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A nursing data base for initial patient assessment.

D Hartman1, J Knudson

  • 1Saddleback Memorial Medical Center in Laguna Hills, CA.

Oncology Nursing Forum
|January 1, 1991
PubMed
Summary
This summary is machine-generated.

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Implementing nursing diagnoses shifted documentation to the nursing process. Gordon

Area of Science:

  • Nursing
  • Healthcare Documentation
  • Clinical Assessment

Background:

  • Nursing diagnoses were introduced, making the nursing process central to documentation.
  • The existing medical model/body system structure hindered holistic nursing assessment.
  • A need arose for an assessment model supporting the nursing process and patient care.

Purpose of the Study:

  • To evaluate the adoption of Gordon's functional health patterns as a nursing assessment format.
  • To determine if this model could improve data collection and diagnosis within the nursing process.
  • To find a holistic assessment approach that complements, rather than disrupts, the nursing process.

Main Methods:

  • Selected Gordon's functional health patterns as the new assessment format.

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  • Implemented this format within the existing nursing documentation system.
  • Focused on data collection and narrative charting using the new pattern-based approach.

    • Main Results:

    • Gordon's functional health patterns provided a standardized method for nursing data collection.
    • The functional health patterns facilitated a more holistic approach to patient assessment and diagnosis.
    • The selected model supported the nursing process without negative impact.

    Conclusions:

    • Gordon's functional health patterns offer a valuable framework for nursing assessment.
    • This model enhances the nursing process by standardizing data collection and promoting holistic care.
    • Adoption of functional health patterns can improve the identification and treatment of patient health issues.