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Nursing, Pages: 3

Holistic Assessment and Application of the Nursing Process (FHP)

Holistic Assessment and Application of the Nursing Process (FHP)

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
  1. 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.

1 Client Profile (chronological events leading to hospitalization & progress since in your own words):

A 66-year-old African-American male presented for his routine clinical visit for diabetes. He is an immigrant and has a college graduate with a degree in civil engineering.  He is a known diabetic with no known allergies. He is currently on metformin and gliclazide.
2 Developmental History (identify Erickson stage of Development with description of crisis resolution, supported by cues):

The patient has never had any developmental challenges across his lifespan. The patient is in the late adulthood stage. He is functioning per the provisions of the late adulthood stage and is proud of all he has achieved during his early life.
3 Health Perception-Management Pattern:

The patient gives his health a score of 8. Five years ago, his health was excellent as he had few health concerns. He hopes to get better in the next five years. He believes his unhealthy lifestyle is the reason for his illness. The patient is committed to learning different aspects of self-care to allow him to care for himself at home. He contacts a clinic in his neighborhood whenever he has a healthcare problem. The patient can name all the medications he is currently using.

The patient has no known allergies. He denies having any significant illness before.

The patient presents to the clinic for his routine monthly examinations on the second week of every month. To maintain his health, he attends all his scheduled clinical visitations. He is also up to date with all his adulthood vaccines. The patient also takes all of his prescribed medications, drinks alcohol, and smokes cigarettes.

The patient is alert and responsive. Vital signs: HR: 69 BP: 119/71 Temp: 97.7 F RR: 17 SpO2: 100%  Height: 5’8 Weight: 170.12 lbs.
4 Nutritional-Metabolic Pattern:

The patient takes a balanced diet and can consume hard foods. His last dental check-up was in February. He has no difficulty eating or drinking. No reports of nausea, vomiting, indigestion, or use of antacids. Denies any recent weight loss and gain.

The patient has a height of 5’8, a weight of 170 lbs, and a BMI of 25.8. His skin is consistent in coloration. No signs of any skin anomalies. His hair is evenly distributed on the scalp. His nails are smooth with a capillary refill of 2 seconds. No signs of finger clubbing. No signs of alopecia or abnormal hair thickening.  The client does not have any feeding precautions. Denies using any probiotics, or vitamin supplements. He is a known diabetic. His past RBS values were 85 mmol/L.
5 Elimination Pattern:

The patient denies having any bowel movement inconsistencies or recent changes in his bowel movements or using anything to aid his bowel movements. He last emptied his bowel the previous day.  The patient has never had any GI surgeries.

The patient’s frequency of voiding has increased significantly. He, however, denies any urinary color changes or malodorous urine. He has no history of bladder surgery.
6 Activity-Exercise Pattern:

The patient can independently perform his daily living activities. He travels for fun and does not exercise. He works as a field engineer in a local organization. His work is an outdoor job that gets him moving around. He denies wheezing, pulmonary rale sounds, shortness of breath, or irregular heart rate or rhythm irregularities. He also denies having any muscle or skeletal pain, excessive bleeding, or having received any respiratory or cardiac interventions.

 
7 Sexuality-Reproduction Pattern:

The patient is sexually active. He denies erectile dysfunction, testicular changes, or prostate problems. His last prostate exam was the previous year. He denies having any STDs or a history of STDs.
8 Sleep-Rest Pattern:

The patient sleeps for at least 8 hours. He denies using anything to induce or maintain sleep. He notes that he has good quality sleep and denies any sleeping difficulties or changes in the pattern of his sleep.
9 Sensory-Perceptual Pattern:

The patient can hear, see, smell, feel and taste. He denies using any hearing or visual aids.
10 Cognitive Pattern:

The patient has a degree in civil engineering. His preferred learning method is reading. His decision-making and judgment are intact. He is also conscious and oriented to place, event, and time.  He can respond to the interview questions asked and recall information. Their attention span is also optimal. His reasoning is logical.
11 Role-Relationship Pattern:

The patient currently lives alone.  The most important person in his life is his eldest brother. His family is not concerned with his illness. The communication between his family members is dysfunctional. He loves his work. He does not participate in any activities.

 
12 Self-Perception-Self-Concept Pattern:

The patient thinks he is a strong person and that illness has not affected him. His strength is in his belief in God. His weakness is his inability to bond with his sons. He thinks his appearance is great and has not been affected by illness. He maintains good hygiene.
13 Coping-Stress Tolerance Pattern:

The most stressful situation in his life was when his wife divorced him. The illness has not affected the stress. He has no difficulty financing his health. He has not experienced any major life change in the past year. He copes with his problem by drinking alcohol and hanging out with friends.
14 Value-Belief Pattern:

Work is the most important thing in the patient’s life. He hopes to build his own company. His major source of hope and strength is his work and God. The patient is a Catholic. His religion is important to him as it is his other source of hope. He has no special request and does not indulge in health practices other than praying.
  1. 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:

·         Diabetes

·         Alcohol consumption.

·         Dysfunctional family
Opportunities for Health Improvement:

·         Healthcare seeking and health promotion.

 
Client Strengths/Weaknesses:

·         The client’s strength is his healthcare-seeking behavior. His weaknesses include indulgence in poor healthcare practices, such as a lack of exercise, alcohol consumption, and smoking.

 

 Part II: Nursing Care Plan

  • Create a nursing care plan for your client using the table below. Be sure to include references.
  1. Nursing Care Plan (Nursing Judgment) –Present data in table on concept map
Priority Nursing Diagnosis (3-part): ______Ineffective health maintenance___________related to (r/t) ___diabetes diagnosis______________ as evidenced by (AEB) ___observed patients inability to meet positive health practices necessary in optimizing blood sugar control______________
Client Goals & Outcomes

(list 2)

 Nursing Interventions

(list 3 for each goal)

 Evidence-based Rationale (for each intervention – with APA in-text citation)
 Patient will verbalize factors contributing to their health status by the end of the session
  1. Educate patients on the detriments of their health behaviors.

 

  1. Coordinate resources to enhance patient understanding of their illness.

 

  1. Discuss programs for addiction and substance abuse

 
  1. Patient education may enhance their understanding of the consequences of their behavior (Garg et al., 2019).

 

  1. Nurses can coordinate educative resources to expand patients’ understanding of their illnesses (Dailah, 2024).

 

  1. Addiction and substance use programs can help patients with addiction risks identify their risk status and disease process (Garg et al., 2019).
The patient will adopt a healthy lifestyle to optimize glycemic control within two months of therapy.
  1. Educate patients on the detriments of a poor lifestyle, such as alcohol use and physical inactivity, in health maintenance.

 

  1. Assess the patient’s knowledge of the best practices for health maintenance among diabetics.

 

  1. Discuss programs for exercise and dietary control of carbs among diabetics.
  1. Alcohol use and physical inactivity predispose individuals to diabetes (Ismail et al., 2021).

 

  1. Assessing patient’s knowledge ensures that they are better accountable for self-care (Garg et al., 2019).

 

  1. Exercise and diet are effective in optimizing blood sugar control (Ismail et al., 2021).

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”)

#1 The client will verbalize at least three factors contributing to their current health status by the end of the session.

#2 The Client will adopt a healthy lifestyle, as demonstrated by reduced alcohol intake, dietary control of carbs, and at least 150 minutes of moderate physical activity weekly within two months of therapy.

 

  1. 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)?

The greatest opportunity for health promotion is the patient’s literacy level. He is a graduate and can decipher health information given to him. Patient education can help the patient understand their disease process and best practices to control it.

 

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

Educating the patient on lifestyle changes to optimize his disease outcomes is the nursing intervention that may produce the greatest impact on the patient. Lifestyle interventions, such as exercise and dietary control of carbohydrates, are effective in optimizing blood sugar control and increasing remission potential in patients with diabetes.

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

Insight 1: Comprehensive assessment of chronic illnesses. The assignment gave me insights into areas of focus when assessing chronic illnesses.

Insight 2: Management approaches to diabetes: The assignment widened my perspectives on non-pharmacological approaches to diabetes.

Insight 3: Personal Factors Interplaying in Disease Development- I learned of how personal factors such as lifestyle predispose individuals to diseases and illnesses.

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

Dailah, H. G. (2024). The influence of nurse-led interventions on diseases management in patients with diabetes mellitus: A narrative review. Healthcare, 12(3), 352. https://doi.org/10.3390/healthcare12030352

Garg, R., Chawla, S. S., Kaur, S., Bharti, A., Kaur, M., Soin, D., Ghosh, A., & Pal, R. (2019). Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. Journal of Family Medicine and Primary Care, 8(1), 261. https://doi.org/10.4103/jfmpc.jfmpc_228_18

Ismail, L., Materwala, H., & Al Kaabi, J. (2021). Association of risk factors with type 2 diabetes: A systematic review. Computational and Structural Biotechnology Journal, 19, 1759–1785. https://doi.org/10.1016/j.csbj.2021.03.003

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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.

    Holistic Assessment and Application of the Nursing Process (FHP)

    Holistic Assessment and Application of the Nursing Process (FHP)

  • 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