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Holistic Assessment and Application of the Nursing Process (FHP)

Objectives:

Conduct a sensitive patient interview using therapeutic communication skills to complete a comprehensive health history of an assigned client in the clinical setting. Do not use patient identifiers i.e. name, DOB, employer, school, etc.
Organize holistic data consistently using Gordon’s Functional Health Patterns as a guide.
Concisely summarize significant patient findings including physical, psychosocial, strengths, & weaknesses.
Identify one priority nursing diagnosis and correctly write it as a diagnostic statement.
Complete an individualized plan of care based on assessment findings and state how you would evaluate if it met patient needs.
Utilize self-reflection to identify health promotion opportunities and the role of the nurse.

Part I: Functional Health Pattern Data Collection and Summary

This portion of the assignment will be completed on a Word document using the template below and submitted to the appropriate drop box in D2L.
Students MUST use the template below and type out assignment

Health History by Functional Health Patterns (Human Flourishing, Nursing Judgment)

*See Medical-Surgical Nursing (Lewis et. al, 2020) Chapter 3: Health History and Physical Examination for description of each functional health pattern area as well as examples of questions to ask client. Also see assignment guide found in D2L.

1	Client Profile (chronological events leading to hospitalization & progress since in your own words):
2	Developmental History (identify Erickson stage of Development with description of crisis resolution, supported by cues):
3	Health Perception-Management Pattern:
4	Nutritional-Metabolic Pattern:
5	Elimination Pattern:
6	Activity-Exercise Pattern:
7	Sexuality-Reproduction Pattern:
8	Sleep-Rest Pattern:
9	Sensory-Perceptual Pattern:
10	Cognitive Pattern:
11	Role-Relationship Pattern:
12	Self-Perception-Self-Concept Pattern:
13	Coping-Stress Tolerance Pattern:
14	Value-Belief Pattern:

Summary: Bullet point out the significant health concerns, opportunities for health improvement, and client strengths/weaknesses. Summary should address psychosocial as well as physical concerns. The summary should make a case for your chosen diagnosis based on the data above.

Significant Health Concerns:

Opportunities for Health Improvement:

Client Strengths/Weaknesses:

Part II: Nursing Care Plan

Create a nursing care plan for your client using the table below. Be sure to include references.

Nursing Care Plan (Nursing Judgment) –Present data in table on concept map

Priority Nursing Diagnosis (3-part): _________________related to (r/t) _________________ as evidenced by (AEB) _________________

Client Goals & Outcomes

(list 2)

Nursing Interventions

(list 3 for each goal)

Evidence-based Rationale (for each intervention – with APA in-text citation)

(Need to be measurable with a time frame i.e. “client will be able to list four snack choices that are in accordance with prescribed diabetic diet prior to hospital discharge”)

(Specific to goal i.e. “give patient a list of snacks allowed on diabetic diet”)

(Justify intervention i.e. “giving patient a list can serve as a reminder and reinforce teaching after discharge (Smith, 2016)”

Describe how you would evaluate the above client goals (These statements should resemble the goals and outcomes and need to be measurable and with a time frame i.e. “client will be able to list a minimum of four snack choices that are in accordance with diabetic diet prior to discharge”)

Reflection Questions (Nursing Judgment & Spirit of Inquiry) – Discuss each question below. Discussion needs to show evidence of depth-of-thought and reflection for each:

In reviewing the comprehensive history of this client, where do you see the greatest opportunities for health promotion? How does this relate to your client’s problem(s)?

As a nurse, what could you do that would have the greatest impact on this client’s health outcome?

Identify at least three insights you gained from completing this assignment and discuss each below.
Insight 1:
Insight 2:
Insight 3:

List of references in APA format for sources cited in care plan

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