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Notes For 3rd Year Essay

2205 words - 9 pages

Nursing 344

Week 1: Report Writing & GFHP

Report Writing

Pt records are sometimes called in evidence before a court of law in order to establish events that may have contributed to a pt’s death or injury. They may also be required as evidence for an inquiry or hearing by the NMB of NSW.

▪ Frequency of documentation relies on:
- physical/ mental status of the pt.
- the type of care provided (self care v. intensive care)
- requirements of health care agency
- any legal or other obligations that the health record must meet

▪ Content of documentation needs to be:
- relevant
- appropriate
- accurate
- requirements will vary according to pt acuity
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- obs at 600hrs: BP, R, Ward U/A NAD, T, P. (shown above in case)

INTERVENTION: She complained of mild pain at 200hrs, so you gave her;
- Pethidine 50mgs IMI with effect and may be repeated PRN
- Kept NBM
- Has IV norm saline which is patent and running over 10 hrs
- You gave her QID Keflin next due at 1200hrs.

- She slept intermittently through this shift
- She will go to theatre at 930am
- her husband remains with her

Gordon’s Funtional Health Patterns (GFHP) (Devised by Majory Gordon)

▪ A holistic approach to providing health care involving 11 components
▪ Nurse assesses clients by organising patterns of behaviour and physiological responses that pertain to a functional health category
▪ GFHP assist in the identification of a pateint’s:
- strengths
- dysfunction in health patterns (nursing diagnosis)
- potential dysfunction patterns exist (risk factors)
▪ These 11 components include:

o Health perception/ health management pattern:
- Client’s own perception of their health and how it is managed
- Compliance with meds regimen, health promo and annual checks
- Family history, risk factors, alcohol/ smoke intake, exercise, allergies etc
o Nutritional metabolic pattern:
- Pattern of food and fluid intake relative to metabolic need and pattern which indicate nutrient supply

|Functional Health Pattern |Description |Sample Questions |
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