Gordons Functional Health Patterns

Ivy Tech Community College Northeast

Student Name FORMTEXT

____________Date(s) of Care___ Patient Age ___ Patient Diagnosis ___Date of Surgery, if applicable____(Circle one) Antepartum / Labor & Delivery / Postpartum Blood Type/ RH _________ G/T/P/A/L __________________ EDB _____________ Gestational Age_________________

Rubella (I) (NI); GBS (+) (-); HEP B (+) (-); HIV (+) (-); Marital Status ___________

Baby (M) (F) Birth WT _____________ Apgar _________ Gordons Functional Health PatternsI. Health History/Health Perception

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

II.NUTRITION - METABOLICSUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

III.ELIMINATION

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

IV.ACTIVITY - EXERCISE

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

V. SLEEP - RESTSUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

VI.COGNITIVE - PERCEPTUAL

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

VII. SELF PERCEPTION - SELF CONCEPTSUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies

VIII.ROLE RELATIONSHIPSUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

IX.SEXUALITY - REPRODUCTIVE

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

X.COPING - STRESS TOLERANCESUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies:

XI.VALUES - BELIEFS

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

DISCHARGE NEEDS

PATHOPHYSIOLOGY/ Disease Process (3) Identify why the client was admitted and any changes that have occurred during this admission, including response to current treatment modalities. Identify the pathophysiology for the primary diagnosis and all interrelated diagnosis. Please be sure to include: What is occurring in the body Signs and symptoms Anticipated/ordered diagnostic/lab studies Anticipated/ordered treatment modalities Nursing care1.2.

3.

Medications-including IV therapy: Medication, indication, dose range, pt dose, adverse reaction, nursing considerations. Medication Indication Dose Range Patients Dose Adverse Reaction Nursing

Considerations

PRIORITIZATION OF NURSING DIAGNOSIS

List all nursing diagnosis in order of priority.Note: It is expected that if a problem is listed as numbers 1, 2, or 3 that these problems would be addressed in the Care Plan. At least one problem should be related to the pathophysiology, example: if the care plan is a heart patient, at least one nursing diagnosis should be related to the heart disorder.

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis: Goal: Actions with rationale: (Minimum of three) Evaluation:

(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it appropriate to keep with the original plan?)

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis: Goal: Actions with rationale: (Minimum of three)

Evaluation:

(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Or, is it appropriate to keep with the original plan?)

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis: Goal: Actions with rationale: (Minimum of three)

Evaluation:

(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Or, is it appropriate to keep with the original plan?)

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