Gordon Functional Health Assessment Case Study

Mr Lee, 72 years old, is referred by social worker and newly admitted to the community centre. He is found to be underweight and have medium risk of malnutrition. This report is written to plan for further investigation on the case and suggestions for the problems. In the report, there will be result of the previous assessment followed by addition investigation needed. Then, two food items are suggested for client to stock at home with rationale. After that, there will be nursing care plan including nutritional, social and psychological aspects. Finally, there will be a short conclusion.

2. Nutritional concern
According to the Malnutrition Screening Tool (MST), the client scored 2 marks in the test, indicating a medium risk of malnutrition.
The Gordon Functional Health Patterns assessment framework is used to gain more information of the suspected problems and investigate for any hidden problems.

i. Accessibility to food
It is related to his self care ability and the presence of any other care-givers. As he is living alone in an old walk up flat, he might need further help if there is any impaired mobility. He might also encounter financial problems as he is eligible to have free lunch.

ii. Social & psychological needs
Factors affecting social and psychological health are required for further investigation. The client might experience loneness when living alone. As he is newly referred to the community center, his usual life might be disturbed and he might not settle in the new environment yet.

iii. Nutritional knowledge and preference
The preference of food and usual diet before admission could help in proposing a suitable diet for him. His knowledge about nutrition is also estimated to determine the health knowledge to be educated.

3.2 Dental assessment
The client will be referred to dentist for his chewing problem. It could help to estimate the time need for treatment and relative financial support
Goals and expected outcomes
The goal of the planning is that the client would attain a balanced diet. It is expected the client will describe the ways to achieve healthy diet after the assessment. It is also expected the client will demonstrate a balanced diet the day after the assessment.

iii. Nursing interventions
There are few interventions to help the client achieving the goal.
First, education will be given to teach the client how to define and achieve a healthy diet. He will also be taught to check the nutritional label when buying food. The client will be told the place to buy the food recommended. He will be suggested buying food in the evening at Wan Chai market to enjoy great discount for vegetables, bread and Chinese buns.
Second, he will be referred to the dentist for his chewing problem. Third, discuss with the cattery service of the community center to process the food to be easier eaten by the client. For example, cook longer time to make food softer or mince the meat before cooking.

5.2 Socail plan
i. Nursing diagnosis
For the social aspect, the client is determined to be possible impaired social interaction related to change in usual social patterns secondary to relocation. (Carpenito-Moyet,