Nursing Related Learning Experience Manual

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Cue Cluster Inference Diagnostic Statement Priority Rationale

Pattern
1. Health Perception & Subjective: Risk for fall Risk for fall rt use of Low The patient is at risk for
Management assistive device and visual falling injuries as he is
Objective: disturbances unable to walk and uses
 Patient uses wheel wheelchair, and in addition
chair the patient has dementia
 Patient is unable to and is almost blind. He
walk because of must be provided safety to
arthritis prevent falling injuries.
 Patient was diagnosed
of dementia
 Patient is almost
completely blind
2. Nutrition / Subjective: Not a problem Not a problem Not a problem No data provided
Metabolism N/a
Objective:
N/a

3. Elimination Pattern Subjective: Not a problem Not a problem Not a problem No data provided
N/a

Objective:
N/a

4. Activity / Exercise
Subjective: Impaired physical mobility Impaired physical mobility High 2 Patient’s arthritis makes it
N/a rt activity intolerance difficult to ambulate and
Objective: secondary to arthritis amb limits ability to perform
 Patient uses wheel inability to walk ADL. He is required to use
chair assistive device
 Patient is unable to (wheelchair) and must be
walk because of provided assistance and

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arthritis safety during transferring

5. Sleep / Rest Subjective: Not a problem Not a problem Not a problem No data provided
N/a

Objective:
N/a

6. Cognitive / Subjective: Disturbed sensory Disturbed sensory High 1 Patient is almost blind and
Perceptual N/a perception (visual) perception (visual) rt so performing ADL is
process of aging amb limited. The patient is at
Objective: change in visual acuity risk for injuries or falling
 Patient was diagnosed due to inability to see
of dementia clearly and must be
 Patient is almost provided assistance
completely blind Impaired memory Impaired memory rt Moderate Patient has problem with
neurologic disturbances memory and was
secondary to dementia amb diagnosed of dementia. He
inability to recall events must be provided
assistance to prevent
complications and be
provided with care.
7. Self – Perception / Subjective: Not a problem Not a problem Not a problem No enough data provided
Self - Concept N/a
Objective:
 Patient is reluctant to
accept his personal
care
8. Role / Relationship Subjective: Not a problem Not a problem Not a problem No data provided
N/a
Objective:
N/a
9. Sexuality / Subjective: Not a problem Not a problem Not a problem No data provided
Reproductive N/a
Objective:
N/a

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 Nursing Related Learning Experience Manual

10. Coping – Stress Subjective: Not a problem Not a problem Not a problem No data provided
Tolerance N/a
Objective:
N/a
11. Value Belief Subjective: Not a problem Not a problem Not a problem No data provided
N/a
Objective:
N/a

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 Nursing Related Learning Experience Manual

PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Disturbed sensory perception (visual) rt N/a N/a N/a
process of aging amb change in visual
acuity

Impaired memory rt neurologic N/a N/a N/a

disturbances secondary to dementia amb
inability to recall events
Impaired physical mobility rt activity N/a N/a N/a
intolerance secondary to arthritis amb
inability to walk

Risk for fall rt use of assistive device and N/a N/a N/a
visual disturbances

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Nursing Diagnosis
Disturbed sensory perception (visual) rt process of aging
amb change in visual acuity
Impaired physical mobility rt activity intolerance
secondary to arthritis amb inability to walk
Impaired memory rt neurologic disturbances secondary
to dementia amb inability to recall events
Risk for fall rt use of assistive device and visual
disturbances
College of Health Sciences Department of Nursing
Nursing Related Learning Experience Manual
PRIORITIZATION OF PROBLEMS
Prioritization Rationale
High 1 Patient is almost blind and so performing ADL is
limited. The patient is at risk for injuries or falling due to
inability to see clearly and must be provided assistance
High 2 Patient’s arthritis makes it difficult to ambulate and
limits ability to perform ADL. He is required to use
assistive device (wheelchair) and must be provided
assistance and safety during transferring
Moderate Patient has problem with memory and was diagnosed of
dementia. He must be provided assistance to prevent
complications and be provided with care.
Low The patient is at risk for falling injuries as he is unable to
walk and uses wheelchair, and in addition the patient has
dementia and is almost blind. He must be provided
safety to prevent falling injuries.
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NURSING CARE PLAN

ASSESSMENT HEALTH NURSING DESIRED INTERVENTION EVALUATION REMARKS

PATTERN DIAGNOSIS OUTCOME
Subjective Cues: Cognitive- Note: Use P-E-S format Goal: Independent: Goal met Continue assistance
Perception Patient will be able to 1. Determine visual acuity, note whether and care
Disturbed sensory deal with the potential one or both eyes are involved. Patient will be
N/a perception (visual) rt for permanent visual Rational: individual needs and choice of able to deal with
process of aging amb loss within 8 hours interventions varied because loss occurs the potential for
change in visual acuity slowly and progressively permanent
Objective: visual loss
1. Patient will maintain 2. Put the items needed / call bell position within 8 hours
a safe environment near patient’s side/bed
with no injury noted Rationale: allows the patient to see objects Objective:
more easily and facilitate the call for help 4. Patient will
Background Knowledge 2. Patient will be able when needed maintain a safe
to use adaptive devices environment
to compensate for 3. Allow expression of feelings about loss with no injury
Objective Cues Visual acuity visual loss and possibility of loss of vision. noted
progressively declines Rationale: Although early intervention can
with age due to 3. Patient will be prevent blindness, the patient faces the 5. Patient will be
decreased pupil size, compliant with possibility or may have already able to use
Patient is almost scatter in the cornea and instructions given, and experienced a partial or complete loss of adaptive devices
completely blind lens, pacification of the will be able to notify vision. Although vision loss cannot be to compensate
lens and vitreous, and physician for restored (even with treatment), a further for visual loss
loss of Photoreceptor emergency symptoms loss can be prevented.
cells in the retina. The Patient will be
most common causes of 4. Implement measures to assist patient to compliant with
vision loss among the manage visual limitations such as reducing instructions
elderly are age-related clutter, arranging furniture out of travel given, and will
macular degeneration, path; turning head to view subjects; be able to notify
glaucoma, cataract and correcting for dim light and problems of physician for
diabetic retinopathy. night vision. emergency
(Quillen DA, 1999) Rationale: Reduces safety hazards related symptoms
to changes in visual fields or loss of vision
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 Nursing Related Learning Experience Manual

and papillary accommodation to

environmental light.

5. Encourage use of sense of touch.

Rationale: Touch encourages patient to
become familiar with unfamiliar objects.

6. Explain sounds or other unusual stimuli

in environment.
Rationale: Explanations reduce fear.

7. Maintain bed in low position with side

rails up, if appropriate.
Rationale: Side rails help remind patient no
to get up without help when needed.

8. Keep bed in locked position.

Rationale: This prevent falls.

9. Instruct patient to hold both arms of

chair before sitting and to feel for the seat
on chairs or sofas without arms.
Rationale: These reduce the risk of falls.

Dependent:
1. Administer medication as ordered by
physician and provide assistance

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ASSESSMENT HEALTH NURSING
PATTERN DIAGNOSIS
Activity- Impaired physical
Subjective: Exercise mobility rt activity
N/a intolerance secondary to
arthritis amb inability to
Objective: walk
 Patient uses
wheel chair
 Patient is Background knowledge:
unable to walk
because of Osteoarthritis falls under
arthritis degenerative arthritis and
is more common in older
people. It is degenerative
arthritis, meaning the
cartilage between the
bones in the joints wears
away. It affects the joints
that get used regularly,
usually the hips and
knees. Symptoms include
early morning joint
stiffness, tiredness,
swollen joints, weight
loss and even skin rashes.
(Swavely-Verenna, 2020)
College of Health Sciences Department of Nursing
Nursing Related Learning Experience Manual
DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
Goal: Independent: Goal Met: Continue assistance
1. Assist client or have client or and care
The patient would be caregiver reposition on regular The patient
able to maintain skin schedule maintained skin
integrity as evidenced Rationale: To prevent pressure ulcers integrity as
by absence of pressure evidenced by
ulcer within 8 hours 2. Support body parts or joints using absence of
pillows, rolls or foams pressure ulcer
Rationale: To maintain position function
Objectives: and reduce risk of pressure ulcer The patient was
1. The patient will be be able to
able to transfer safely 3. Frequently assess patient’s skin for transfer safely
signs of breakdown, with emphasis on with assistance
2. The patient will be bony areas and dependent body parts.
able to use assistive Rationale: To maintain position function The patient was
devices properly and reduce risk of pressure ulcer able to use
assistive devices
3. The patient and 4. Provide regular skin care to include properly
caregiver will pressure are management
implement strategies to Rationale: To maintain position function The patient and
increase safety and and reduce risk of pressure ulcer caregiver
prevent falls implement
5. Provide for safety measures as strategies to
4. The patient will not indicated by individual situation, increase safety
have falling injuries including environmental management and prevent falls
and fall prevention such as assistance
5. The patient will be when walking, securing rags, locking The patient did
able to participate in wheelchairs and use of side rails. not have falling
self-care activities Rationale: To prevent the patient from injuries
falling and prevent injury
The patient was
6. Encourage the caregiver to keep the be able to
patient independent as possible participate in
Rationale: To promote independence and self-care
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sense of control activities

7. Allow sufficient time for dressing and

undressing
Rationale: To promote independence and
sense of control

8. Use adaptive clothing such as

clothing with front closure, wide
sleeves and pant legs
Rationale: Such clothes can help patient
with limited arm or leg movement and
cognitive impairment to dress

9. Provide or assist with use of

wheelchair and during transferring
Rationale: To promote in sitting down and
or arising from toilet or to aid elimination
when patient is unable to go to the toilet

10. Turn and position the patient every 2

hours or as needed.
Rationale: Position changes optimize
circulation to all tissues and relieve
pressure.

Dependent:
1. Administer medication as ordered by
physician

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ASSESSMENT HEALTH NURSING
PATTERN DIAGNOSIS
Cognitive- Impaired memory rt
Perception neurologic disturbances
Subjective: secondary to dementia
N/a amb inability to recall
events
Objective:
 Patient was
diagnosed of Background knowledge:
dementia
Dementia is a general
term for loss of memory,
language, problem-
solving and other
thinking abilities that are
severe enough to
interfere with daily
life.Common signs and
symptoms includes:
memory loss.; difficulty
concentrating; finding it
hard to carry out familiar
daily tasks; struggling to
follow a conversation or
find the right word; being
confused about time and
place; and mood changes.
(Alzheimer's Association,
2021)
College of Health Sciences Department of Nursing
Nursing Related Learning Experience Manual
DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
Goal: Independent: Goal Met Continue care for
1. Assess the patient’s ability to cope with patient
The patient will be able events, interests in surroundings and With assistance
to interrupt non-reality- activity, motivation, and changes in from caregiver,
based thinking with memory pattern. patient is able to
assistance from health Rationale: The elderly may have a distinguish
care provider within 3 decrease in memory for more recent between reality-
days. events, more active memory for past based and non-
events, and more active memory for past reality based
Objectives: events and reminisce about the pleasant thinking.
ones.
1. patient will verbalize Prospective
awareness of memory 2. Frequently orient patient to reality and caregivers are
problems within 8 hours surroundings. Allow patient to have able to verbalize
familiar objects around him or her; use ways in which
2. patient will accept other items, such as a clock, a calendar, to orient patient
limitations of condition and daily schedules, to assist in to reality, as
and use resources maintaining reality orientation. needed
effectively within 8 Rationale: To orient patient
hours patient is able to
3. Allow the patient the freedom to sit in a response well
3. patient will accept chair near the window, utilize books and with
explanations of magazines as desired. interventions,
inaccurate interpretation Rationale: Validates the patient’s sense of teachings and
within the environment reality and assists the patient in action
within 8 hours differentiating between day and night. performed
Respect for the patient’s personal space
4. patient will establish allows the patient to exert some control. patient
methods to help in verbalizes
remembering essential 4. Let the patient accomplish tasks at his awareness of
things when possible or her own pace. Do not hurry the patient. memory
within 8 hours Encourage independent activity as able problems
and safe.
Rationale: Healthcare providers and patient accepts
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significant others are often in a hurry and limitations

do more for patients than needed. Thereby
slowing the patient’s recovery and Patient
reducing his or her confidence. establishes
methods to help
5. Label drawers, use written reminders remembering
notes, pictures, or color-coding articles to with help of
assist patients. support system
Rationale: Assists the patient’s memory
by using reminders of what to do and the
location of articles.

6. Enforce with positive feedback. Give

positive feedback when thinking and
behavior are appropriate, or when patient
verbalizes that certain ideas expressed are
not based in reality.
Rationale: Positive feedback increases
self-esteem and enhances desire to repeat
appropriate behavior.

7. Explain simply. Use simple

explanations and face-to-face interaction
when communicating with patient. Do not
shout message into patient’s ear.
Rationale: Speaking slowly and in a face-
to-face position is most effective when
communicating with an elderly individual
experiencing a hearing loss.

8. Be supportive and convey warmth and

concern when communicating with the
patient.
Rationale: Patients frequently have
feelings of loneliness, isolation, and
depression, and they respond positively to
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 Nursing Related Learning Experience Manual

a smile, friendly voice, and gentle touch.

9. Express reasonable doubt if patient

relays suspicious beliefs in response to
delusional thinking. Discuss with the
patient the potential personal negative
effects of continued suspiciousness of
others.
Rationale: To discourage suspiciousness
of others.

10. Do not permit rumination of false

ideas. When this begins, talk to patient
about real people and real events.
Rationale: To avoid cultivation of false
ideas.

11. Inform the patient of care to be done,

with one instruction at a time.
Rationale: Patient require extended time
for processing information. Removal of
decision-making may facilitate improved
compliance and feelings of security.

12. Offer diversional activities. Observe

emotional or behavioral reactions to
immobility.
Rationale: Diversional activity helps in
refocusing attention and promotes coping
with limitations.

Dependent:
1. Administer medication as ordered by
physician

Collaborative:
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 Nursing Related Learning Experience Manual

1. Collaborate with medical and

psychiatric providers in evaluating
orientation, attention span, ability to
follow directions
Rationale: To determine presence or
severity of impairment

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