Gordon’s Functional Health Health Assessment or Laboratory and Diagnostic Therapeutic Management Key Nursing Problems
Functions Physical Examination Labs
HEALTH PERCEPTION Thoracic and Lungs:
AND HEALTH • Respiration of 26cpm.
MAINTENANCE: • O2 Saturation of 88% Ineffective Airway
Patient verbalized that she has • Crackles heard upon Clearance
productive cough with greenish auscultation of both lungs
mucus secretions.
HEALTH PERCEPTION
AND HEALTH
MAINTENANCE:
Patient verbalized feelings of
easily fatigability.
SLEEP-REST PATTERN: Thoracic and Lungs: • Iron 14 (L)
•Respiratory of 26cpm • TIBC 207 (L) Impaired Blood Gas
She also verbalized feelings of
• O2 Saturation of 88% • Ferritin 5510.69 (H) Exchange
fatigability even with enough
sleep.
ACTIVITY-EXERCISE
PATTERN:
The patient has only been lying
because she feels easily
fatigued.
NUTRITION AND Skin, Hair, and Nails:
METABOLIC PATTERN: • Poor Skin Turgor
• Client verbalized that she has • Anorexia
loss of appetite. • Oral fluid intake limited to
• Client eats often. She eats 800mL/day
oatmeal most of the time. She • Total Protein 4.1 (L)
rarely eats vegetables. • Albumin 1.7 (L)
• A/G Ratio 0.7 (L) Imbalanced Nutrition: Less
than Body Requirements
SELF-PERCEPTION SELF-
CONCEPT PATTERN:
Patient that she loss more than
10kg of her weight in less than a
month.
INEFFECTIVE AIRWAY CLEARANCE r/t THICK MUCUS SECRETIONS
Defining Chacteristics Expected Outcomes Nursing Interventions Rationale Evaluation
Subjective: Short-Term: • Assess respiratory • Diminished breath Short-Term:
function noting breath sounds may reflect
HEALTH PERCEPTION After 8 hours of nursing sounds, rate, rhythm, atelectasis. Ronchi, After 8 hours of nursing
AND HEALTH intervention, patient will and depth, and use of wheezes, indicate intervention, patient was
MAINTENANCE: be able to demonstrate accessory muscles accumulation of able to demonstrate
Patient verbalized that behaviors that would secretions & inability to behaviors that help
she has productive improve maintenance of clear airways that may improve maintenance of
cough with greenish airway clearance. lead to use of accessory airway clearance.
mucus secretions. muscles and increased
Long-Term: work of breathing. Long-Term:
Objective:
After 3 days of nursing • Note ability to • Expectoration may be After 3 days of nursing
• Respiration of 26cpm. intervention, the patient expectorate mucus & difficult when secretions intervention, the patient
• O2 Saturation of 88% will be able to maintain a cough effectively, are thick as a result of will be able to maintain a
• Crackles heard upon patent airway. document character, infection/ inadequate patent airway.
auscultation of both amount of sputum, hydration.
lungs presence of hemoptysis.
• Place patient in semi- • Positioning helps
fowler’s position. maximize lung
expansion and
decreases respiratory
effort.
• Maintain oral fluid • Fluid intake helps thin
intake of 800mL as secretions, making them
prescribed. easier to expectorate.
•Administer oxygen or • Prevents drying of
humidify inspired air and mucus membranes and
oxygen. help thin secretions.
IMPAIRED BLOOD GAS EXCHANGE r/t INSUFFICIENT RED BLOOD CELLS
Defining Chacteristics Expected Outcomes Nursing Interventions Rationale Evaluation
Subjective: Short-Term: • Position patient with • Upright position allows Short-Term:
head of bed elevated, in increased thoracic
HEALTH PERCEPTION After 1 hour of nursing semi-fowler’s position as capacity, full descent of After 1 hour of nursing
AND HEALTH interventions, the client tolerated. diaphragm, and interventions, the client
MAINTENANCE: will verbalize increased lung expansion verbalized
Patient verbalized understanding of oxygen preventing the abdominal understanding of oxygen
feelings of easily and other therapeutic contents from crowding. and other therapeutic
fatigability. intervention. intervention.
• Maintain an oxygen • Supplemental oxygen
SLEEP-REST PATTERN: administration device as may be required to
Long-Term: Long-Term:
She also verbalized ordered, attempting to maintain PaO2 at an
feelings of fatigability maintain oxygen acceptable level.
After 3 days of nursing saturation at 90% or After 3 days of nursing
even with enough sleep. intervention, the patient intervention, the patient
greater
will manifest resolution • A patient with chronic manifested resolution or
ACTIVITY-EXERCISE
or absence of symptoms • Administer humidified lung disease may need a absence of symptoms of
PATTERN:
of respiratory distress. oxygen through hypoxic drive to breathe respiratory distress.
The patient has only
been lying because she appropriate device; watch and may hypoventilate
feels easily fatigued. for onset of during oxygen therapy
hypoventilation as
Objective: evidenced by increased
somnolence after
• The client is able to
initiating or increasing
oxygen therapy • Anxiety increases
shrug shoulders against
dyspnea, respiratory rate,
resistance slightly due to
• Provide reassurance and work of breathing.
fatigability and reduce anxiety.
• Iron 14 (L) • Activities will increase
• TIBC 207 (L) oxygen consumption and
• Ferritin 5510.69 (H) •Pace activities and should be planned so the
•Respiratory of 26cpm schedule rest periods to patient does not become
• O2 Saturation of 88% prevent fatigue. Assist hypoxic.
with ADLs.
IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS R/T POOR DIET AND LOSS OF APPETITE
Defining Characteristics Expected Outcomes Nursing Interventions Rationale Evaluation
Subjective: Short-Term: • Document patient’s • Useful in defining Short-Term:
nutritional status, noting degree or extent of
NUTRITION AND After 1 hour of nursing skin turgor, weight, problem and appropriate After 1 hour of nursing
METABOLIC PATTERN: interventions, the client degree of weight loss, choice of interventions. interventions, the client
• Client verbalized that will present integrity of oral mucosa, presented
she has loss of appetite. understanding of ability or inability to understanding of
• Client eats often. She significance of nutrition swallow, presence of significance of nutrition
eats oatmeal most of the to healing process and bowel tones, history of to healing process and
time. She rarely eats general health. nausea and vomiting or general health.
vegetables. diarrhea.
Long-Term: Long-Term:
SELF-PERCEPTION •Ascertain patient’s usual • Helpful in identifying
SELF-CONCEPT dietary pattern specific needs and
After 5 days of nursing strengths. After 5 days of nursing
PATTERN:
intervention, the client intervention, the client
Patient verbalized that
will display nutritional • Monitor I&O • Useful in measuring the displayed nutritional
she loss more than 10kg
ingestion sufficient to periodically effectiveness of ingestion sufficient to
of her weight in less
metabolic needs as nutritional and fluid metabolic needs as
than a month.
manifested by stable support manifested by stable
weight or muscle-mass weight or muscle-mass
Objective:
requirements, positive • Provide companion • Attention to the social requirements, positive
nitrogen balance, tissue during mealtime. perspectives of eating is nitrogen balance, tissue
• Anorexia
regeneration and important in both hospital regeneration and
• Oral fluid intake limited
exhibits improved and home settings. exhibits improved
to 800mL/day
energy level. energy level.
• Poor Skin Turgor • Offer high protein • Such supplements can
• Total Protein 4.1 (L) supplements based on be used to increase
• Albumin 1.7 (L) individual needs and calories and protein
• A/G Ratio 0.7 (L) capabilities. without conflict with
voluntary food intake.
•Monitor lab studies : • Low values reflect
BUN, serum, protein, pre- malnutrition and indicate
albumin & albumin. need for intervention.
Name of Drug Classification MOA Indication Contraindication Adverse Nursing
Reaction Responsibilities
Generic Name: Therapeutic Inhibits proton • Symptomatic GERD • Contraindicated in CNS: asthenia, BEFORE:
Omeprazole Classification: pump activity by w/o esophageal lesions patients dizziness, headache •Assess patient’s
Anti-ulcer binding to • Erosive esophagitis hypersensitive to the GI: abdominal pain, vital signs
Trade Name: hydrogen- • Pathologic drug or its constipation, • Instruct patient’s
Losec, Prilosec Pharmacologic potassium hypersecretory components diarrhea, flatulence, SO on therapeutic
Classification: adenosine conditions • Use cautiously in N&V value of the drug
Patient’s Dose: PPIs triphophatase • Duodenal ulcer (short patients with Musculoskeletal: • Caution patient’s
40mg 1 capsule, located at secretory term tx) hypokalemia and back pain SO on different A/E
PO, OD surface of gastric • H.pylori infection and respiratory alkalosis Respiratory: and S/E of drug
parietal cells, to duodenal ulcer dse. to in patients on a low cough, URTI • Proper preparation
Maximum Dose: suppress gastric eradicate h.pylori w/ sodium diet, and in Skin: Rash of the drug
Capsule: 40mg acid secretion. clarithromycin (dual breastfeeding
Powder: 10 mg therapy) women. DURING:
Tablet: 20mg • H. pylori infection and • Long-term • Verify patient’s
duodenal ulcer dse. to administration of identity
Minimum Dose: eradicate h. pylori w/ bicarbonate with • Make sure patient
Capsule: 10mg clarithromycin and calcium or milk; can doesn’t crush
Powder: 2.5mg amoxicillin (triple cause milk alkali capsule or tablet
Tablet: 10mg therapy) syndrome • For patients who
• Short term treatment have difficulty
of active benign gastric swallowing, capsules
ulcer may be opened and
• Frequent heartburn (2 contents mixed with
or more days/wk) 15mL applesauce.
• Stress ulcer Follow up water to
prophylaxis ensure complete
swallowing of
Patient’s Indication: pellets.
•Patient is taking
antibiotics which can AFTER:
irritate the GI tract • Document
administration of the
drug to the
corresponding
patient’s chart
• Monitor patient’s
vital signs
• Instruct patient’s
SO to report any
unsualities.
Name of Drug Classification MOA Indication Contraindication Adverse Reaction Nursing
Responsibilities
Generic Name: Therapeutic Piperacillin is an • Treatment of • Contraindicated in •diarrhea/constipation BEFORE:
Piperacillin+ Classification: extended-spectrum moderate to sever patients with critical •headache, insomnia • Ask patient if he is
Tazobactam • Piperacillin= penicillin antibiotic, complicated and illness, dialysis, renal • nausea, fever, oral allergic to piperacillin
Penicillin but it can be uncomplicated skin failure, renal candidiasis, rash, and tazobactam or
Trade Name: • Tazobactam= destroyed by an and skin structure impairment vomiting, dyspepsia, to any other
Zosyn Beta-Lactamase enzyme produced infection. • biliary obstruction, pruritus, pain, HPN, penicillin antibiotics
inhibitor by bacteria called • Intra-abdominal electrolyte imbalance, leukopenia, such as amoxicillin,
Patient’s Dose: betalactamase. infections appendicitis heart failure, thrombocytopenia, ampicillin, oxacillin,
4.5g, q8h, to run for Pharmacologic Tazobactam complicated by rupture hypokalemia, seizure, jaundice, etc.
3 hours, IVTT Classification: inhibits beta or intra-abdominal neonates, sodium epistaxis • Ask patient if he
Penicillin and lactamase and abcess. restriction, asthma, has a kidney
Maximum Dose: Beta-Lactamase prevents the • pneumonia, CAP, penicillin disease, a bleeding/
4.5g IV q6-8h, not Inhibitor destruction of nosocomial hypersensitivity, clotting disorder, low
to exceed 18g/day Combination piperacillin. pneumonia, pleural cephalosporin levels of potassium
Antibiotics Therefore, empyema hypersensitivity, in blood, cystic
Minimum Dose: tazobactam is CAP, nosocomial carbapenem fibrosis, history of
3.375g IV q6h, not given with pneumonia, pleural hypersensitivity, allergies, allergic to
to exceed 18g/day piperacillin to empyema cystic fibrosis, a cephalosporin
enhance activity of • PID, endometritis, diarrhea, GI disease, antibiotic such as
piperacillin to pyelonephritis, UTI colitis, inflammatory cefdinir, cefprozil,
enhance the • treatment of acute bowel disease, cefuroxime,
activity of pulmonary pregnancy, cephalexin, etc.
piperacillin in exacerbations in breastfeeding, DM
eradicating patients with cystic and STD patients DURING:
bacterial infections. fibrosis. • Monitor for
bleeding, especially
Patient’s Indication: in people with kidney
•Patient’s Tuberculosis disease of using
certain medicines.
AFTER:
• Store unmixed med
and liquid diluent at
cool room
temperature
• Mixed medication
in an IV bag can be
stored in the
refrigerator for up to
7 days.
• Do not freeze.
