Report Gordons

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a N-205 2009 INP 2012 Biographical Information: Provider of Information: Relationship to patient: Name: Age: Birth date: Birthplace: Gender: Marital Status: Spouse’s Name: Age: Occupation: Race: Educational Level: Reason for Seeking Care: Admitting diagnosis: Current Diagnosis: Advanced Directives: Living Will DNR MPOA Requests information Allergies (w/ reaction): (drug, food, latex) Pain: Character: Onset: Location: Duration: Severity: Pattern: Associated Factors: Past Health history:

Transcript of Report Gordons

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a N-205 2009INP 2012

Biographical Information:

Provider of Information: Relationship to patient:

Name:

Age: Birth date:

Birthplace: Gender:

Marital Status: Spouse’s Name: Age:

Occupation: Race:

Educational Level:

Reason for Seeking Care:

Admitting diagnosis: Current Diagnosis:

Advanced Directives: Living Will DNR

MPOA Requests information

Allergies (w/ reaction): (drug, food, latex)

Pain:Character:

Onset:

Location:

Duration:

Severity:

Pattern:

Associated Factors:

Past Health history:

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Problems at birth:

Childhood illnesses:

When? How long?

Immunizations:

MMR

 Tetanus

Pneumonia

Flu

Polio

HIB

Hep B

Others:

Other illnesses:When? How long?

Surgeries: When? Post-op Treatment

Accidents:When? How long?

Intermittent Pain / Prolonged Pain:

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Family Health History: (Grandparents, Parents, Siblings, Children)

Cause of death Date Age

Grandfather(F)

Grandmother(F)

Grandfather(M)

Grandmother(M)

Father

Mother

Siblings:

Children:

Genogram:

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Health perception:

Health Status: Good Fair Bad

Satisfied with health status? Y N

Reason:

 Tobacco/Cigarettes? Y N # of Packs/day:

Alcohol: Type:

How often? How much?

Street Drugs? Type:

How often? How much?

Chronic Diseases?When? How long?

Health Seeking behavior:

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Working Conditions: Excellent,Fair, Poor

 ______ safety

 ______ noise

 ______ space

 ______ heating/cold

 ______ water

 ______ ventilation

Living Conditions:Residence:

 ______ safety

 ______ noise

 ______ space

 ______ heating/cold

 ______ water

 ______ ventilation

Household members:

Problem areas:

Access to:

Grocery

Pharmacy

Clinic

Hospital

 Transportation

Church  Telephone

Medications before admission or current OTC medications used:meds # How often Reason

Alternative medications used:meds # How often Reason

Did you follow routine prescribed for med, diet, exercise? Why?

Problems with wounds/healing?

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Exercise: Type How often?

Ringing in the ears?y/n How often How long

Right

Left

Vertigo?How

often?Sincewhen?

How long doesit last?

How is itrelieved?

subjective

objective

Safety gear Seat belts Helmets

Padding Children’s seat

Suggestion for care?

Self examinations (breast/testicular)

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Nutrition

Weight fluctuations in last 6 months: Prefer to gain or lose?Gain

Loss

Appetite Good Fair Bad

Food Intolerances:food reaction

Dietary RestrictionsVoluntary

Health Regimen

Average Food intake in a day:Food / drink amount

Breakfast

Lunch

Dinner

In between

Food PreferencesLikes

Dislikes

Problems with (describe):

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Nausea

Vomiting

Swallowing

Chewing

Indigestion

Diarrhea

Constipation

Lifestyle: Active Sedate

Activities/Hobbies: How often is it done?

Chronic Health problems?

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Elimination

Frequency:

Same time each time? Y N time:

Strain during elimination?

Last bowel movement:

Changes in the last week:

Character of Stool Hard Soft liquid

Color of Stool brown black

yellow clay

variety:

Incontinence? Y NRelated to laughing, coughing or sneezing?

Recent travel:Where Inclusive Dates Remarks

Voiding Pattern: Frequency

Changes in pattern awareness to void urge to void

amount difficulty voiding

Color: Orange Bright yellow Light yellow

Smoky Dark

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Incontinence? Y NRelated to laughing, coughing or sneezing?Others:

Have time to go to the bathroom? Why/why not?

Any problem with:

Reaching the bathroom? Why/why not?

Retention? describe

Pain/Burning senasation? describe

Bladder Spasms? describe

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Activity / Exercise

Legend:0 = completely independent1 = requires device/eqpt

2 = requires assistance

3 = requires help frompeople/eqpt

4 = dependent

 ______ Feeding ______ Bath/hygien

e ______ toileting ______ grooming

 ______ ambulation ______ shopping ______ care of 

home

 ______ mealpreparation

 ______ laundry ______ transportati

on

Who helps?

Is oxygen used at home? Y N

Pillow used in bed:

Fatigued? Y NWhen?

How often?

Describe

Climbing Stairs: How many steps/flights before feeling tired?

Walking: How far before feeling tired?

Falls?How often?

How bad?

Last Fall: Where: When:

Severity of Injury:

Weakness? Lack of Energy?

Difficulty doing things?

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Difficulty in Concentration?

Wheelchair management?

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Sleep – Rest Patterns

Sleep: _______ hrs/night

Naps:AM PM

Rested at waking?

Problems: Going to Sleep? Wakened at night?

Early Waking? Insomnia (describe)

Methods to promote sleeping:Meds:

Warm Fluids? What? How much?

Relaxation Techniques:

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Cognitive – Perceptual Pattern

Decision Making Easy Moderately Easy

Moderately Hard Hard

Inclined to make decisions Quickly Slowly Delayed

Knowledge Level:Current Problem

Current Therapy/Regimen

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Self-Perception / Self-Concept Pattern

Major concern right now?

Will this confinement alter the patient’s lifestyle?

Will this confinement alter the patient’s body image?

View of self: Positive Neutral Negative

Describe:

Problem with current situation

Perception of control 0 1 2 3 4 5None full

Assertion level 0 1 2 3 4 5Not very

Recent loss (social, physical, emotional)? Describe

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Role Relationship Pattern

Living with Spouse / Partner?

Relationship with spouse/partner is:

Parenting Skills: Not difficultaverage difficult

Recent losses (social, personal, psychological)

Will this confinement result in a loss?

Other diagnosis been made on the patient recently?

Does the patient express Sadness?

Will there be changes in the patient’s role in the family due to illness?

Social Activities: very active active limited none

Comfort in social situations 0 1 2 3 4 5Not very

Patient was caregiver? To whom?

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Sexuality

FEMALE:

Last menses:

Pregnancies para gravida

Menopause

Birth control

Vaginal discharges, bleeding, lesions

Pap smear Last pap smear

Mammogram (last)

STDInclusive dates Remarks

If raped:Physical symptoms experienced:

Emotional reaction:

Coping mechanism:

Rape Crisis Center: (via nurse?)

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Sexuality

MALE

Prostate problems?

Penile discharge, bleeding, lesions?

STDInclusive dates Remarks

BOTH

Problems with sexual functioning?

Satisfied with sexual relationship?

Admission to impact sexual functioning?

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Coping – Stress Tolerance

Stressful even in last year?

How do you handle stress? Poor 0 1 2 GoodDescribe:

Family support available?

Does the patient go to Counseling?

Are these support systems helpful?

Primary reason for admission?

Do you see a doctor as soon as there are symptoms? Why?

Caregiver:What is your understanding of care at home after admission?

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Values – Beliefs

Is the patient satisfied with life?

Does this admission interfere with any plans?

Religion:

Does this admission interfere with religious duties?

Religious restrictions (diet, treatment)

Does the patient desire counseling with minister, priest, rabbi, others?

Does Religion help in dealing with problems in the past?

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OBJECTIVE DATA

Vitals

site 1st __:____ 2nd __:____ 

 Temperature

PR

RR - Abdominal

Diaphragmatic

Depth

BPWeight - lbs

Height - ft. ins.

Mental Status

Orientation:length of time

oriented /

disoriented

time

place

person

Sensorium: Alert Drowsy lethargic

stuporous comatose cooperati

ve

combative delusio

nal fluctuating

Appropriate response to stimuli:

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General Appearance

Body Build Ectomorph Mesopmorph Endomorph

Current body status:

Hair

Skin Color

Eczema

 Turgor

Edema

Lesions

Skin Temperature cool warm

Nails

Body odor

Facial Expression

Eyes

Vision: Both Right Left

Focusing

Peripheral Vision

Pupils

 Teeth

Dentures

Gums

 Tongue

Mode of dressing

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References:

Handout: Gordon’s Functional Health Patterns

Carson, V., Shoemaker, N., Varcarolis, E. (2006) The Clinical Interview and Communications

Skills, Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 5th

Edition, (pp. 171-194), Missouri: Saunders Elsevier 

Doenges, M., Moorhouse, M, Murr, A., (2006) Nurse’s Pocket Guide: Diagnoses, PrioritizedInterventions and Rationales, 11th Edition, Philadelphia: F.A. Davis Company

Kelley, J, Weber. J, (2007) Unit 2: Nursing Data Collection, Documentation and Analysis, and

Unit 3: Nursing Assessment of the Adult (Chapters on General Survey, Vital Signs,

 Nutritional Assessment, Skin, Hair and Nails Assessment, Head and Neck Assessment,Eye Assessment, Mouth, Throat, Nose and Sinus Assessment), Health Assessment in

 Nursing, 3rd Edition (pp. 27-74, 83-85, 119-142, 157-296), Philadelphia: Lippincott,

Williams & Wilkins