GORDON'S FUNCTIONAL HEALTH PATTERNS

DONEVA LYN B. MEDINA

#1 HEALTH MAINTENANCE MGMT.
BSN4-B #5 COGNITIVE/PERCEPTUAL

 Patient Name: Mr. E Before Hospitalization:

 Age: 64  Wears eyeglasses
 Has normal sensory functions
Before Hospitalization:
 The patient has fever and cough for 1 week. During Hospitalization
 Has rashes on both arms and abdomen.  GCS 15
 The patient has no difficulty hearing or
During Hospitalization: comprehending words.
 The patient is currently diagnosed with Multiple  Does not experience nor altered level of
Electrolytes Imbalance and Community- consciousness, wears sensory aid.
Acquired Pneumonia- Low Risk
 No allergies to food and medicines #6 SLEEP/REST SUBJECTIVE OBJECTIVE
 The patient was on DAT
Before Hospitalization:
 Unable to sleep properly at night due to cough.
#2 NUTRITION/METABOLIC
During Hospitalization:
Height: 162 cm  The patient often experienced difficulty
Weight: 63.8 kg sleeping at night because of itchy throat and
cough.
Before hospitalization:
 The patient eats 3 times a day. Not picky with #7 SELF-PERCEPTION/SELF-ESTEEM
any food.
 Drinks more than 8 glasses a day. Before Hospitalization:
 The patient has a positive outlook of himself.
During Hospitalization: He believes in his abilities.
 On diet as tolerated.
 Drink more than 8 glasses a day. During Hospitalization:
 IV fluid is PNSS
 Throughout the 12 hours duty, the patient  The patient appears relaxed, calm and
maintained the temperature of 36-36.5 responsive throughout the shift.
 Intake: 1750  Can maintain eye contact.
 Output: 800 cc
#8 ROLE/RELATIONSHIP

#3 ELIMINATION Before Hospitalization:

 Patient is a retired mechanical engineer. His
Before Hospitalization: wife is a teacher and they have 2 children who
 He often urinates and defecates without any are now working abroad.
problem.
During Hospitalization:
During Hospitalization:  His wife is present in taking care of him and
 Throughout the shift, he voids 4 times, does was able to provide his needs.
not experience any incontinence, dysuria,
burning sensation, dribbling, polyuria.
#9 SEXUALITY
 The stool is yellow and watery. He doesn't have
Before Hospitalization:
any problems in defecating nor any pain. Patient
 The patient is married and has 2 children.
doesn’t utilize suppositories supplements or
medication during hospitalization. During Hospitalization:

 The patient is married and is a father of 3

children. No noted abnormalities around the
reproductive area.

#4 ACTIVITY/EXERCISE #10 COPING/STRESS

Before Hospitalization: Before Hospitalization:

  The patient had a moderate pattern of activity  The patient verbalized that he is impatient
like walking and jogging. sometimes and easily get angry.
 He reads bible as a coping mechanism.
During Hospitalization:  His family is his strength.
 RR- 20
 SpO2 - 96% During Hospitalization:
 HR- 83  He bought his bible and read the words of God.
 BP- 120/80
 Can walk around the room without any
assistance. #11 VALUE/BELIEF
 With dry cough
Before Hospitalization:
 He is a Protestant and has a strong faith with
God.

During Hospitalization:
 He verbalized that Jesus is his savior and
salvation of mankind.
DONEVA LYN B. MEDINA BSN4-B
PEROS (Physical Assessment and Review of Systems)

Areas Assessed Subjective Findings Objective Findings Problem Identified

General Health “Kapoy akong lawas kay  GCS15 (E4V5M6)  Activity Intolerance
Survey dili ko katulog og tarong  Height: 162 cm related to exhaustion
sa gabie kay motukar  Weight: 63.8 kg and sleep interruption
akong ubo nya katol  Clean and appropriate secondary to
akong tutunlan”, as grooming. pneumonia as
verbalized by the patient.  How does the pt. evidenced by
smell? – Odorless. persistent dry cough,
 No signs of fatigue and disturbed
respiratory distress, sleep.
awake, calm, and
responsive.
 Memory is displayed
to be well as he could
easily recall
information of the
past without any
signs of struggling.
 Mood is generally
normal and happy.
 Able to eat without
assistance.

Integumentary System “Naa koy rashes dris  With rashes on both  Risk for Impaired
kamot og tiyan, daan arms and abdomen. Skin Integrity related
nanis balay”, as  Intact skin to itching as
verbalized by the patient  Bald evidenced by rashes
 Nails on both the on arms and
“Katol siya”, as upper and lower abdomen.
verbalized by the patient extremities were
well-trimmed,
 No presence of
edema.
 Warm skin

HEENT Head and face –  Disturbed Sensory

a. Head and face Eyes – Inspection Perception: Visual
b. Eyes “Na operahan kog ikatulo related to Poor Visual
c. Ears sa mata dri sa left side”,  Normal head symmetry Acuity
d. Nose as verbalized by the  Both lateral sides of a
e. Oral Cavity patient. face move
 simultaneously

(Palpation)
 No presence of any
masses.

Eyes – (inspection)
 Opens eye
spontaneously.
 With eye glasses
 Watery eyes

Ears –(Inspection)

 No presence of
discharges and no odor.

Nose – (Inspection)

 Normal symmetry,
pointed nose.
 No presence of
discharges.
 No presence of masses
and displacement of
bone and cartilage.

Oral cavity–(inspection).

Neck  No enlargement of No problems identified

cervical nodes and
enlargement of thyroid
gland of the neck.

Respiratory System “Gilok kayo akong  No spinal deformities  Ineffective Airway

tutunlan”, as verbalized alignment for clearance related to
by the patient. deformities. increased sputum
 Dry cough noted production.
“Di ko katulog og tarong  Equal chest expansion,
inig gabie kay motukar visible ribcage,
akong ubo”, as supraclavicular
verbalized by the patient. retractions, normal rate
of respirations.
“dali rasad ko hangakon
basta mag alsa og
bug.at”, as verbalized by
the patient.

Cardio-  Normal heart rate No problems identified

vascular System
Breast and axilla  Normal symmetry, No No problems identified
presence of lesions and
discharges.
Gastro-intestinal “Nakalibang ko ganinang  Flat Risk for Diarrhea
System and the buntag basa-basa akong  No scar and abrasions
abdomen tae”, as verbalized by the  Yellow and watery
patient. stool
 Can swallow
normally.
.
Genito-urinary /  No pain in urinating No problems identified
Reproductive system  No lesion.

M “dili na kaaayo ko kaalsa  No swelling or  Activity Intolerance

U og bug.at”, as verbalized deformities related to inability to
S by the patient.  Good balance and lift heavy objects.
C normal gait
U
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System
Neurologic System “malipong ko inig  Client is alert and  Risk for Falls related
motindog og kalit”, as oriented to to dizziness when
verbalized by the patient.  person, place, and standing.
time with  Risk for Injury
 normal speech. related to falls.
 No motor deficits
noted
 Sensation is intact

Lymphatic / Hemato- .  No lumps or  Risk for Impaired

logic System enlargement of the Skin Integrity related
limb. to itching as
 Rashes on both arms evidenced by rashes
and abdomen on arms and
. abdomen.