Nsg110 Nursing Concept Map Part I Assessment Data By Body Sy

Nsg110 Nursing Concept Map Part Iassessment Data By Body Systemsubjec

Identify a client with a chronic illness, gather assessment data, categorize data into body systems and subjective/objective categories, and organize findings into Gordon Functional Patterns (GFP).

Paper For Above instruction

Introduction

Effective nursing care for patients with chronic illnesses requires a comprehensive understanding of their health status across multiple body systems. The assessment process involves collecting detailed subjective and objective data, categorizing these findings appropriately, and synthesizing them into functional health patterns. This structured approach facilitates individualized care planning that addresses the complex needs of patients. In this paper, a 48-year-old female patient diagnosed with ductal carcinoma in situ (DCIS) breast cancer exemplifies this process. Through systematic assessment and application of Gordon’s Functional Health Patterns, the nursing implications and potential interventions are discussed comprehensively.

Patient Demographics and Medical Background

The patient, identified by initials SL, is a 48-year-old woman diagnosed with breast cancer, specifically ductal carcinoma in situ. She has no immediate family history of breast cancer or other significant medical diagnoses. The patient reports feeling hopeful and maintains a spiritual belief in God, although she experiences loneliness. Her demographic details, assessment findings, and health history serve as the foundation for her nursing care plan.

Assessment Data by Body System and Data Category

Neurological

• Subjective: Patient appears unconcerned about her health status; no neurological complaints such as dizziness or weakness.
• Objective: Patient correctly identifies her age, with no noted neurological deficits or signs of cognitive impairment.

HEENT

• Subjective: Reports headache and neck stiffness.
• Objective: Swollen lymph nodes identified during physical examination.

Integumentary

• Subjective: Reports itchy, dry skin around the breast area.
• Objective: Skin is dry, intact, warm to touch, with no open wounds or lesions.

Musculoskeletal

• Subjective: No joint pain or limitations reported.
• Objective: Shoulder range of motion is smooth; movements are symmetrical and simultaneous, indicating no musculoskeletal impairment.

Cardiovascular

• Subjective: Patient denies chest pain but reports faint chest pains and shortness of breath.
• Objective: Apical pulse rate is 85 BPM; no abnormal heart sounds detected during auscultation.

Respiratory

• Subjective: Difficulty breathing, coughing present.
• Objective: Presence of cough, pleuritic pain, shortness of breath observed.

Gastrointestinal

• Subjective: Denies nausea or constipation.
• Objective: Bowel sounds are gurgling every 5–10 seconds; no abnormalities noted.

Genitourinary

• Subjective: No painful urination or difficulty voiding reported.
• Objective: Urination appears unaltered; no urinary abnormalities observed.

Emotional, Social, and Spiritual

• Subjective: Feelings of loneliness; maintains hope and belief in God.
• Objective: Expresses a positive outlook despite emotional distress.

Reproductive

• Subjective: Loss of interest in sexual activity.
• Objective: No children; sexual dysfunction reported.

Mapping Assessment Data to Gordon’s Functional Patterns

The collected data were organized into Gordon’s Functional Patterns, recognizing that some findings intersect multiple patterns, thus informing holistic nursing interventions.

Health Perception-Health Management Pattern

• Considerations include treatment costs and lifestyle modifications due to cancer diagnosis and treatment plan.

Sleep and Rest Pattern

• Disturbed sleep patterns noted, with anxiety contributing to sleep disturbance.

Sexuality-Reproductive Pattern

• Decreased sexual interest, fatigue, and emotional distress related to cancer diagnosis observed.

Elimination Pattern

• Incontinence issues noted, along with fatigue which may influence elimination routines.

Nutritional-Metabolic Pattern

• Readiness for fluid intake optimization and maintenance of tissue integrity are relevant nursing focuses.

Cognitive-Perceptual Pattern

• Social isolation, fear, anxiety, and knowledge deficit about the disease highlight the need for patient education and support.

Activity-Exercise Pattern

• Fatigue, pain, and self-care deficits indicate potential areas for activity modification and supportive therapies.

Self-Perception-Self-Concept Pattern

• Depression, fear, and feelings of powerlessness emphasize psychological support needs.

Value-Belief Pattern

• Spiritual belief and health-seeking behaviors influence care approaches tailored to the patient’s values.

Coping-Stress Tolerance Pattern

• Denial, stress management, and absence of suicidal ideation are significant factors in care planning.

Role-Relationship Pattern

• Social isolation, loneliness, and decreased interest in relationships necessitate social support interventions.

Conclusion

The systematic assessment and organization of data using Gordon’s Functional Patterns provide a comprehensive framework to address the multidimensional needs of a patient with breast cancer. Recognizing how each body system and pattern interrelate helps nurses develop holistic, individualized care plans that promote healing, psychosocial well-being, and quality of life. Continuous assessment and tailored interventions are essential to optimize health outcomes for patients facing chronic illnesses such as cancer.

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