Gordon’s Function Assessment AREA OF HEALTH SUBJECTIVE DATA OBJECTIVE DATA INDIRECT DATA *Identify source of indirect data (effective patterns or barriers) HEALTH MANAGEMENT General Survey, perceived health & well-being, strategies, utilization of preventative health behaviors and/or services. D.H. stated that she is but she is having a good day today. Patient states pain is 2/10 on vascular scale. Signs: Respirations 16 and unlabored, pulse 68, temp 97.5°F, pulse ox 95% on room air, BP 143/78. Patient demonstrates personal hygiene with grooming and is dressed in clothes from home. Patient actively participates in self-care but needs assistance x 1 when becomes tired. Patient enjoys spending time doing group activities but also enjoys private time in her room. Patient seems to be well oriented to facility and is cooperative with staff Patient being treated for right lower leg cellulitis (chart). Patient has orders for wound treatments every 12 hours (chart). Patient has PRN medications for pain, i.e. acetaminophen and hydrocodone (chart). Patient is up with assistance x 1(chart). Patient to get upset that she is not as independent as she was before she entered the facility. Although patient enjoys company, she needs her privacy at times as well. management
members. NUTRITIONAL/ METABOLIC Patterns of food and fluid consumption, Weight, skin turgor. (Skin, Hair, Nails; Head & Neck; Mouth, Nose, Sinus; swallowing, Ht., Wt) Patient states that she will eat between 75-100 percent of her meals, depending on what is offered. Patient states that she drinks all of the beverages offered with the meals, as well as a cup of coffee in the morning and water throughout the day. During shift pt. ate 75% of dinner. Skin turgor was less than three seconds, and no tenting present. Skin was dry and warm with good color. Oral cavity was moist and pink. DH stated that she wore dentures. DD is 62 inches tall, 108 lbs. DD is partially able to perform own self care. Patient is given polyethylene glycol once a day. Patient is given docusate sodium once a day. Regular diet (chart) Patient seems to have adequate nutritional intake for dietary needs, but may need additional protein and carbohydrates for wound healing. ELIMINATION Patterns of excretory function & Elimination of waste; relevant labs, Medications, impacting, etc. Patient states “I have no pain or urgency when I need to go to the bathroom”. Patient states, “My last bowel Abdomen soft symmetrical and Bowel sounds present in all four quadrants. Pt. denies pain Patient may have elimination problems related to opioid analgesic therapy PRN.
(Abdominal - and bladder) movement was on 2/5/12”. with palpitation. Patient is given 17gm of polyethylene glycol once per day. Patient is given 240 mg of docusate sodium once per day. Patient may take 500mg of hydrocodone q 6h as needed for pain. Patterns of exercise & daily living, self-care activities include body systems involved. (Thoracic & Lung; Cardiac; Peripheral vascular; Musculoskeletal, vital signs) DH denies any shortness of breath or presence of cough. DH states that she tries to do as much as she can on her own, but needs assistance when she becomes tired during self-care activities. DH states that she enjoys participating in activities during the day but enjoys her private time as well. Heart sounds were regular. Lung sounds were Patient was breathing at 16 respirations per minute. Katz ADL score was 3 out of 6. Patient had a Braden score of 18/23. Patient had a Fall Risk score of 6. Patient is taking Cordarone 200 mg daily. Patient is taking levothyroxine Patient is up with assist (chart). Patient is encouraged to change position in bed q 2 (chart). DH had an assessment for PT ordered (chart). There were no results indicated in her chart. Patient’s Braden score indicates a risk for developing a pressure ulcer. Patient is cooperative and willing to try to perform self-care activities unless becomes too tired to do so. Due to lack of mobility, patient is at a greater risk of developing infection or DVT.
Patterns of thinking & ways of Perceiving environment, orientation Mentation, neuron status, glasses, Hearing aids, etc. birthdate, where she was and her situation very descriptively. DH stated that she was admitted to the facility in January after she was released from a local hospital. time situation PERRLA Does not use hearing aid. indicate patient has regularly been alert and oriented (chart). impairment during shift. Patterns of engagement with others, Ability to form & maintain meaningful Relationships, assumed roles; Family communication, response, Visitation, occupation, community involvement Patient states that she used to be an accountant for a printing company in Canton. Patient states she lived independently up until this past year. Patient states she was residing with her daughter’s family just before she was admitted into the hospital. Patient had several pictures of family members in her room. Patient’s daughter visited during shift. Nothing indicated on chart about relationships with family or within community. Although patient preferred to live independently, she seemed to have a positive relationship with her daughter and appreciated her help. SELF-CONCEPT Patterns of viewing & valuing Self; body image & psychological Patient states that when she is at home, she relies on her daughter to take her places. DH states that she misses her independence since being DH was calm and cooperative during assessment. DH asked questions about assessment findings throughout assessment. Patient is a (chart). DH to miss her independence. DH to have an altered due to her admission into the facility.
admitted into the facility. Patient states that she is not afraid to die and she has lived a good life. Patient states that her level of anxiety is a 3 on a scale of 1-10. Patient says that she usually has a positive view of self. Patient feels that his level of control in his current situation is a 5 on a scale of 1 to 10. Patient that his normal level of assertiveness is a 6 on a scale of 1 to 10. DH provided information past employment history. COPING/STRESS TOLERANCE Stress tolerance, behaviors, patterns of coping with stressful events & level of effectiveness, depression, anxiety. Patient states that she would love to go back to living independently. Patient states that she does not often feel very stressed. Patient scored a 10 on the Geriatric Depression Scale, which is indicative of a slight risk of depression. Patient is not currently ordered any medications for anxiety (chart). Patient seems to handle stress of facility and health issues well, but it is clear that she misses her independence. VALUE/BELIEF Patterns of belief, values, Perception of meaning of life that guide choices or decision; includes but is not limited to DH states that she is Protestant and has enjoyed the services in the facility. DH keeps a bible in her room. DH has a in her room. Patient is of Protestant faith (chart). DH is DNR-CCA patient DH did not indicate that she like any religious measures taken in the event of her sudden illness or passing.
See 2. Table 2 Medication Name (Generic/Trade) Drug Action/ Purpose Normal Dose Range Major Side Effects Nursing Considerations 325 mg (2 tabs) PO q 6 hr PRN for pain Antipyretic, analgesic. Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. PO:325-650mg q 4-6hr or 1 gm 3-4 times daily or 1300 mg q 8 hr (not to exceed 4g or 2.5g/24hr in patients with hepatic/renal impairment. Hepatic failure, hepatotoxicity, failure, neutropenia, pancytopenia, leucopenia, rash, urticaria Assess type of pain, location, and intensity prior to and 30-60 minutes following administration. Assess fever, note presence of associated signs, i.e. malaise, tachycardia, diaphoresis Evaluate hepatic, hematologic, and renal function during prolonged therapy. May alter results of blood glucose monitoring by falsely lowering values when measured with glucose method. Amiodarone (Cordarone) 200 mg PO q am Antiarryhthmics III) Prolongs action potential and refractory period, slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation). in 1-2 doses for 1-3 weeks, then 600-800 mg/day in 1-2 doses for 1 month, then 400 mg/day maint. Dose Dizziness, fatigue, malaise, corneal microdeposits, adult resp. distress syndrome, pulmonary fibrosis, pulmonary toxicity, chf, worsening of arrhythmias, bradycardia, Monitor ECG continuously during initial oral therapy. Monitor heart rate and rhythm throughout therapy. Assess for signs of pulmonary toxicity (rales/crackles, decreased
menstrual irregularities, heat intolerance, weight loss Monitor thyroid function studies before and during therapy. Overdose is manifested as hyperthyroidism (tachycardia, chest pain, nervousness, tremors, weight loss) (Vicodin) 500 mg PO QID Antitussive, opioid analgesic combinations Bind to opiate receptors in the CNS. the perception and response to painful stimuli while producing generalized CNS depression. 2.5-10 mg q 3-6 hr; dosage should not exceed 4g/day and should not exceed 5 tablets per day of products. Confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea, respiratory depression, urinary retention. Assess blood pressure, pulse, and respirations before and periodically during administration. If respirations are less than 10 per minute, assess level of sedation. Assess bowel function routinely. Assess type, location, and intensity of pain prior to and one hour after administration. Prolonged use may lead to physical and psychological dependence. Medication references used: Drug Guide (12th ed).