Health History

Topics: Nursing, Nursing care plan, Health care Pages: 6 (1765 words) Published: June 23, 2013
Introduction
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. The following will be relatively compare by using Gordon’s Functional Health Patterns as framework between the assessment from health care setting is currently using about interview on an adult. Compare these two interviews in term of structure, comprehensiveness, and applicability.

Structure
Gordon’s functional health patterns, which are consistent with the human need philosophy, can provide a framework for nursing education. The eleven functional health patterns identified by Gordon’s are as follow: Health Perception and Management, Activity and Exercise, Nutrition and Metabolism, Elimination, Sleep and Rest, Congnition and Perception, Self-Perception and Self-Concept, Roles and Relationships, Coping and stress Management, Sexuality and Reproduction, Values and Beliefs. (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...
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