gordons ni tibat

8/2/2019 gordons ni tibat

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Assessment

Date:

Vital Signs

Temperature : 37.5°C Route : Axillary

Pulse Rate : 98 b.p.m. Site : Radial

Respiratory Rate : 21 c.p.m. Diaphragmatic

Blood Pressure : 130/100mmHg Left arm

Weight : 46.8 kg

Height : feet inches

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Gordon’s Functional Health Pattern

Subjective Subjective Objective

Health Perception –

Health Management

Pattern

● She graded her health as 3/10 for

difficulty of breathing, shortness of

breath, and fatigue.● She takes Paracetamol and sleeps

whenever she is not feeling well.

● She consults to a physician only

when she can no longer treat herself.

● She takes multivitamins daily.

● She had fever and coughs with the

past three months.

● She graded her health as 8/10 for

she felt relieved after taking out the

fluid in her right lung(thoracentesis). She also said that

she no longer has difficulty of

breathing or even shortness of

breath.

● She complies with all her

medications prescribed by the

physician.

General:

● She has an intravenous

fluid of of 0.9% PNSS 1L xKVO at her right arm.

● The patient is well-

groomed.

● The patient is calm,

assertive, and cooperative.



● She had no accidents for the past

years.

● She does not have any vices.

● She is somewhat worried about

the result of her laboratory because

she does not know if she has

tuberculosis or pneumonia.

● When asked what her she thinksthat caused her illness; she said that

maybe it was brought about by

aging.

Nutritional – Metabolic

Pattern

● Patient said that she only eats

whenever she feels like it.

● She admitted of losing her appetite

for the past three months.

● She likes to eat fruits and

vegetables.

● She does not eat pork.

● She takes her multivitamins daily.

● She drinks 8 glasses of water every

day.

● She drinks milk and coffee every

morning.

● She has no difficulty swallowing

but she said that she feels weak

chewing her foods.

● She eats her meal three times a

day.

● She said that her appetite is

coming back.

● She only eats half of the food

being rationed to her.

● She eats more vegetables and

fruits.

● She no longer takes her

multivitamins.

● She drinks more than 8 glasses of

water a day.

● Se has no difficulty in swallowing

and already has the energy chewing

her foods.● She can eat independently.

Integumentary/Oral:

● She is warm to touch.

● Her hair color is black and

equally distributed.

● Skin turgor is normal.

● Skin is not dry.

● She has dentures.

● Lips are moist.

● Oral mucosa is moist and

pinkish.

● Diet as tolerated

● Patient is constipated.

● She defecates 3x a week.

● Her stool color is black.

● She urinates 8x a day.

● Her urine color is yellowish.

● She is still constipated.

● He defecates once a day.

● Her stool color is brownish.

● She urinates 8 times a day.

● Her urine color is yellowish.

Genitourinary:

● Bladder is not distended.

● Urine color is yellow.

● Urine frequency is 8 times

a day.



Elimination Pattern ● She is not using any laxatives, or

diuretics.

● She is not using any laxatives

● She has companion when going to

the comfort room.

Genitointestinal:

● She has constipation.

● Stool color is normal.

● She has normoactivebowel movements.

Activity – Exercise

Pattern

● Though she has DOB, she still

manage to regularly do some

stretching for 15mins and after

sometime, clean the house for

another 15mins.

● She does not play any sports.

● She runs a school supplies store as

part of her daily activities.

● She ambulates herself every now

and then.

● She tries to sit and only lies to bed

when she wants to take a

nap/sleep.

Musculoskeletal:

●Muscle tone is normal.

● She has slightly kyphotic

posture.

● Gait is normal.

● Patient has Active Range

of Motion.

● Lovett scale with grade of

4 ; Complete ROM against

gravity with full resistance.

Respiratory:

● She has no tachypnea.

● Normal chest expansion.

● No chest pain.

Cardiovascular:● Pulse rate of 98 c.p.m.

● Nail color is pink.

● Capillary refill is less than

2 seconds.

● Negative for Homan’s

sign.

● No jugular vein



Role RelationshipPattern

● She visits her nieces once a week.

● She helps her family members in

terms finances.

● They help each other to afford

what they need.● She has good circle of friends in

their community.

and visits her once in awhile. with her niece.

Coping – Stress

Tolerance Pattern

● She has good social support system

especially in her community.

● They are always available for her.

● She said that whenever she feels

sad or needed to relax, she goes to

her neighbor to have some chit-chat.

● She feels at ease when she has

someone to talk to and when she

listens to the radio.

● She prays to handle her problems.

● Her niece is the one who

accompanies her.

● Once in awhile, her neighbors visit

her.

● He feels anxious about her

laboratory results.

● Patient smiles and shows

a positive outlook.

Value – Belief Pattern

● She is a Roman Catholic.

● Her religion is important to her.

● She thinks that this helps her

whenever she is faced with

difficulties in life.

● She goes to mass every Sunday●She prays every morning and at

night.

● She always prays.

● She believes that her prayer gives

her strength every day.

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gordons ni tibat

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