Gordons Health Patterns

HEALTH PATTERN
HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

DEFINITION
Perceived pattern of health and well being and how health is managed.

ASSESSMENT
Quality of usual health (scale 1 10). Perceived ability to control health. Health history. Self care measures used. Medications. Allergies. Reason for this admission and history of presenting challenge(s). Expectations for outcome of current health problem. Endocrine System Gastrointestinal System Integumentary System Diet. 24 hour diet recall. Quality of appetite. Swallowing. Dentures. Food likes and dislikes. Use of supplements. Usual weight. Nutrition knowledge. Skin.

NUTRITIONAL METABOLIC PATTERN

Food and fluid consumption relative to metabolic need and pattern indictors of local nutrient supply.

ELIMINATION PATTERN

Excretory function (bowel, bladder, and skin).

Genitourinary System Integumentary System Musculoskeletal System Neurological System Usual bladder pattern (discomfort voiding, difficulty starting stream, frequency, nocturia, incontinence, self care, assistance, other ie., catheter and etc.) Gastrointestinal System Musculoskeletal System Neurological System Usual bowel pattern (frequency, description, last bowel movement, incontinence, ileostomy, colostomy, aids, self care, assistance).

ACTIVITY EXERCISE PATTERN

Exercise, activity, leisure, and recreation

Cardiovascular System Musculoskeletal System Neurological System Pulmonary System Self care ability. Activities of daily living (eating/drinking, bathing, dressing/grooming, toileting, bed mobility, transferring, ambulating, other). Description of usual daily and, if different, weekend activities. Gait/balance. Respirations. Cough. Hobbies. Occupation.

COGNITIVE PERCEPTUAL PATTERN

Sensory perceptual and cognitive pattern

Neurological System Sensory System Mental status. Ability to understand. Education level. Eyes, vision, hearing, taste, smell, feel, and sensation. Communication. Pain (description, frequency, duration, location, and relief measures).

HEALTH PATTERN
SLEEP REST PATTERN

DEFINITION
Sleep, rest, relaxation.

ASSESSMENT
Genitourinary System Musculoskeletal System Pulmonary System Sleep schedule. Usual bedtime and waking time. Naps. Uncommon sleep patterns/difficulty sleeping (problems falling asleep or staying asleep and solutions).

SELF-PERCEPTION SELF CONCEPT PATTERN

Self concept and perceptions of self (body comfort, body image, feeling state). Pattern of role engagements and relationships.

Body image and feelings about self. Emotional status. Effects of illness on self perception. Personal factors contributing to illness, recovery, and health maintenance. Significant others. Next of kin/emergency contact. Family members and their relationship to client. Roles client and family members fill. Housing arrangements. Available assistance at home. Destination upon discharge. Anticipated changes as related to health challenges. Previous utilization of community resources. Discharge transportation. Genitourinary System Reproductive System Sexuality and Reproduction System Sexuality activity. Contraception. Concerns (discharge, bleeding, sores, and itching) Last menstrual period. Menstrual concerns. Obstetrical history. Pregnancy.

ROLE RELATIONSHIP PATTERN

SEXUALITY REPRODUCTIVE PATTERN

Satisfaction and dissatisfaction with sexuality pattern, describes reproductive patterns.

COPING STRESS TOLERANCE PATTERN

General coping patterns and effectiveness of patterns in terms of stress tolerance.

Cardiovascular System Endocrine System Gastrointestinal System Genitourinary System Integumentary System Pulmonary System Possible problems or concerns anticipated as related to your hospitalization or health challenges. Coping strategies used and their effectiveness. Personal losses or major stresses in last year. Comfort and security needs. Tobacco use. Alcohol use Cage Questionnaire. Street drugs.

VALUE BELIEF PATTERN

Values, beliefs (including spiritual) or goals that guide choice of decisions.

Religious/cultural/spiritual practices. Sources of strength and hope. Life goals. Spiritual needs generally and during time of stress. Need for clergy/support person visits.

Functional Health Patterns Health-perception-health-management pattern: Describes clients perceived pattern of health and well-being and how health is managed Nutritional-metabolic pattern: Describes pattern of food and fluid consumption relative to metablock need and pattern indicators of local nutrient supply Elimination pattern: Describes patterns of excretory function (bowel, bladder, and skin) Activity-exercise pattern: Describes pattern of exercise, activity, leisure, and recreation Cognitive-perceptual pattern: Describes sensory-perceptual and cognitive pattern Sleep-rest pattern: Describes patterns of sleep, rest, and relaxation Self-perception-self-concept pattern: Describes self-concept pattern and perceptions of self (eg. body comfort, body image, feeling state) Role-relationship pattern: Describes pattern of role-engagements and relationships Sexuality-reproductive pattern: Describes clients patterns of satisfaction and dissatisfaction with sexuality pattern; describe reproductive patterns Coping-stress-tolerance pattern: Describes general coping pattern and effectiveness of the pattern in terms of stress tolerance Value-belief pattern: Describes patterns of values, beliefs (including spiritual), or goals that guide choices of decisions

(Gordon, M [1987]. Nursing diagnosis: Process and application [2nd ed., p. 93]. New York: McGraw-Hill)

Functional health patterns of clients, whether individuals, families, or communities, evolve from client-environment interaction. Each pattern is an expression of biopsychosocial integration. No one pattern can be understood without knowledge of the other patterns. Functional patterns are influenced by biological, developmental, cultural, social and spiritual factors. Dysfunctional health patterns (described by nursing diagnoses) may occur with disease; dysfunctional health patterns also may lead to disease. The judgement of whether a pattern is functional or dysfunctional is made by comparing assessment data to one or more of the following: 1) individual baselines 2) established norms for age groups 3) cultural, social, or other norms. A particular pattern has to be evaluated in the context of other patterns and its contributions to optimal function of the client assessed. 1. HEALTH-PERCEPTION-HEALTH-MANAGEMENT PATTERN Describe the clients perceived pattern of health and well-being and how health is managed. Includes the individuals perception of health status and its relevance to current activities and future planning. Also included is the individuals general level of health care behaviour, such as adherence to mental and physical preventative health practices, medical or nursing perceptions, and follow-up care. 2. NUTRITIONAL-METABOLIC PATTERN Describe pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply. Includes the individuals pattern of food and fluid consumption, daily eating times, the type and quantity of food and fluids consumed, particular food preferences and the use of nutrient or vitamin supplements. Reports of any skin lesions and general ability to heal are included. The condition of skin, hair, nails, mucous membranes, and teeth and measures of body temperature, height, and weight are included. 3. ELIMINATON PATTERN Describes patterns of excretory function (bowel, bladder, and skin). Includes the individuals perceived regularity of excretory function, use of routines or laxatives for bowel elimination, and any changes or disturbances in time-pattern, mode of excretion, quality or quantity. Also included are any devises employed to control excretion. 4. ACTIVITY-EXERCISE PATTERN Describes patterns of exercise, activity, leisure, and recreation. Includes activities of daily living requiring energy expenditure such as hygiene, cooking, shopping, eating, working, and home maintenance. Also included are the type, quantity, and quality of exercise, including sports, which describe the typical pattern for the individual. Factors that interfere with the desired or expected pattern for the individual (such as neuromuscular deficits and compensations, dyspnea, angina, or muscle cramping on exertion, and cardiac/pulmonary classification, if appropriate) are included. Leisure patterns are also included and describe the activities the individual undertakes as recreation either with a group or as an individual. Emphasis is on the activities of high importance or significance to the individual.

5. SLEEP-REST PATTERN Describes patterns of sleep, rest, and relaxation. Includes patterns of sleep and restrelaxation periods during the 24-hour day. Includes the individuals perceptions of the quality and quantity of sleep and rest, and perception of energy level. Included also are aids to sleep such as medications or nighttime routines that the individual employs. 6. COGNITIVE-PERCEPTUAL PATTERN Describes sensory-perceptual and cognitive pattern. Includes the adequacy of sensory modes, such as vision, hearing, taste, touch and the compensation or prothesthetics utilized for disturbances. Reports of pain, perception and how pain is managed are also included when appropriate. Also included are the cognitive functional abilities, such as language, memory, and decision making. 7. SELF-PERCEPTION-SELF-CONCEPT PATTERN Describes self-concept pattern and perceptions of self. Includes the individuals attitudes about himself or herself, perception of abilities (cognitive, affective, or physical), body image, identity, general sense of worth, and general emotional pattern. Pattern of body posture and movement, eye contact, voice, and speech pattern are included. 8. ROLE-RELATIONSHIP PATTERN Describes pattern of role engagements and relationships. Includes the individuals perception of the major roles and responsibilities, in current life situation. Satisfaction of disturbances in family, work, social relationships and responsibilities related to these roles are included. 9. SEXUALITY-REPRODUCTIVE PATTERN Describes patterns of satisfaction or dissatisfaction with sexuality; describes reproductive pattern. Includes the individuals perceived satisfaction or disturbances in his or her sexuality. Included also is the females reproductive stage, pre or post-menopause, and any perceived problems. 10. COPING-STRESS-TOLERANCE PATTERN Describes general coping pattern and effectiveness of the pattern in terms of stress tolerance. Includes the individuals reserve or capacity to resist challenge to self-integrity, models of handling stress, family or other support systems, and perceived ability to control and manage situations. 11. VALUE-BELIEF PATTERN Describes patterns of values, goals, or beliefs (including spiritual) that guide choices or decisions. Includes what is perceived as important in life and any perceived conflicts in values, beliefs, or expectations that are health related. Gordon, Marjory (1991) Manual of Nursing Diagnosis

FUNCTIONAL HEALTH PATTERNS ASSESSMENT FORMAT INDIVIDUAL ASSESSMENT

HISTORY
1. a. b. c. How has general health been? Any colds in past year? If appropriate: absences from work? Most important things you do to keep healthy? Think these things make a difference to health? (Include family folk remedies, if appropriate.) Use of cigarettes, alcohol, drugs? Breast selfexamination. Accidents (home, work, driving)? In past, been easy to find ways to follow things doctors or nurses suggest? If appropriate: What do you think caused this illness? Actions taken when symptoms perceived? Results of action? If appropriate: Things important to you while youre here? How can we be most helpful? NUTRITIONAL METABOLIC PATTERN Typical daily food intake? (Describe.) Supplements (vitamins, type of snacks) Typical daily fluid intake. (Describe.) Weight loss/gain? (Amount.) Height loss/gain? (Amount.) Appetite? Food or eating: Discomfort? Swallowing? Diet restrictions? Heal well or poorly? Skin problems: Lesions, dryness? Dental problems? ELIMINATION PATTERN Bowel elimination pattern. (Describe.) Frequency? Character? Discomfort? Problem in control? Laxatives, etc.? Urinary elimination pattern. (Describe.) Frequency? Problem in control? Excess perspiration? Odor problem? Body cavity drainage, suction, etc. (Specify.) ACTIVITY EXERCISE PATTERN Sufficient energy for desired/required activities? Exercise pattern? Type? Regularity? Spare time (leisure) activities? Child: play activities. a. If indicated: Examine excreta or drainage color and consistency. a. b. c. d. e. f. Skin: bony prominences? Lesions? Color changes? Moistness? Oral mucous membranes: color, moistness, lesions. Teeth: General appearance and alignment. Dentures? Cavities? Missing teeth? Actual weight, height? Temperature. Intravenous/parenteral feeding (specify.) a.

EXAMINATION
General health appearance

HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

d. e. f.

g. 2. a. b.

c. d. e. f. g. 3. a.

b. c. d. 4. a. b. c.

HISTORY

EXAMINATION

Functional Level Codes: Level 0: Full self-care Level I: Requires use of equipment or device Level II: Requires assistance or supervision from another person Level III: Is dependent and does not participate d. Perceived ability (code for level) for: Feeding Bathing Toileting Bed Mobility Dressing _____ _____ _____ _____ _____ Grooming General Mobility Cooking Home maintenance Shopping _____ _____ _____ _____ _____ b. c. d. e. f. g. h. 5. a. b. c. 6. a. b. c. d. e. f. 7. a. b. c. d. SLEEP REST PATTERN Generally rested and ready for daily activities after sleep? Early awakening? Rest-relaxation periods? COGNITIVE PERCEPTUAL PATTERN Hearing difficulty? Aid? Vision? Wear glasses? Last checked? When last changed? Any change in memory lately? Big decision easy/difficult to make? Easiest way for you to learn things? Any difficulty? Any discomfort? Pain? If appropriate: how do you manage it? a. b. c. d. e. f. Orientation. Hear whisper? Reads newsprint? Grasps ideas and questions (abstract, concrete)? Language spoken. Vocabulary level. Attention span. a. If appropriate: Observe sleep pattern a. Demonstrated ability (code listed above) for: Feeding Bathing Toileting Bed Mobility Dressing _____ _____ _____ _____ _____ Grooming General Mobility Cooking Home maintenance Shopping _____ _____ _____ _____ _____

Gait _____ Posture _____ Absent body part? (specify) _____ Range of motion (joints) _____ Muscle firmness _____ Hand grip _____ Can pick up pencil? _____ Pulse (rate) _____ (rhythm) _____ (strength) _____ Respiration (rate) _____ (rhythm) _____ Breath sounds _____ Blood pressure _____ General appearance (grooming, hygiene, energy level)

SELF-PERCEPTION SELF-CONCEPT PATTERN How describe self? Most of the time, feel good (not so good) about self? Changes in body or things you can do? Problem to you? Changes in way you feel about self or body (since illness started)? Things frequently makes you angry? Annoyed? Fearful? Anxious? Depressed? Not being able to control things? Ever feel you lose hope? a. b. c. d. Eye contact. Attention span (distraction). Voice and speech pattern. Body posture. Nervous (5) or relaxed (1); rate from 1 to 5. Assertive (5) or passive (1); rate from 1 to 5.

e.

HISTORY
8. a. b. c. d. e. f. g. h. i. 9. a. b. c. ROLE RELATIONSHIP PATTERN Live alone? Family? Family structure (diagram)? Any family problems you have difficulty handling (nuclear/extended)? Family or others depend on you for things? How managing? If appropriate: How family/others feel about illness/hospitalization? If appropriate: Problems with children? Difficulty handling? Belong to social groups? Close friends? Feel lonely (frequency)? Things generally go well at work (school)? If appropriate: Income sufficient for needs? Feel part of (or isolated in) neighbourhood where living? SEXUALITY REPRODUCTIVE PATTERN If appropriate to age and situation: Sexual relationships satisfying? Changes? Problems? If appropriate: Use of contraceptives? Problems? Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? COPING STRESS TOLERANCE PATTERN Any big changes in your life in the last year or two? Crisis? Whos most helpful in talking things over? Available to you now? Tense or relaxed most of the time? When tense what helps? Use any medicines, drugs, alcohol? When (if) have big problems (any problems) in your life, how do you handle them? Most of the time is this (are these) way(s) successful? VALUE BELIEF PATTERN Generally get things you want from life? Important plans for the future? Religion important in life? If appropriate: Does this help when difficulties arise? If appropriate: Will being here interfere with any religious practices? No examination. No examination. a. a.

EXAMINATION
Interaction with family member(s) or others (if present).

None unless problem identified or pelvic exam is part of full physical assessment.

10. a. b. c. d. e. f. 11. a. b. c.

Gordon, Marjory. (1987). Nursing Diagnosis Process and Application. McGraw Hill: New York.

FUNCTIONAL HEALTH PATTERNS ASSESSMENT FORMAT FAMILY ASSESSMENT

HISTORY
1. a. b. c. How has familys general health been (in last few years)? Colds in past year? Absences from work/school? Most important things you do to keep healthy? Think these things make a difference to health? (Include family folk remedies, if appropriate.) Members use of cigarettes, alcohol, drugs? Immunizations? Health care provider? Frequency of check-ups? Accidents (home, work, school, driving)? (If appropriate: Storage of drugs, cleaning products; scatter rugs, etc.) In past, been easy to find ways to follow things doctors, nurses, social worker (if appropriate) suggest? Things important in familys health that I could help you with? NUTRITIONAL METABOLIC PATTERN Typical family meal pattern/food intake? (Describe.) Supplements (vitamins, type of snacks, etc.)? Typical family fluid intake. (Describe.) Supplements: type available: fruit juices, soft drinks, coffee, etc.? Appetites? Dental problems? Dental care (frequency)? Anyone have skin problems? Healing problems? ELIMINATION PATTERN Family use of laxatives, other aids? Problems in waste/garbage disposal? Pet animals waste disposal (indoor/outdoor)? If indicated: Problems with flies, roaches, rodents? ACTIVITY EXERCISE PATTERN In general, does family get a lot/little exercise? Type? Regularity? Family leisure activities? Active/passive? Problems in shopping (transportation), cooking, keeping up the house, budgeting for food, clothes, housekeeping, house costs? SLEEP REST PATTERN Generally, family members seem to be well rested and ready for school/work? Sufficient sleeping space and quiet? Family find time to relax? a. If opportunity available: Observe sleeping space and arrangements. a. Pattern of general home maintenance, personal maintenance. a. If opportunity available: Examine toilet facilities, garbage disposal, pet waste disposal; indicators of risk for flies, roaches, rodents. a. b. c. If opportunity available: Refrigerator contents, meal preparation, contents of meal, etc. Food purchases (Observations of food store check-out counters). Junk food (machines in schools, etc.). a. b.

EXAMINATION
General appearance of family members and home. If appropriate: Storage of medicines; cribs, playpens, stove, scatter rugs, hazards, etc.

HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

d. e.

f.

g. 2. a.

b.

c. d. e. 3. a. b. c. d. 4. a. b. c.

5. a. b. c.

HISTORY
6. a. b. 7. a. b. 8. a. b. c. d. e. 9. a. COGNITIVE PERCEPTUAL PATTERN Visual or hearing problem? How managed? Any big decisions family has had to make? How made? a. b. c.

EXAMINATION
If indicated: Language spoken at home. Grasp of ideas and questions (abstract/concrete). Vocabulary level.

SELF-PERCEPTION SELF CONCEPT PATTERN Most of time family feels good (not so good) about themselves as a family? General mood of family? Happy? Anxious? Depressed? What helps family mood? ROLE RELATIONSHIP PATTERN Family (or household) members? Member age and family structure (diagram). Any family problems that are difficult to handle (nuclear/extended)? Child rearing? Relationships good (not so good) among family members? Siblings? Support each other? If appropriate: Income sufficient for needs? Feel part (or isolated) from community? Neighbours? SEXUALITY REPRODUCTIVE PATTERN If appropriate (sexual partner within household or situation): Sexual relations satisfying? Changes? Problems? Use of family planning? Contraceptives? Problems? If appropriate (to age of children): Feel comfortable in explaining/discussing sexual subjects? COPING STRESS TOLERANCE PATTERN Any big changes within family in last few years? Family tense or relaxed most of time? When tense what helps? Anyone use medicines, drug, alcohol to decrease tension? When (if) family problems, how handled? Most of the time is this way(s) successful? VALUE BELIEF PATTERN Generally, family get things they want out of life? Important things for the future? Any rules in the family that everyone believes are important? Religion important in family? Does this help when difficulties arise? No examination. No examination. No examination. a. b. Interaction among family members (if present). Observed family leadership roles. a. b. General mood state: nervous (5) or relaxed (1); rate from 1 to 5 Members generally assertive (5) or passive (1); rate from 1 to 5

b. c.

10. a. b.

c. d. 11. a. b. c. d.

Gordon, Marjory. (1987). Nursing Diagnosis Process and Application. McGraw Hill: New York.

FUNCTIONAL HEALTH PATTERNS ASSESSMENT FORMAT COMMUNITY ASSESSMENT

HISTORY
1. a. In general, what is the health/wellness level of the population on a scale of 1-5, with 5 being the highest level of health/wellness? Any major health problems? Any strong cultural patterns influencing health practices? People feel they have access to health services? Demand for any particular health services or prevention program? People feel fire, police, safety programs sufficient? NUTRITIONAL METABOLIC PATTERN In general, do most people seem well nourished? Children? Elderly? Food supplement programs? Food stamps: rate of use? Food reasonable cost in this area relative to income? Stores accessible for most? Meals on Wheels available? Water supply and quality? Testing services (if most have own wells)? (If appropriate: Water usage cost? Any drought restrictions?) Any concern that community growth will exceed good water supply? Heating/cooling costs manageable for most? Programs? ELIMINATION PATTERN a. b. Communicable disease statistics. Air pollution statistics. a. General appearance (nutritional appearance; teeth; clothing appropriate to climate)? Children? Adults? Elderly?

EXAMINATION
Examination (community records) a. Morbidity , mortality, disability rates (by age group, if appropriate). b. Accident rates (by district, if appropriate). c. Currently operating health facilities (types). d. On-going health promotion-prevention programs; utilization rates. e. Ratio of health professionals to population. f. Laws regarding drinking age. g. Arrest statistics for drugs, drunk driving by age groups.

HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

b. c. d. e. 2. a. b. c. d. e.

f. g. 3.

History (community representatives) a. Major kinds of wastes (industrial, sewage, etc.)? b. Disposal systems? Recycling programs? Any problems perceived by community? c. Pest control? Food service inspection (restaurants, street vendors, etc.)? 4. a. b. ACTIVITY EXERCISE PATTERN How do people find the transportation here? To work? To recreation? To health care? People have/use community centres (seniors, others)? Recreation facilities for children? Adults? Seniors? Is housing adequate (availability, cost)? Public housing? SLEEP REST PATTERN

a. b. c. d. e. a.

c. 5.

Recreation/cultural programs. Aids for the disabled. Residential centres, nursing homes, rehabilitation facilities relative to population needs. External maintenance of homes, yards, apartment houses. General activity level (e.g., bustling, quiet.) Activity-noise levels in business district. In residential district.

(community representatives) a. Generally quiet at night in most neighbourhoods? b. Usual business hours? Industries round-theclock?

HISTORY
6. a. b. c. d. COGNITIVE PERCEPTUAL PATTERN Most groups speak English? Bilingual? Educational levels of population? Schools seen as good/need improving? Adult education desired/available? Types of problems that require community decisions? Decision making process? Whats the best way to get things done/changed here? a. b.

EXAMINATION
School facilities. Drop-out rate. Community government structure; decision making lines.

7.

SELF-PERCEPTION SELF CONCEPT PATTERN a. b. c. Racial, ethnic mix (if appropriate). Socioeconomic level. General observations of mood.

(community representatives) a. Good community to live in? Going up in status, down, about same? b. Old community? Fairly new? c. Any age group predominate? d. Peoples moods in general: Enjoying life, stressed, feeling down? e. People generally have kind of abilities needed in this community? f. Community/neighbourhood functions? Parades? 8. ROLE RELATIONSHIP PATTERN

(community representatives) a. People seem to get along well together here? Places where people tend to go to socialize? b. Do people feel they are heard by government? High/low participation in meetings? c. Enough work/jobs for everybody? Wages good/fair? Do people seem to like kind of work available (happy in their jobs/job stress)? d. Any problems with riots, violence in the neighbourhoods? Family violence? Problems with child/spouse/elder abuse? e. Get along with adjacent communities? Collaborate on any community projects? f. Do neighbours seem to support each other? g. Community get-togethers? 9. SEXUALITY REPRODUCTIVE PATTERN

a. b. c. d.

Observation of interactions (generally or at specific meetings). Statistics on interpersonal violence. Statistics on employment, income/poverty. Divorce rate.

(community representatives) a. Average family size? b. Do people feel there are any problems with pornography, prostitution? Other? c. Do people want/support sex education in schools/community?

a. b. c. d. e. f. g.

Family size and types of households. Male/female ratio. Average material age. Maternal mortality rate. Infant mortality rate. Teen pregnancy rate. Abortion rate. Sexual violence statistics. Laws/regulations regarding information on birth control. Delinquency, drug abuse, alcoholism, suicide, psychiatric illness, statistics. Unemployment rate by race/ethnic/sex.

10.

COPING STRESS TOLERANCE PATTERN a. b.

(community representatives) a. Any groups that seem to be under stress? b. Need/availability of phone help-lines? Support groups (health related, other)?

HISTORY
11. a. VALUE-BELIEF PATTERN Community values: What seems to be the top four things that people living here see as important in their lives (note health-related values, priorities)? Do people tend to get involved in causes/local fund raising campaigns (note if any are health related)? Religious groups in community? Churches available? Do people tend to tolerate/not tolerate differences/socially deviant behaviour? a. b. c.

EXAMINATION
Zoning laws. Scan of community government health committee reports (goals, priorities). Health budget relative to total budget.

b.

c. d.

Gordon, Marjory. (1987). Nursing Diagnosis Process and Application. McGraw Hill: New York.