Nursing Process-Gordon`s

Report
Introduction
Core Competencies for Healthcare Professionals
Roles of the Nurse in Medical-Surgical Nursing
Gordon’s Functional Health Pattern
The Nursing Process and Critical Thinking
Nursing Diagnosis for Patients with Complex Disorders.
Core Competencies for Healthcare Professionals
What is a Competency and Why is it Important?
 Competence is a multifaceted and dynamic concept that is
more than knowledge and includes the understanding of
knowledge, clinical skills, interpersonal skills, problem
solving, clinical judgment, and technical skills.
Nursing Professional Competencies
11 CORE COMPETENCIES IN NURSING
 SAFE AND QUALITY NURSING CARE
 MANAGEMENT OF RESOURCES AND
ENVIRONMENT'S
 HEALTH EDUCATION
 LEGAL RESPONSIBILITY
 ETHIC/MORAL RESPONSIBILITY
 PERSONAL AND PROFESSIONAL DEVELOPMENT
 QUALITY IMPROVEMENT
 RESEARCH
 RECORD MANAGEMENT
 COMMUNICATION
 COLLABORATION AND TEAMWORK
A. Safe and Quality Nursing Care
1. Demonstrates knowledge based on the health/illness
status of individual groups.
2. Provides sound decision making in the care of
individuals/groups.
3. Promotes wholeness and well-being including safety and
comfort of patients.
4. Sets priorities in nursing care based on patients' need.
5. Ensures continuity of care.
6. Administers medications and other health therapeutics.
7. Utilizes the nursing process as framework for nursing.
8. Formulates a plan of care in collaboration with patients and
other members of the health team.
9. Implements planned nursing care to achieve identified
outcomes.
10. Evaluates progress toward expected outcomes.
11. Responds to the urgency of the patient's condition.
B. Management of Resources and Environment
1. Organizes work load to facilitate patient care
2. Utilizes resources to support patient care
3. Ensures availability of human resources
4. Checks proper functioning of equipment/ facilities.
5. Maintains a safe and therapeutic environment.
6. Practices stewardship in the management of
resources
C. Health Education
1. Assesses the learning needs of the patient and family.
2. Develops health education plan based on assessed and
anticipated.
3. Develops learning materials for health education.
4. Implements the health education plan.
5. Evaluates the outcome of health education.
D. Legal Responsibility
1. Adheres to practice in accordance with the nursing law
and other relevant legislation including contracts,
informed consent
2. Adheres to organizational policies and procedures, local
and national
3. Documents care rendered to patients
E. Ethico-Moral Responsibility
1. Respects the rights of individuals/groups
2. Accepts responsibility and accountability for own
decisions and actions
3. Adheres to the national and international code of ethics for
nurses.
F. Personal and Professional Development
1. Identifies own learning needs.
2. Pursues continuing education.
3. Gets involved in professional organizations and civic
activities.
4. Projects a professional image of the nurse.
5. Possesses positive attitude towards change and criticism.
6. Performs function according to professional standards.
G. Quality Improvement
1. Utilizes data for quality improvement.
2. Participates in nursing audits and rounds
3. Identifies and reports variances.
4. Recommends solutions to identified causes of the
problems.
5. Recommends improvement of systems and processes.
H. Research
1. Utilizes varied methods of inquiry in solving problems.
2. Recommends actions for implementation.
3. Disseminates results of research findings.
4. Applies research findings in nursing practice.
I. Record Management
1. Maintains accurate and updated documentation of
patient care.
2. Records outcome of patient care.
3. Observes legal imperatives in record keeping.
4. Maintains an effective recording and reporting system.
J. Communication
1. Utilizes effective communication in relating with
2.
3.
4.
5.
clients, members with the team and the public in
general.
Utilizes effective communication in therapeutic
use of self to meet the needs of clients.
Utilizes formal and informal channels.
Responds to needs of individuals, families,
groups and communities.
Uses appropriate information technology to
facilitate communication.
K. Collaboration and Teamwork
1. Establishes collaborative relationship with colleagues
and other members of the health team for the health
plan.
2. Functions effectively as a team player.
Gordon’s Functional Health
Patterns
 Gordon's functional health patterns is a method
devised by Marjory Gordon to be used by nurses in the
nursing process to provide a more comprehensive nursing
assessment of the patient.
 A guide for establishing a comprehensive nursing data
base. These 11 categories make possible a systematic and
standardized approach to data collection, and enable the
nurse to determine the following aspects of health and
human function:
GORDON’ Functional Health Patterns
1. PATTERN OF HEALTH PERCEPTION & HEALTH
MANAGEMENT
How does the person describe her/ his current health?
What does the person do to improve or maintain her/ his
health?
What does the person know about links between lifestyle
choices and health?
How big a problem is financing health care for this person?
Can this person report the names of current medications s/he is
taking and their purpose?
If this person has allergies, what does s/he do to prevent
problems?
What does this person know about medical problems in the
family?
Have there been any important illnesses or injuries in this
person's life?
2. NUTRITIONAL - METABOLIC PATTERN
Is the person well nourished?
How do the person's food choices compare with
recommended food intake?
Does the person have any disease that effects nutritionalmetabolic function?
3. PATTERN OF ELIMINATION
Are the person's excretory functions within the normal
range?
Does the person have any disease of the digestive system,
urinary system or skin?
4.PATTERN OF ACTIVITY &
EXERCISE
How does the person describe her/ his weekly pattern of
activity and leisure, exercise and recreation?
Does the person have any disease that effects her/ his
cardio-respiratory system or musculo-skeletal system?
5. COGNITIVE - PERCEPTUAL PATTERN
Does the person have any sensory deficits? Are they
corrected?
Can this person express her/ himself clearly and logically?
How educated is this person?
Does the person have any disease that effects mental or
sensory functions?
If this person has pain, describe it and it's causes.
6. PATTERN OF SLEEP & REST
Describe this person's sleep-wake cycle.
Does this person appear physically rested and relaxed?
7.
PATTERN OF SELF PERCEPTION & SELF
CONCEPT
Is there anything unusual about this person's
appearance?
Does this person seem comfortable with her/
his appearance?
Describe this person's feeling state?
8. ROLE - RELATIONSHIP PATTERN
How does this person describe her/ his various roles in
life?
Has, or does this person now have positive role models for
these roles?
Which relationships are most important to this person at
present?
Is this person currently going though any big changes in
role or relationship? What are they?
9. SEXUALITY - REPRODUCTIVE PATTERN
Is this person satisfied with her/ his situation related to sexuality?
How have the person's plans and experience matched regarding having
children?
Does this person have any disease/ dysfunction of the reproductive system?
10. PATTERN OF COPING & STRESS
TOLERANCE
How does this person usually cope with
problems?
Do these actions help or make things worse?
Has this person had any treatment for
emotional distress?
11. PATTERN OF VALUES & BELIEFS
What principals did this person learn as a child that are
still important to her/ him?
Does this person identify with any cultural, ethnic,
religious, regional, or other groups?
What support systems does this person currently have?
Test
Check your understanding of the differences between these 11 functional patterns, and
how a nursing diagnosis might express a dysfunction in one or more patterns.
Identify the specific functional pattern(s) that would be at-risk or dysfunctional for the
following nursing diagnoses to be made:
1. Social isolation related to immobility (presence of contagious infection).
2. Chronic low self-esteem related to obesity
3. knowledge deficit (signs of hypoglycemia) (signs and symptoms of
hyperglycemia)
4. Spiritual distress related to inability to practice religious rituals
5. Diversional activity deficit related to long-term confinement to home.
6. Sleep pattern disturbance related to sensory overload.
7. Ineffective family coping: disabling related to recurrent marital discord.
8. Role performance disturbance related to effects of chronic pain.
9. Potential for violence directed at others related to effects of
hallucinations.
The Nursing Process
Assessment
 Nursing assessment
 Collection and verification of data
 Analysis of data
 Database
 Consists of client’s perceived needs, health problems, and responses to
problems
Ex: Newly diagnosed Diabetes Mellitus Type 1
client coming to physician’s office for a routine appointment. Client’s
verbalized that she has been losing weight ( 7 pounds in 2 weeks), keep
waking up at night to go to bathroom and always thirsty. Her mood also
changed – irritable and moody. The MD ordered to check client’s blood
sugar level. After checking noted BSL is 600 mg/dl.
Assessment
 Subjective data
 Objective data
 Sources of data
 Client
 Family and significant others
 Health care team
 Medical record
Methods of Data Collection
 Interview
 Nursing Health History
Biographical Information
Client expectations
Present illness or health concerns
Health history
Family history
Environmental history
Psychosocial history
Spiritual health
Review of systems
Documentation of findings
 Physical Examination
Data Documentation
 The last component of assessment
 Legal and professional responsibility
 Requires accurate and approved terminology and
abbreviations
Nursing Diagnosis
 1. Medical diagnosis
 A clinical judgment about the client in response to an
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actual or potential health problem
2. Nursing diagnosis
The identification of a disease condition based on specific
evaluation of signs and symptoms
3. Collaborative problem
An actual or potential complication that nurses monitor to
detect a change in client status
Critical Thinking and the Nursing
Process
 Diagnostic reasoning
 A process of using assessment data to create a nursing
diagnosis
 Defining characteristics
 Clinical criteria or assessment findings
 Clinical criteria
 Objective or subjective signs and symptoms
Concept Mapping Nursing
Diagnosis
 A way to graphically represent the connections
between concepts and ideas that are related to a
central subject such as a client’s health problem.
 Concept maps promote problem solving and critical
thinking skills by organizing complex client data,
analyzing concept relationships and identifying
interventions.
Nursing Diagnosis: Application
to Care Planning
 By learning to make accurate nursing diagnoses, your
care plan will help communicate the client’s health
care problems to other professionals.
 A nursing diagnosis will ensure that you select relevant
and appropriate nursing interventions.
Planning
 Establishing Priorities
 Helps nurses to anticipate and sequence nursing
interventions
 Classification of priorities:
 High
 Intermediate
 Low
Critical Thinking in Establishing
Goals and Expected Outcomes
 Goal
 A broad statement that describes the desired change in a
client’s condition or behavior
 An aim, intent, or end
 Expected outcome
 Measurable criteria to evaluate goal achievement
Guidelines for Writing Goals
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Combining goals and outcomes statements
Client centered
Singular goal or outcome
Observable
Measurable
Time limited
Mutual factors
Realistic
Implementing Nursing Care
 Critical Thinking in Implementation.
 Review the set of all possible nursing interventions.
 Review all possible consequences associated with each
possible nursing action.
 Determine the probability of all possible
consequences.
 Make a judgment of the value of that consequence to
the client.
Evaluation
 Evaluation is an ongoing process.
 If outcomes are met, client goals are met.
 Positive evaluations occur when nurses meet desired
outcomes.
 Positive evaluations lead nurses to conclude that
interventions were successful.

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