Holistic Assessment and Application of the Nursing Process (FHP)

Part I: Functional Health Pattern Data Collection and Summary

Health History by Functional Health Patterns (Human Flourishing, Nursing Judgment)

1	Client Profile The patient is a 72-year-old female with multiple chronic conditions, including chronic obstructive pulmonary disease (COPD), pneumonia, renal artery stenosis, hypercapnic respiratory failure, hypertension, and right breast cancer, which is currently in remission. The patient has a history of allergy to penicillin, amlodipine, and environmental sensitivity. She currently uses oxygen, antihypertensive diuretics, and inhalers for COPD management. The patient sought care due to a worsening of her COPD symptoms, including shortness of breath, productive cough, and low oxygen saturation levels. She has been hospitalized multiple times for respiratory issues, the most recent being pneumonia. These hospitalizations have significantly affected her respiratory health, contributing to her progressive decline in physical capabilities. The patient rates her health 5 out of 10, indicating a significant decline from five years ago when she rated it at 7. Her realistic approach to managing her condition is evident, but she remains hopeful for improvement despite her physical limitations.
2	Developmental The patient is at Erikson’s stage of Integrity versus Despair, which is appropriate for older adults. In this stage, she focuses on a summary of her accomplishments, which include family, and gains a feeling of satisfaction. Although she has chronic diseases and uses oxygen therapy, there are some negative emotions, such as frustration and despair due to loss of independence. The patient acknowledges that she receives adequate support from her family, hence reducing the psychological ailments that are accompanied by illnesses. These are some of the challenges that the patient has to undergo, and she is far strong enough to adapt her life to all these limitations; in this context, the patient is in the process of finding a positive solution to the crisis characteristic of this stage. However, feelings of hopelessness are noticeable, for example, when she talks about her dependency on others in aspects such as personal care.
3	Health Perception-Management Pattern: The patient feels her health is getting worse, rating it 5 out of 10, down from a rating of 7 five years ago. Her main concern is COPD and hypercapnic respiratory failure, for which she needs supplemental oxygen for almost all activities. She complies with prescribed drugs such as inhalers for COPD and diuretics for hypertension; however, she requires help in remembering to take medicines due to the complexity of dosing. Nonetheless, she still strives to remain as independent as possible, which has appealed to the caregiver’s assistance more often. Her recent hospitalization due to pneumonia has worsened her respiratory system, which she admits has made coping with the disease hard. The patient also tries to avoid allergens such as penicillin and amlodipine and environmental factors that trigger severe allergic reactions.
4	Nutritional-Metabolic Pattern: The patient maintains a stable weight but experiences a decreased appetite, primarily due to the disease process. She typically consumes small portions, which raises concerns about her nutritional status. In the lab profile, there is evidence of low albumin; therefore, there is a good indication that the patient could be malnourished. The identified patient lacks adequate nutrients and has to be encouraged to take fluids and nutrient-rich foods in order to boost her overall health and energy level for the activities of the day.
5	Elimination Pattern: Regarding bowel movement, which could reflect more about the patient’s diet and physical activity, the patient has constipation on some days due to limited mobility and less intake of fluids. She has a normal bowel movement and slight abnormality of cycling frequent urination due to the intake of diuretics in the treatment of hypertension. While she does not present herself with incontinence problems, her elimination problems should be closely monitored to ensure that she does not develop complications such as dehydration or constipation, which would worsen her condition. Previously, the patient had regular bowel habits, typically experiencing a daily bowel movement without any constipation. Currently, she occasionally has irregular bowel habits, but she does not report any significant discomfort or constipation at this time. Addressing her fluid intake and mobility will be important in managing her elimination pattern effectively.
6	Activity-Exercise Pattern: The patient’s activity level has decreased significantly due to her COPD and hypercapnic respiratory failure. She requires assistance with most activities of daily living (ADLs), such as bathing, dressing, and eating. Even with oxygen therapy, her endurance is severely limited, and she becomes fatigued after minimal exertion. The patient is aware of the impact her respiratory condition has on her physical capabilities, and she reports frustration with her reduced independence. Normal pattern: The patient was previously independent in performing all ADLs and engaged in light physical activities. Current changes: She now requires assistance with most ADLs and experiences significant fatigue with minimal exertion
7	Sexuality-Reproduction Pattern: The patient is 72 years old. She has gone through the menopausal stage and does not report any specific issues with her reproductive organs after menopause. Currently, there are no records of sexual dysfunction or any reproductive issues regarding the subject. The patient’s concern is her primary well-being, and concepts related to her sexual sphere of life have not been introduced into the process of her treatment and care.
8	Sleep-Rest Pattern: The patient complains of nighttime awakenings because of shortness of breath and, therefore, poor quality sleep. Despite this, she has had oxygen during sleep and continues to have a disturbed pattern that causes her to feel fatigued during the day. This lack of rest further worsens her overall health and hinders her from effective and meaningful functioning during the day. The treatment of her nighttime respiratory disorder is therefore paramount to improving her sleep quality. Optimizing oxygen therapy and examining ways to de-stress the quality of the patient’s sleep environment may help improve the patient’s sleep quality and health in the long term.
9	Sensory-Perceptual Pattern: The patient’s sensory-perceptual function remains largely intact, as she is alert and oriented to person, place, and time. However, at times, she may have mild problems with concentration, which might be owing to the fact that she is a patient with chronic respiratory disorders. As for the eyes and ears, she had no change in her vision or hearing. Her current cognitive state may be adequate; however, keeping her mentally engaged will be a key endeavor to ensure her cognitive well-being and improve her quality of life.
10	Cognitive Pattern: The patient has normal cognitive ability; she is fully oriented in terms of person, place, and time. She engages in a conversation regarding her care and shows various health conditions that are important for her care. Nevertheless, she may sometimes have a degree of attention deficit, which is probably a result of her fatigue along with her chronic respiratory problems. Explaining her case in detail and ensuring she has an active role in decision-making will enable her to come up with the best decisions for her health. Normal pattern: The patient previously had no issues with concentration and was able to manage her daily tasks without difficulty. Current changes: She now reports some difficulty with concentration, likely related to her fatigue and respiratory issues.
11	Role-Relationship Pattern: The patient’s family plays a significant role in her support system. She has strong relationships with her children and grandchildren, who assist her with daily activities and provide emotional support. The patient’s reliance on her family for assistance has increased due to her health conditions, affecting her sense of independence. Having regular conversations with her family about her health condition and requirements is significant for her. Taking family members through her care plan will assist them in knowing what the patient prefers and how they can support her.
12	Self-Perception-Self-Concept Pattern: The patient’s self-perception is profoundly impacted by her chronic health conditions, which have transformed her once-active lifestyle into one marked by frustration and sadness. She worries about how her illnesses affect her identity and relationships with family and friends. Previously, she had a positive self-image, actively participating in family gatherings and organizing events. Currently, she feels less capable and increasingly relies on her family for support, which undermines her confidence and independence. Despite these challenges, she maintains her personal hygiene and appearance, finding comfort in grooming routines that help her feel a sense of control over her situation.
13	Coping-Stress Tolerance Pattern: The patient employs a mix of problem-focused and emotion-focused coping strategies to manage the stress associated with her chronic illnesses. She looks for some information about her condition and participates in discussions with her family for encouragement. Earlier, she was able to cope with stress by engaging herself in social activities and doing other enjoyable things. For the last few months, she was enjoying less of her health, and this resulted in an elevated level of stress as she lost her ability to control stress through interacting with others. She says she uses deep breathing during some episodes of anxiety, but she also knows that some of the methods she uses are inadequate at the moment. Further assessment and interventions may require some additional help to improve her coping skills and decrease her stress response.
14	Value-Belief Pattern: The patient strongly believes in the importance of family and personal dignity, which are central to her identity. She finds strength and hope in her faith, actively participating in her religious community when her health allows. This involvement provides her with a sense of purpose and belonging. However, her chronic health issues have limited her participation in community activities, leading to feelings of disconnection. She emphasizes the need for healthcare providers to respect her values and engage in shared decision-making regarding her treatment. This respect is crucial for her emotional well-being and overall care experience.

Summary

Summary of Functional Health Pattern

Significant Health Concerns:

· The patient’s main health concerns are the inability to clear secretions because of COPD with hypercapnia, resulting in recurrent shortness of breath and vulnerability to respiratory infections.

· There is also an issue of malnutrition because the patient has a problem with appetite due to diseases and consequent weight loss attributed to her respiratory complications. They culminate in the deterioration of her general health and, thus, poor quality of life.

· Self-esteem, confidence, and mood are also interfered with because health challenges deprive the patient of the ability to participate in family and community activities, making her recovery even harder.

Opportunities for Health Improvement:

· Opportunities for health improvement for the patient include enhancing nutritional intake through dietary modifications and counseling, which can help address her malnutrition and support overall recovery.

· Hydration can also be useful for the thinning of secretions, which aids in clearing the airway.

· Incorporation of an organized pulmonary rehabilitation plan may further boost her respiratory strength, thus allowing her to perform more activities independently.

· Furthermore, a massive education can improve her emotional intelligence, such as her knowledge of how to manage disease.

· Lastly, building rapport with the team of healthcare providers will allow her values and preferences to be considered to capture a higher degree of personalized care.

Client Strengths/Weaknesses:

· The patient’s strengths include her mental alertness and proactive engagement in her healthcare, as she actively participates in discussions and decision-making about her treatment.

· She has robust family support, which translates to hailing, comforting, and boosting her throughout the process.

· Nevertheless, she presents with physical limitations associated with COPD, which compromised her ability to move around and to do activities on her own. The chronic diseases and associated symptoms of frustration and sadness reduce her self-esteem and emotional well-being further and require constant follow-up care.

Part II: Nursing Care Plan

Nursing Care Plan (Nursing Judgment)

Priority Nursing Diagnosis: Ineffective airway clearance related to COPD and hypercapnic respiratory failure as evidenced by shortness of breath, productive cough, and oxygen saturation levels below 90%.

Client Goals & Outcomes

Nursing Interventions

Evidence-based Rationale

1. Short-term Goal: The patient will maintain oxygen saturation levels above 90% within the next 24 hours with the use of oxygen therapy.

Outcome: Oxygen saturation will be monitored hourly, and the patient’s levels will remain above 90%.

1. Administer prescribed oxygen therapy at the appropriate flow rate to maintain oxygen saturation above 90%

2. Monitor oxygen saturation levels every hour and adjust therapy based on readings.

3. Teach and assist the patient with pursed-lip breathing techniques to enhance ventilation and facilitate airway clearance.

1. Supplemental oxygen is essential in maintaining adequate oxygen levels in patients with chronic lung disease, preventing hypoxia (Weekley & Bland, 2023).

2. Continuous monitoring allows for timely interventions to ensure adequate oxygenation (Sonmezoglu et al., 2021).

3. Pursed-lip breathing slows the breathing rate and improves oxygenation by keeping airways open longer (Nguyen & Duong, 2023).

2. Long-term Goal: The patient will demonstrate effective coughing techniques to clear secretions within three days.

Outcome: The patient will report improved ability to clear secretions, as evidenced by clear lung sounds and reduced respiratory distress.

1. Encourage adequate fluid intake (at least 2 liters per day) to help thin secretions, promoting effective coughing and airway clearance.

2. Assist the patient with deep breathing and coughing exercises every two hours to promote effective airway clearance.

3. Provide education on the importance of effective coughing techniques to prevent infections.

1. Proper hydration assists in thinning mucus, making it easier to expel, and can reduce the risk of respiratory infections (Belli et al., 2021).

2. These exercises can help mobilize secretions and improve lung function, reducing the risk of pneumonia (Xiong et al., 2023).

3. Educating patients on airway management reduces the risk of respiratory infections and enhances recovery (Bowman-Woodall et al., 2020).

Evaluation Criteria

Goal #1: Oxygen saturation levels will be monitored hourly. If the patient maintains saturation levels above 90% within 24 hours, the goal will be considered met.
Goal #2: The patient will demonstrate effective coughing techniques by day three, with improved lung sounds and the ability to expectorate secretions independently. Evaluation will include the nurse’s observation of the patient’s breathing patterns and lung auscultation findings (Bowman-Woodall et al., 2020).

Reflection Questions
Where do you see the greatest opportunities for health promotion? How does this relate to your client’s problem(s)?

The greatest opportunity for health promotion lies in improving the patient’s respiratory function and nutritional status. Given her chronic obstructive pulmonary disease and recent hospitalization for pneumonia, educating her on effective breathing techniques and encouraging proper hydration can significantly enhance her airway clearance. Additionally, promoting a balanced diet rich in nutrients will help combat her malnutrition and improve her overall strength and resilience.

As a nurse, what could you do that would have the greatest impact on this client’s health outcome?

As a nurse, I could facilitate effective communication and education about her condition, focusing on the importance of adhering to the treatment plan and recognizing early signs of respiratory distress. By providing tailored education on managing her COPD and teaching self-care strategies, I can empower the patient to take an active role in her health, potentially improving her quality of life and reducing hospital readmissions.

Identify at least three insights you gained from completing this assignment. Discuss each below.

Insight 1: Understanding the significance of holistic assessment reveals how interconnected physical, emotional, and cognitive factors influence a patient’s overall health. This perspective allows for more comprehensive care tailored to individual needs.
Insight 2: The importance of effective communication and patient education emerged as critical elements in managing chronic illnesses. Providing clear instructions and involving patients in their care can enhance adherence and self-management.
Insight 3: The necessity of continuous evaluation and adaptation of care plans was highlighted. Each patient’s condition can fluctuate, necessitating ongoing assessment and adjustments to ensure that interventions remain effective and relevant.

References

Belli, S., Prince, I., Savio, G., Paracchini, E., Cattaneo, D., Bianchi, M., Masocco, F., Bellanti, M. T., & Balbi, B. (2021). Airway clearance techniques: The right choice for the right patient. Frontiers in Medicine, 8(1). https://doi.org/10.3389/fmed.2021.544826

Bowman-Woodall, C., Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Study guide for Lewis’s medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier Inc.

Nguyen, J., & Duong, H. (2023). Pursed-lip breathing. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545289/

Sonmezoglu, S., Fineman, J. R., Maltepe, E., & Maharbiz, M. M. (2021). Monitoring deep-tissue oxygenation with a millimeter-scale ultrasonic implant. Nature Biotechnology, 39(7), 855–864. https://doi.org/10.1038/s41587-021-00866-y

Weekley, M. S., & Bland, L. E. (2023). Oxygen administration. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551617/

Xiong, T., Bai, X., Wei, X., Wang, L., Li, F., Shi, H., & Shi, Y. (2023). Exercise rehabilitation and chronic respiratory diseases: Effects, mechanisms, and therapeutic benefits. International Journal of Chronic Obstructive Pulmonary Disease, Volume 18(56), 1251–1266. https://doi.org/10.2147/copd.s408325

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Question

Objectives:

Conduct a sensitive patient interview using therapeutic communication skills to complete a comprehensive health history of an assigned client in the clinical setting. Do not use patient identifiers i.e. name, DOB, employer, school, etc.
Organize holistic data consistently using Gordon’s Functional Health Patterns as a guide.
Concisely summarize significant patient findings including physical, psychosocial, strengths, & weaknesses.
Identify one priority nursing diagnosis and correctly write it as a diagnostic statement.
Complete an individualized plan of care based on assessment findings and state how you would evaluate if it met patient needs.
Utilize self-reflection to identify health promotion opportunities and the role of the nurse.

Part I: Functional Health Pattern Data Collection and Summary

This portion of the assignment will be completed on a Word document using the template below and submitted to the appropriate drop box in D2L.
Students MUST use the template below and type out assignment

Health History by Functional Health Patterns (Human Flourishing, Nursing Judgment)

*See Medical-Surgical Nursing (Lewis et. al, 2020) Chapter 3: Health History and Physical Examination for description of each functional health pattern area as well as examples of questions to ask client. Also see assignment guide found in D2L.

Holistic Assessment and Application of the Nursing Process (FHP)

1	Client Profile (chronological events leading to hospitalization & progress since in your own words):
2	Developmental History (identify Erickson stage of Development with description of crisis resolution, supported by cues):
3	Health Perception-Management Pattern:
4	Nutritional-Metabolic Pattern:
5	Elimination Pattern:
6	Activity-Exercise Pattern:
7	Sexuality-Reproduction Pattern:
8	Sleep-Rest Pattern:
9	Sensory-Perceptual Pattern:
10	Cognitive Pattern:
11	Role-Relationship Pattern:
12	Self-Perception-Self-Concept Pattern:
13	Coping-Stress Tolerance Pattern:
14	Value-Belief Pattern:

Summary: Bullet point out the significant health concerns, opportunities for health improvement, and client strengths/weaknesses. Summary should address psychosocial as well as physical concerns. The summary should make a case for your chosen diagnosis based on the data above.

Significant Health Concerns:

Opportunities for Health Improvement:

Client Strengths/Weaknesses:

Part II: Nursing Care Plan

Create a nursing care plan for your client using the table below. Be sure to include references.

Nursing Care Plan (Nursing Judgment) –Present data in table on concept map

Priority Nursing Diagnosis (3-part): _________________related to (r/t) _________________ as evidenced by (AEB) _________________

Client Goals & Outcomes

(list 2)

Nursing Interventions

(list 3 for each goal)

Evidence-based Rationale (for each intervention – with APA in-text citation)

(Need to be measurable with a time frame i.e. “client will be able to list four snack choices that are in accordance with prescribed diabetic diet prior to hospital discharge”)

(Specific to goal i.e. “give patient a list of snacks allowed on diabetic diet”)

(Justify intervention i.e. “giving patient a list can serve as a reminder and reinforce teaching after discharge (Smith, 2016)”

Describe how you would evaluate the above client goals (These statements should resemble the goals and outcomes and need to be measurable and with a time frame i.e. “client will be able to list a minimum of four snack choices that are in accordance with diabetic diet prior to discharge”)

Reflection Questions (Nursing Judgment & Spirit of Inquiry) – Discuss each question below. Discussion needs to show evidence of depth-of-thought and reflection for each:

In reviewing the comprehensive history of this client, where do you see the greatest opportunities for health promotion? How does this relate to your client’s problem(s)?

As a nurse, what could you do that would have the greatest impact on this client’s health outcome?

Identify at least three insights you gained from completing this assignment and discuss each below.
Insight 1:
Insight 2:
Insight 3:

List of references in APA format for sources cited in care plan

Holistic Assessment and Application of the Nursing Process (FHP)

Holistic Assessment and Application of the Nursing Process (FHP)

References

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