Gordon’s Function Assessment AREA OF HEALTH SUBJECTIVE OBJECTIVE INDIRECT DATA DATA DATA (effective *Identify source patterns or of indirect data barriers) Patient to get D.H. stated that Signs: Patient being upset that she is she is but Respirations 16 treated for right not as she is having a and unlabored, lower leg HEALTH independent as good day today. pulse 68, temp cellulitis (chart). MANAGEMENT she was before 97.5°F, pulse General Survey, she entered the ox 95% on perceived health Patient states Patient has orders facility. room air, BP & well-being, pain is 2/10 on for wound 143/78. management vascular scale. treatments every Although patient Patient strategies, utilization 12 hours (chart). enjoys company, demonstrates of she needs her personal preventative health Patient has PRN privacy at times hygiene with as well. behaviors medications for grooming and pain, i.e. and/or services. is dressed in acetaminophen clothes from and hydrocodone home. (chart). Patient actively participates in Patient is up with self-care but assistance x needs 1(chart). assistance x 1 when becomes tired. Patient enjoys spending time doing group activities but also enjoys private time in her room. Patient seems to be well oriented to facility and is cooperative with staff
Gordon’s Function Assessment AREA OF HEALTH SUBJECTIVE DATA OBJECTIVE DATA INDIRECT DATA *Identify source of indirect data (effective patterns or barriers) HEALTH MANAGEMENT General Survey, perceived health & well-being, strategies, utilization of preventative health behaviors and/or services. D.H. stated that she is but she is having a good day today. Patient states pain is 2/10 on vascular scale. Signs: Respirations 16 and unlabored, pulse 68, temp 97.5°F, pulse ox 95% on room air, BP 143/78. Patient demonstrates personal hygiene with grooming and is dressed in clothes from home. Patient actively participates in self-care but needs assistance x 1 when becomes tired. Patient enjoys spending time doing group activities but also enjoys private time in her room. Patient seems to be well oriented to facility and is cooperative with staff Patient being treated for right lower leg cellulitis (chart). Patient has orders for wound treatments every 12 hours (chart). Patient has PRN medications for pain, i.e. acetaminophen and hydrocodone (chart). Patient is up with assistance x 1(chart). Patient to get upset that she is not as independent as she was before she entered the facility. Although patient enjoys company, she needs her privacy at times as well. management
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