Health History

Health assessment thus plays an important role to provide information about one’s health. Assessment is the first step in the nursing process and includes collection, verification, organization, interpretation and documentation of data. (Sue C. DeLaune and Patriciak . Ladner,2011) Almost every admitted patient the first time required the implementation of the health assessment to determine their health condition to enable healthcare plans and implementation what they need to do.

On way of organizing the information that nurse need to collect is by using a nursing framework .

A framework for assessment , the nurse systematically collecting the physical, psychological, socio cultural and different aspects of the activities of living. There are a number of organizing frameworks for collection of data. For example, the Gordon’s functional health patterns. Many health care agencies use an admission assessment format which assists the nurse in collecting data in specific categories of functioning. Richard Hogston and Penelope M. Simpson,2002) Most of the hospital and health care agencies have developed their own structured assessment tools.

Carol R. Taylor, Priscilla Lemone, Carol Lillis, Pamcla Lynn, 2008) These functional health patterns areas allow gathering and clustering of information about a patient’s usual patterns and any recent changes in order to decide if the patient’s response is functional or dysfunctional. If the assessment is effective or positive that will not have to deal. If the results of the assessment is invalid or negative that will have to deal with through nursing care plan.

The assessment from health care setting which are consistent with Profile such as name, age, sex, religion, reason for seeking healthcare, family history, allergy history, health history, current health status, self-care ability, general condition, consciousness, communicative ability, language, nutritional state, skin state, limbs, special senses, emotional state, daily habits ,leisure, introduction of environment, use of facilities, religion and risk assessment .

The assessment from health care setting as the same as Gordon’s functional assessment are including Health-Perception Health-Management, Elimination, Nutritional-Metabolic, Activity- exercise, Value-belief patterns and Sleep-rest. Not the same as Gordon’s functional assessment form, the assessment from health care did not mention of Congnitive- Perception, Self-Perception-Self Concept, Role-Relationship, Sexuality-Reproductive and Coping-Stress-Tolerance.

The assessment form health care setting can be divided into seven section including Biographical data, Reason for seeking health care provider, History of present health concern, Rest health history, Family health history, review of body systems for current health problem, life-style and health practices profile. The Gordon’s functional pattern mainly is open-ended questions such as have you religions beliefs helped you to deal with problems in the past? How? Contrary, the assessment from health care setting mainly is closed-ended question such as what is your religion. The Gordon’s functional health patterns is more concentrated.

Each type of health patterns divided into objective and subjective information. The assessment from health care setting structure is more untrammeled. The same types of problems can be classified into different types of items such as nutritional state it can be combine with diet of daily habits. Comprehensiveness Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by the nurse in the nursing process to provide more comprehensive assessment of the patient. Gordon emphasizes that the eleven functional patterns artificially divided integrated human functioning.

Eleven functional health patterns described as follows. Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin). Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input. Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth. Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Sexuality and Reproduction.

It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies. Value-Belief Pattern it’s focused on the person’s values and beliefs. (Janet Weber, Jane Kelly ,1998) Indeed, Gordon’s functional health pattern can reflect the potential of the patient health problem. The assessment from health care setting is less comprehensive than Gordon’s patterns.

The assessment from health institution reflect the patient’s admission status, previous health status, daily habits and risk assessment. The form are lack of assess such as congnitive and percepyual, sexuality and reproductive, role and relationship, self-perception and self concept, coping and stress. It is not difficult to find Gordon functional assessment are more detailed than assessment form health care setting. For example, Gordon functional assessment including nutritional metabolic that it contain skin examination. Mucous membranes, edema status, thyroid status, gag reflex and assess jugular vein distention etc.

On the contrary, the assessment from health institution about nutritional status can only choose normal or abnormal. It is lack of sufficient information than Gordon’s patterns. In addition, the case of infertility patient often leads to significant pressure for fear of failed surgery. After the embryo transfer, she have to face with the failure of implantation. Both physically and mentally cause to great pressure. According Gordon’s assessment, form coping –stress tolerance pattern, it is able to know patient was very unhappy because of infertility. Patient thought it is too much pressure if the embryo cannot implantation.

Nurse can give psychological counseling to the patient that allows patient to reduce stress through assessment. In comparison of assessment from health institution, it is not mention about coping-stress tolerance patterns. So there is no assess of the infertility patient that need to take care of their psychologic problem. Compare with two different assessment form, Gordon’s patterns was more comprehensive than assessment from health institution, but it is not the most comprehensive assessment. If two new domains add to the assessment tool safety/protection and growth/development that the assessment will become more complete.

Safety/Protection for a risk of injury as a result of the interaction of environmental conditions interacting with the individual’s adaptive and defensive resources. (Wilson Giddens,2001) Growth and Development for altered physical growth, typical of age group, inability to perform self –care or self control activities appropriate for age etc. (Wilson Giddens,2001) Through these two items that nurse can prevent some of risk environment and assess patient growth/development to let nurse understanding what problem patient have be exist.

Applicability Gordon’s patterns can provide extensive and detailed information that can reflect patient’s health status but it is very time-consuming and may have to one hour or more. It is not difficult to imagine that nurse have to deal with numerous new patients in each day. The situation is difficult to use Gordon’s patterns to assess patient’s condition in the limited manpower especially at the night duty. Second, patient discharged from hospital earlier than before because based on cost-effectiveness and patient well-being.

For example in-vitro fertilization(IVF), colonoscopy, inguinal hernia such as this operation usually encourage patients rest in the day care center replace of stay in the hospital for a few day. This situation need nurse faster and more efficient assess of the patient condition. Third, patient admitted to hospital in a critical situation simply can not conduct a detailed physical assessment. In this situation like cardiac arrest, choking, an immediate diagnosis is needed to provide prompt treatment. That why initial comprehensive assessment like Gordon’s assessment is not suitable for this condition.

Fourth, the patient’s disease information may have already obtained by the attending doctor before patient admission. Therefore it is not meaningful for the nurse to collect the same health’s information. The nurse can more in-depth to assess patient base on the information obtained by doctors. For this IVF case, it suggest using a assessment from institution. Compare with Gordon’s assessment, it easy showed cause of admission and patient;s general condition. The Gordon’s assessment of many question is irrelevant. For example, general appearance is no need to assess for the IVF case.

On the other hand ,embryo transfer just a minor surgery that patient are not request stay in hospital . Using simple assessment like assessment from institution for the sake of save more time and work more effectively. Gordon’s assessment is more complex than assessment from institution so assessment from institution it is more applicable than Gordon’s assessment form. Conclusion There are many nursing assessment frameworks have been developed. The most widely used organize frameworks for nursing diagnoses it based on functional health patterns described by Gordon.

Using systematic guidelines specifically developed for a nursing assessment ensures that comprehensive, holistic data are collected for each patient. Health care institutions establish a minimum data set that specifies the information that must be collective from every patient and use a structured assessment form to organize or cluster this data. A nurse chooses a particular framework for a variety of reason. Choice may be based on what is used in the particular health care institution or nursing needs of a particular patient population.