semester 1 AHN 5
  • 6. Subjective Data  Client's Perception of Health: Describe your health.  Client's Perception of Illness Describe your illness or current health problem.  Health Management and Habits Tell me what you do when you have a health problem.  Compliance with Prescribed Medications and Treatments Have you been able to take your prescribed medications? If not, what caused your inability to do so? 2/8/2020 Post RN semester 1 AHN 6 Objective Data Refer to General Physical Survey
  • 7. Associated Nursing Diagnoses  Wellness Diagnoses Effective Management of Therapeutic Regimen  Risk Diagnoses Risk for Injury Risk for Suffocation Risk for Trauma  Actual Diagnoses Altered Growth and Development Ineffective Management of Therapeutic Regimen: Individual Ineffective Management of Therapeutic Regimen: Family Ineffective Management of Therapeutic Regimen: Community Noncompliance 2/8/2020 Post RN semester 1 AHN 7
  • 8. Nutritional-Metabolic Pattern Assessing the client's nutritional-metabolic pattern is to determine the client's dietary habits and metabolic needs. The conditions of hair, skin, nails, teeth and mucous membranes are assessed. Subjective Data  Dietary and Fluid Intake Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day. Do-you take any vitamin supplements? Describe. Do you find it difficult to tolerate certain foods? Specify. Do you ever experience nausea and vomiting? Describe. Do you ever experience abdominal pains? Describe. 2/8/2020 Post RN semester 1 AHN 8
  • 9. Condition of Skin Describe the condition of your skin. How well and how quickly does your skin heal? Do you have any skin lesions? Describe. Do you have any itching? What do you do for relief? Condition of Hair and Nails Have you had difficulty with scalp itching or sores? Do you use any special hair or scalp care products? Have you noticed any changes in your nails? Color Cracking? Shape? Lines? 2/8/2020 Post RN semester 1 AHN 9
  • 10. Metabolism What would you consider to be your "ideal weight"? Have you had any recent weight gains or losses? Do you have any intolerance to heat or cold? Have you noted any changes in your eating or drinking habits? Explain. Have you noticed any voice changes? 2/8/2020 Post RN semester 1 AHN 10 Objective Data Assess the client's temperature, pulse, respirations, and height and weight.
  • 11. Wellness Diagnoses Opportunity to enhance nutritional metabolic pattern Opportunity to enhance effective breastfeeding Opportunity to enhance skin integrity Risk Diagnoses Risk for Altered Body Temperature Hypothermia Risk for Infection Risk for altered nutrition less than body requirements . Risk for Aspiration 2/8/2020 Post RN semester 1 AHN 11
  • 12. Actual Diagnoses Fluid Volume Deficit Fluid Volume Excess Altered Nutrition: Less than body requirements Altered Nutrition: More than body requirements Ineffective Breastfeeding Altered Oral Mucous Membrane Impaired Skin Integrity. 2/8/2020 Post RN semester 1 AHN 12
  • 13. Elimination Pattern Adequacy of the client's bowel and bladder. The client's bowel and urinary habits. Bowel or urinary problems. Use of urinary or bowel elimination devices. 2/8/2020 Post RN semester 1 AHN 13
  • 14. Subjective Data Bowel Habits How frequent are your bowel movements? Do you use laxatives? What kind and how often do you use them? Do you use enemas or suppositories? How often and what kind? Do you have any discomfort with your bowel movements? Describe. 2/8/2020 Post RN semester 1 AHN 14
  • 15. Bladder Habits How frequently do you urinate? What is the amount and color of your urine? Do you have any of the following problems with urinating:  Pain? Blood in urine? Difficulty starting a stream? Incontinence? Voiding frequently at night? Voiding frequently during day? Bladder infections?  Have you ever had a urinary catheter? Describe. When? How long? Objective Data Refer to abdominal assessment, and the rectal assessment. 2/8/2020 Post RN semester 1 AHN 15
  • 16. Associated nursing-Diagnoses Wellness Diagnoses Opportunity to enhance adequate bowel elimination pattern Opportunity to enhance adequate urinary elimination pattern Risk Diagnoses Risk for constipation Risk for altered urinary elimination 2/8/2020 Post RN semester 1 AHN 16
  • 17. Actual Diagnoses Altered Bowel Elimination Constipation Diarrhea Bowel Incontinence Altered Urinary Elimination Patterns of Urinary Retention Total Incontinence Stress Incontinence 2/8/2020 Post RN semester 1 AHN 17
  • 18. Activity-Exercise Pattern Activities of daily living, including routines of exercise, leisure, and recreation. Activities necessary for personal hygiene, cooking, shopping, eating, maintaining the home, and working. An assessment is made of any factors that affect or interfere with the client's routine activities of daily living. 2/8/2020 Post RN semester 1 AHN 18
  • 19. Subjective Data  Describe your activities on a normal day (Including hygiene activities, eating activities).  Do you have difficulty with any of these self-care activities? Explain.  Does anyone help you with these activities? How?  Do you use any special devices to help you with your activities?  Does your current physical health affect any of these activities e.g. dyspnea, shortness of breath, palpations, chest pain. pain, stiffness, weakness)? Explain. Occupational Activities  Describe what you do to make a living.  Do you feel it has affected your health?  How has your health affected your ability to work? 2/8/2020 Post RN semester 1 AHN 19
  • 20. Objective Data Refer to Thoracic and Lung Assessment Cardiac Assessment Peripheral Vascular Assessment Musculoskeletal Assessment Associated Nursing Diagnoses Wellness Diagnoses Opportunity to enhance effective cardiac output Opportunity to enhance effective self-care activities Opportunity to enhance adequate tissue perfusion Opportunity to enhance effective breathing pattern 2/8/2020 Post RN semester 1 AHN 20
  • 21. Risk Diagnoses Risk for Disorganized Infant Behavior Risk for Peripheral Neurovascular Dysfunction Risk for altered respiratory function Actual Diagnoses  Activity Intolerance  Impaired Gas Exchange  Ineffective Airway Clearance  Ineffective Breathing Pattern  Disuse syndrome  Impaired Physical Mobility  Inability to Sustain Spontaneous Ventilation  Altered Tissue Perfusion 2/8/2020 Post RN semester 1 AHN 21
  • 22. Sexuality-Reproduction Pattern Subjective Data 1- Female Menstrual history: Last cycle begin? Duration ? Any change or abnormality ? Describe any mood changes or discomfort before, during, or after your cycle 2/8/2020 Post RN semester 1 AHN 22
  • 23. Obstetric history  How many times have you been pregnant?  Describe the outcome of each of your pregnancies.  If you have children, what are the ages and sex of each?  Explain any health problems or concerns you had with each pregnancy. If pregnant now . Contraception  What do you or your partner do to prevent pregnancy?  Describe any discomfort or undesirable effects this method produces.  Have you had any difficulty with fertility? Explain 2/8/2020 Post RN semester 1 AHN 23
  • 24. Special problems Do you have or have you ever had a sexually transmitted disease? Describe. Describe any pain, burning, or discomfort you have while voiding. Objective Data Refer to Breast Assessment, d Abdominal Assessment, and urinary-Reproductive Assessment 2/8/2020 Post RN semester 1 AHN 24
  • 25. Associated nursing Diagnoses Wellness Diagnosis: Opportunity to enhance sexuality patterns Risk-Diagnosis Risk for altered sexuality pattern Actual Diagnoses Sexual Dysfunction, Altered Sexuality Patterns 2/8/2020 Post RN semester 1 AHN 25
  • 26. Sleep-Rest Pattern Subjective data Sleep Habits: How would you rate the quality of your sleep? Special Problems Do you ever experience difficulty with falling asleep? Remaining asleep? Do you ever feel fatigued after a sleep period? Sleep Aids What helps you to fall asleep? medications? reading? relaxation technique? Watching TV? Listening to music? 2/8/2020 Post RN semester 1 AHN 26
  • 27. Objective Data 1. Observe appearance a. Pale b. Puffy eyes with dark circles 2. Observe behavior a. Yawning b. Dozing during day c. Irritability d. Short attention span 2/8/2020 Post RN semester 1 AHN 27
  • 28. Associated nursing Diagnoses Wellness Diagnosis: Opportunity to enhance sleep Risk Diagnosis Risk for sleep pattern disturbance Actual Diagnosis: Sleep Pattern Disturbance. 2/8/2020 Post RN semester 1 AHN 28
  • 29. Sensory-Perceptual Pattern Subjective Data Describe your ability to see, hear, feel, taste, and smell. Describe any difficulty you have with your vision, hearing, and ability to feel (e.g., touch, pain, heat, cold), taste (salty, sweet, bitter, sour), or smell. Pain Assessment Complete Symptom Analysis Special Aids: What devices (e.g., glasses, contact lenses, hearing aids) Describe any medications you take to help you with these problems. Objective Data Refer to the section on Nose and Sinus Assessment, Eye Assessment, and Ear Assessment. 2/8/2020 Post RN semester 1 AHN 29
  • 30. Associated Nursing Diagnoses Wellness Diagnosis: Opportunity to enhance comfort level Risk Diagnoses Risk for pain Actual Diagnoses Pain 2/8/2020 Post RN semester 1 AHN 30
  • 31. Cognitive Pattern Subjective Data Ability to Understand: Explain what your doctor has told you about your health. Ability to Communicate: Can you tell me how you feel about your current state of health? Ability to Remember: Are you able to remember recent events and events of long ago? Explain. Ability to Make Decisions: Describe how you feel when faced with a decision. 2/8/2020 Post RN semester 1 AHN 31
  • 32. Objective Data Refer to the Mental Status Assessment (GCS) Associated nursing Diagnoses Wellness Diagnosis: Opportunity to enhance cognition Risk Diagnosis: Risk for altered thought processes Actual Diagnoses: Acute confusion Chronic Confusion Knowledge Deficit (Specify) Impaired Memory 2/8/2020 Post RN semester 1 AHN 32
  • 33. Role-Relationship Pattern Subjective Data Perception of Major Roles and Responsibilities in Family Describe your family. Are there any major problems now? Perception of Major Roles and Responsibilities at Work Describe your occupation. What is your major responsibility at work? Perception of Major Social Roles and Responsibilities Describe your neighborhood and the community in which you live. 2/8/2020 Post RN semester 1 AHN 33
  • 34. Objective Data 1. Outline a family genogram for your client. 2. Observe your client's family members. Associated Nursing Diagnoses Wellness Diagnoses: Opportunity to enhance effective relationships Opportunity to enhance effective communication Risk Diagnoses: High risk for Loneliness Risk for Altered Parent/Infant/Child Attachment Actual Diagnoses: Impaired Verbal Communication Impaired Social Interaction: Social Isolation 2/8/2020 Post RN semester 1 AHN 34
  • 35. Coping-Stress Tolerance Pattern Subjective Data Perception of Stress and Problems in Life Describe what you believe to be the most stressful situation in your Life. How has your illness affected the stress you feel? Coping Methods and Support Systems: What do you usually do first when faced with a problem? What helps you to relieve stress and tension? Do you use medication, drugs, or alcohol to help relieve stress? Explain. Objective Data Refer to the Mental Status Assessment. 2/8/2020 Post RN semester 1 AHN 35
  • 36. Associated nursing Diagnoses Wellness Diagnoses Opportunity to enhance effective individual coping. Opportunity to enhance family coping Risk Diagnoses: Risk for self-harm Risk for suicide Actual Diagnoses: Ineffective Individual Coping Ineffective Family Coping: Disabling 2/8/2020 Post RN semester 1 AHN 36
  • 37. Value-Belief Pattern Subjective Data Values, Goals, and Philosophical Beliefs Religious and Spiritual Beliefs: Are there certain health practices or restrictions that are important for you to follow while you are ill or hospitalized? Explain. Objective Data Observe religious practices Bible , clergy Observe client's behavior for signs of spiritual distress Anxiety, Anger , Depression , Doubt, Hopelessness and Powerlessness 2/8/2020 Post RN semester 1 AHN 37
  • 38. Associated Nursing Diagnoses Wellness Diagnosis: Potential for Enhanced Spiritual Well-Being Risk diagnosis: Risk for spiritual distress Actual Diagnosis: Spiritual disturbance (distress of the human spirit). 2/8/2020 Post RN semester 1 AHN 38
  • 39. References 1. Dillon PM., Nursing Health Assessment; A Critical Thinking, Case Studies Approach, 2nd ed. Copyright © 2007 by F. A. Davis. 2. Kozier & Erb, G. K., (2015). Fundamentals of Nursing: Concept, process and practice (10th ed.). Addison. 3. Wesley.Bruner, L.S., & Suddarth, D.S. (2015). Text book of Medical-Surgical Nursing (14 Ed.). Philadelphia: Lippincott. 2/8/2020 39Post RN semester one
  • 40. Thanks for Attention 2/8/2020 Post RN semester 1 AHN 40