In nursing education, the curriculum's organizing framework must be reflected in all areas of student learning. Assessment tools are no exception. At our institution, Marjory Gordons (1987) functional health patterns are used as the framework for patient assessment tools. These health patterns provide a nursing focus to our assessment tools. Assessments that are nursing focused lead to nursing diagnoses and assist the student with developing a nursing plan of care.
Defining the Problem
The literature supports using nursingfocused tools to assess patient needs. Assessments based solely on medical models or on body systems hinder the use of the nursing process (Hartman & Knudson, 1991). Each discipline pays attention to different data or sees the same data from a different reference point so that what is not pertinent to medicine is pertinent to nursing (Smith, 1968).
Nurses are responsible for providing independent interventions along with physician-ordered dependent nursing interventions. Nursing data collection tools are focused on problems that are within the realm of independent nursing intervention. Hartman and Knudson (1991) stated that a functional health pattern format provided a standard method for collecting a nursing database regardless of age, level of care, or disease. Using an initial patient assessment tool based on functional health patterns improved the nurses' ability to target patient problems.
Laschinger (1990) "found the use of concrete tools, which make explicit those components of the theory related to patient care, helpful in assisting students apply nursing models in their practice" (p. 20). For this reason, assessment tools used in education are rather extensive. Assessments have been developed to assist students with applying the nursing process when caring for patients. The information gathered on each health pattern provides cues that lead the student to nursing diagnoses. At our university, the assessment tool used in Nursing Foundations guides students through an assessment of all 11 functional health patterns and consists of 13 pages. Because our students begin clinical practice by caring for medically stable patients in extended care facilities, the long tool meets our needs for teaching diagnostic reasoning and developing nursing diagnoses. Self-care deficits, high risk for injury, and high risk for infection have been the major problems that these patients exhibit.
Recent curriculum revision, however, required our students to spend only half of their clinical practice time in extended care and the other half in acute care facilities. This change required that students be able to assess patients in a much shorter time period. In acute care, a patient's status can change very quickly. Frequent critical assessments are required so that appropriate care can be given.
The major objectives of nursing care are to stabilize physiological or psychological processes and to prevent further complications during the critical phase of an illness. Although a life-threatening emergency is always expressed, however subtly, in all functional health patterns, only a few pattern indicators need to be assessed to determine that an emergency exists (Gordon, 1987). Corrigan (1986) found that levels of nursing assessment are appropriate for emergency room patients and that all 11 health patterns need not be addressed on every patient. We also recognized that acute care required a different level of initial assessment.
It was noted that nursing practice records lacked focus for assessment and few nursing units used a nursing model as a basis for care (Derdiarian, 1991; Laschinger, 1990). Information on hospital data forms, we found, was randomly grouped, inconsistent, and lacking in focus. Sections were labeled "tubes," "comfort," "respiratory assessment," "dressings," "mental status," and "incisions." Using functional health patterns for an organizing framework would provide a nursing focus and help the students to transfer classroom learning to the clinical area.
The Essential Health Pattern Assessment Tool was developed to assess the critical needs of patients in acute care. Data is collected on six health patterns prioritized on the tool as follows: activity/ exercise, nutritional/metabolic, elimination, cognitive/perceptual, health perception/ health management, and self-perception/ self-concept. Assessment of these patterns gives the student information needed to determine if the patient's status has changed to the degree that immediate nursing or medical intervention is required. The data on the Essential Health Pattern Assessment Tool is similar to information obtained by registered nurses at the beginning of their work day. It is one page long with both sides used. The data collected is mainly objective. Subjective questions asked of the patient are relative to pain, nausea, and sensations.
The front of the page begins with demographic data, reason for admission, allergies, and the patient's general appearance. The activity/exercise health pattern follows with a detailed cardiovascular and respiratory assessment. It includes temperature; blood pressure; the apical, radial, and pedal pulses; plus a Homan's sign assessment. The respiratory rate with description of breath sounds, cough, and oxygen delivery system is next. Neurovascular assessments and range of motion of the extremities are also included in the activity/exercise health pattern. The neurovascular assessment of the extremities uses a grid to document pulse, color, sensation, pain, temperature, and capillary refill.
The nutritional/metabolic health pattern is also on the front and includes assessment of the skin including color, temperature, moisture, turgor, integrity, and edema. Descriptions of dressings and drains are also found here. Diet, appetite, enteral feedings, and/or nasogastric suction are then assessed. Intravenous infusions are included in this health pattern assessment relative to solution, rate of flow, and complications at the infusion site.
On the back of the page are four health patterns beginning with elimination. It includes an abdominal assessment, bowel and bladder status, and assessment of any assistive devices to aid in elimination. Again, a grid is used to document assessment of bowel sounds and abdominal tenderness of all four quadrants.
The cognitive/perceptual health pattern follows with questions related to orientation, hearing and vision deficits, and pain. Pain is assessed relative to quality, region, severity, and timing.
In the health perception/health management pattern, which appears next, the patient is assessed for any factors that cause high risk for injury. Space is left for the student to write in a full description of the problem.
Finally, the self-perception/self-concept pattern assesses obvious psychosocial problems that the patient may be having. Of particular concern would be an acute state of anxiety, fear, or hopelessness.
Evaluating the results of diagnostic studies is another important part of nursing assessment. Selected diagnostic studies appear at the end of the assessment tool. Included are complete blood count, cultures and sensitivities, electrolytes, fasting blood sugars, arterial blood gases, coagulation studies, and x-ray results. These specific tests are based on the type of patient assignments made and the classroom information students receive during the semester.
The entire focus for this tool is one of patient safety. It is the required tool for the acute care portion of the student's experience and must be completed in its entirety within 20 to 30 minutes of initial patient contact. All abnormal findings must be reported to the instructor or the registered nurse in charge ofthat patient's care so that appropriate interventions can follow and patient safety is maintained.
There have been many positive outcomes since the introduction of the Essential Health Pattern Assessment Tool. Primarily, the quality of patient care has been maintained or improved because the students have quickly identified and reported patient needs requiring immediate intervention. Some examples of critical assessments reported by students within 30 minutes of initial patient assessment were positive Homan's sign, stage I decubitus ulcer, elevated prothrombin time, blood in the urine, abdominal distention, and several altered vital signs. Another advantage is the transfer of classroom learning to the clinical area. Through the grouping of critical assessment data under functional health patterns, the students learned to identify high priority nursing diagnoses and potential complications. The assessment tool also enabled the students to gather critical data and plan care without exposing acutely ill patients to lengthy interviews. The tool has also been adapted and is currently in use in our medicalsurgical, maternal and child health, and pediatric nursing courses.
With the rapid processing of patients through the acute care settings, coupled with accelerated nursing curricula, the safety of patients cannot be left to chance. Long and detailed assessment forms with many subjective questions asked of patients will not identify high priority needs. The Essential Health Pattern Assessment Tool has helped to guide our nursing students to meet the critical needs of patients and still maintain a nursing focus. Abnormal findings have been reported within 30 minutes of initial assessment. Students have used diagnostic reasoning to identify actual or high-risk nursing diagnoses and plan care accordingly because the data is organized within the functional health pattern framework.
- Corrigan, J. O. (1986). Functional health pattern assessment in the emergency department. Journal of Emergency Nursing, 12, 163-167.
- Derdiarian, A.K. (1991). Effects of using a nursing model-based assessment instrument on quality of nursing care. Nursing Administration Quarterly, 15(3), 1-16.
- Gordon, M. (1987). Nursing diagnosis: Process and application (2nd ed.). New York: McGrawHill, Inc.
- Hartman, D., & Knudson, J. (1991). A nursing data base for initial patient assessment. Oncology Nursing Forum, 18(1), 125-130.
- Laschinger, H.S. (1990). Helping students apply a nursing conceptual framework in the clinical setting. Nurse Educator, 15(3), 20-24.
- Smith, D.M. (1968). A clinical nursing tool. American Journal of Nursing, 68, 23842388.