DEPARTMENT OF NURSING
Nursing Plan of Care based on Gordon?s Functional Health Pattern


Student Name: _________________________ Date: ____________________

Client Initials: W. B. Setting: hospital Sex: M Age: 77 Contact Date: ___________________

Reason for Seeking Health Care:
___________________________cough ? several weeks, thick yellow phlegm _____________________________________
___________________________________________________________________________________________________________

Medical Diagnosis: _leukopenia, fever, myeloma__


Pathophysiology of Medical Diagnosis:
myeloma ? cancer of the WBCs known as plasma cells, which produce the antibodies
leukopenia ? decrease in the number of WBCs found in the blood




Preexisting Medical Conditions:
_______Htn, multiple myeloma, anemia, cataracts, arthritis _______________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________


Form
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
ASSESSMENT
ALLERGIES ___none ___________________________________________
________________________________________ ______________________________________________________________________________ INTERVENTIONS


PERCEPTION OF ILLNESS/QUALITY OF LIFE __slowly getting better_____ __________ I.D. BAND ON __yes___________________________
EFFECT OF ILLNESS ON ADLS _prevents ability to do things used to do____ _____________________________ SEIZURE / ASSPIRATION PRECAUTIONS _no_____
USE OF ALCOHOL _no___________________________________________ SIDE RAILS UP X__2___________________________
TOBACCO _no___________________________________________ BED POSITION LOW _yes______________________
DRUGS _no______________________________________________ RESTRAINTS: TYPE _none_____________________
SPECIAL HEALTH HABITS _none___________________________________ _____________________________________________
ACCIDENTS/INJURIES __none_____________________________________
IMMUNIZATIONS UP TO DATE _yes ______________________________ MEDICATIONS: __see med sheet_______________
COMPLIANCE WITH TREATMENTS __yes, full ______________________ _____________________________________________
SUPPORT SYTEMS _wife and daughter at home ____________________ _____________________________________________
APPEARANCE _well kept and groomed_______________________________ _____________________________________________
HT__5? 9?_______ WT__120 lbs__________ Calculate BMI ___17.7________ _____________________________________________
PULSE_65_________ RESP__18_________
TEMP__98.7______ BP__134/62________ PATIENT TEACHING __avoiding infections and what _
CBC: WBC_1.7____ X 103 (7.8 3 ) __to do if one ocurs__________________________
RBC _________ X 106 (M 5.4 0.7) (F 4.8 0.6) ______________________________________________
Hgb__________ g/dl (M 16 2) (F 14 2) ______________________________________________
Hct __________ % (M 47 5) (F 42 5)
MCV _______ fL (M 80 - 94) (F 81 - 99)
MCH________ pg (27 - 31)
MCHC _______ g/dl ( 33 - 37)
RDW ________ % (11.5 - 14.5 )
Platelets ______ x 103 (130 - 400 )
Differential : Neut _____________ Baso _____________
Lymph ___________ Other ______________
Monos ___________ Morph _____________
Eosin _____________

Advance Directives __none___________________________________________
DNR Orders ___none _______________________________________________







NUTRITIONAL-METABOLIC PATTERN INTERVENTIONS
ASSESSMENT FLUIDS: RESTRICTED _no___ PUSH _no_________
Diet__1800 ADA____ BREAKFAST________% SPEECH THERAPY __no________________________
LUNCH_____________%
DINNER__50________% I.V. SOLUTIONS_0.9% NaCl_ RATE_100 mL/hr____
SUPPLIMENT_______% SITE LOCATION: _Rt chest____________________
REFUSED NAUSESA VOMITITNG SITE: REDDEN ___ DRY _*_ DRAINING ___
SWALLOWING PROBLEMS __none_________________ TYPE: PERIPHERAL _no__ SALINE LOCK _no___
MIETHOD OF FEEDING: SELF * FEED ___ TUBE FEEDING ___
TEETH: CONDITION OF TEETH _some fillings/caps______ ___________ PICC/ CENTRAL LINE LOCATION ___Rt chest_____
CONDITION OF GUMS _pink, moist _______________________ PUMP __100 mL/hr ___________________________
DENTURES: UPPER LOWER none__ DRESSING CHANGE: TYPE_______ TIME ________
ABDOMEN: SOFT ___ FIRM _*_ RIGID ___ TENDER ___
NON-TENDER ___ DISTENDED ___
BOWEL SOUNDS: NORMAL ___ ABSENT ___ BGM__N/A_ SLIDING SCALE COVERAGE__________
HYPER ___ HYPO _*_ FLATUS ___
LIVER OR SPLEEN ENLARGEMENT __none_______________________ PAST 3 DAYS WEIGHT GAIN OR LOSS __no_______
SKIN: TURGOR _elastic__ COLOR __brown____ PAST 3 DAY I & O TOTALS:
COLD ___ WARM _*_ DRY _*_ MOIST ___ INTAKE _____________ OUTPUT ______________
INTACT _*_ NOT INTACT ABDOMINAL GIRTH __no change________________
DECUBITIS: STAGE_N/A___ LOCATION_____________________________ DRESSING / INCISION LOCATION __none_________
SIZE____________DEPTH______________ WOUND MEASUREMENTS _none_______________
INCISSION TYPE__N/A_______ LOCATION________________________ DESCRIPTION __none__________________________
APPROXIMATED_______ GAPING______ STAPLES___DERMABOND____ ____________________________________________
DRAINS/TUBES: HEMOVAC JP OTHER _none____________ ____________________________________________
N/G_________ CLAMPED___ SUCTION______DRAINING________

YELLOW MUCOID GREEN SEROUS SEROSANGUINOUS
LABS: GLUCOSE____ BUN _____ Creatinine_____ NA ______ K _____
Cl_______ Co2 _____ Bilirubin Total _____ Direct _____ Indirect _____
CA _____ Phosphorus_____ Magnesium ____ Uric Acid _____ Total Protein _____
Albumin _____ Total Cholesterol_____ LDL _____ HDL _____Triglycerides_____
Iron _____ TSH _____ T3 _____ T 4 _____
SGOT____ AST_____ALT_____GGT_____ HEPATITIS PROFILE_____________ DRESSING change /type: __none________________ ________________________
Miscellaneous Diagnostic tests__________________________________________ _____________________________________________

___________________________________________________________________ ______________________________________________
________________________________________________________________________ _____________________________________________
CONDITION OF HAIR: __dry, evenly distributed____________________________
CONDITION OF NAILS: __no clubbing, cap refill 2 seconds___________________
FAT LOSS OR MUSCLE WASTING: __none_______________________________ SPECIALTY MATTRESS OR TREATMENTS __none__
PRESENCE OF PETECHIE, BRUISING, OR PURPURA __none_______________ ____________________________________________
BRADEN RISK ASSESSMENT SCALE:
MEDICATIONS: __see med sheet_____________
A. MOBILITY __3______ Ability to change and control body position. _____________________________________________
1. COMPLETELY LIMITED 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO LIMITATIONS ____________________________________________
_
B. MOISTURE ___4______________ Degree to which skin is exposed to moisture. _____________________________________________
1. CONSTANTLY MOIST 2. VERY MOIST 3. OCCASIONALLY MOIST 4. RARELY MOIST
C. ACTIVITY ___3___________ Degree of physical activity
1. BEDFAST 2. CHAIRFAST 3. WALKS OCCASIONALLY 4. WALKS FREQUENTLY
D. FRICTION & SHEAR ___3______ Patient teaching: __none________________
1. PROBLEM 2. POTENTIAL PROBLEM. 3. NO APPARENT PROBLEM _____________________________________________
E. NUTRITION ____3_________ Usual food intake pattern. ____________________________________________
1. VERY POOR 2. PROBABLY INADEQUATE 3 ADE QAUTE
4 EXCELLENT
F. SENSORY PERCEPTION ___4_______


1. COMPLETELY LIMITED 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO IMPAIRMENT ,
TOTAL SCORES:(add all sections) __20 __
INTERVENTION
ELIMINATION PATTERN BLADDER SCAN _no___________________________
ASSESSMENT CATHETERS: FOLEY _no__ SUPRAPUBIC________
NORMAL BOWEL HABITS: Frequency _BID _ Consistency _solid Color _brown_ FOLEY SIZE____________ INSERTION DATE ________
Last Bowel Movement _3 days ago ILEOSTOMY no_ COLOSTOMY no_ TEXAS CBI STRAIGHT CATH
BLADDER HABITS : Continence _yes_ Frequency _QID_ Amount _____ OSTOMY: TYPE __no__________________________
Color _yellow_ Hematuria _no__ Nocturia _no__ Retension _no__ CHANGED SATE______________________________
LABS: Urinalysis: Specific Gravity _____ Ph _____ Protein _____ Glucose ____ SELF ASSISTED
Acetone _____ Blood _____ WBCs _____ Rbcs _____ Bacteria _____ ENEMAS: TYPE _none_________________________
BUN _____ Creatinine _____

AMOUNT_____________________________
Stool: Ova and Parasites _____ C- Difff ______ VRE _____ Cultures _____ RESULTS____________________________
Hemacult _____ BRP BSC BEDPAN