GORDON’S FUNCTIONAL HEALTH PATTERN
A. Health perception – health management pattern
S > Patient verbalized: “Noong una akala ko hindi na ma-iimprove health ko.
Laging problemado at nagiisip dahil sa kalagayan at sakit na nararanasan ko.”
O > The patient looks drowsy and lethargic but cooperative during
conversation. She is oriented about the time, place and person when asked, well-
groomed. Movement was limited. General appearance: hair distribution is equal,
color gray, skin is dry, fingernails and toenails are thickened and brittle. No foul
body odor.
Vital signs: BP: 140/ 60 mmHg
T: 35.9ºC
PR: 66 bpm
RR: 26 cpm
Height: 4’10”
DBW: 98lbs
A > Readiness for enhanced health management
B. Nutritional – metabolic pattern
S> Patient verbalizes: “Bumigat ata ako ngaun. Ginaganahan naman ako
kumain kapag gutom. Pakiramdam ko pagod ako at nanghihina katawan ko. May
mga pagkain akong dapat at hindi dapat kainin. Nakaka ¼ akong paginom ng
tubig . Gusto kong pagkain ay yung may kasamang soup. Minsan nahihilo ako
pero hindi nagsusuka. Konti lang naiihi ko ngayon.”
O> Patient has a dry skin, without lesions and rash, skin turgor is fragile,
cyanotic. Mucous membranes of mouth is moist, no lesions, color is pale, has
false teeth, no dentures, gums are pale. Have moist eyes, pale conjunctiva, no
lesions. Have edema in arms and legs. Patient cannot turn without assistance.
Diaper weighs: Monday-360, Tuesday- 355.
A> Fluid volume excess r/t retention of Na and water as manifested by edema,
and decreased urine output
C. Elimination pattern
S> Patient verbalizes: “Minsan isang beses o dalawang beses ako dumudumi
sa isang araw. Basta minsan magkaiba. Pero minsan nahihirapan ako dumumi.
Kapag hindi ako dumudumi ng apat na araw, umiinom ako ng gamot. Hindi ko na
nakikita kung anong kulay ng dumi ko. Dati nagkaroon na ako ng diarrhea. Ang
kulay naman ng ihi ko ay dilaw pero minsan nahihirapan din ako umihi. Hindi ko
nararamdaman minsan kung umiihi na ko sa diaper ko.”
O> Patient has diaper and urine output of 360 during morning shift of monday.
Abdomen is soft, no masses. No stool in rectum during perineal care.
A> Constipation r/t poor eating habits
D. Activity – exercise pattern
S> Patient verbalizes: “Nagsasaka ako, at nagtutubig ng mga halaman sa
umaga hanggang hapon.”
O> Radial and temporal pulse is easily palpable. Moist eyes, dry and soft skin,
with cold and clammy skin. Extremities are cold to touch because of the presence
of air-conditioner. Capillary refill is delayed, nails are whitish in color.
Respiratory rate is 26, shallow. Limited mobility that needs assistance in turning
and positioning. ADLs assisted – feeding, bathing, grooming.
A> Activity intolerance r/t bed rest or immobility as manifested by weakness
E. Sexuality – reproduction pattern
S> Patient verbalizes: “Menopause na ako nung 45 years old ako.
Nakalimutan ko na kung kalian huling regla ko. Sampung beses akong nanganak
at nagbuntis. Hindi rin ako nakunan nung nagbubuntis ako.”
O> The patient was able to discuss her sexual concerns comfortably.
F. Sleep – rest pattern
S> Patient verbalizes: “Natutulog ako 10pm ng gabi, at gumigising ng 5:30am
kapag may trabaho. At nagigising ng 8am kapag walang trabaho.”
O> There is presence of darkening about the periorbital area. The client
demonstrates a slouched posture and lethargy through her facial gestures and she
frequently yawns and closes her eyes. Appears to be very sleepy but still shows
alertness.
A> Sleep deprivation r/t aging-related sleep stage shifts as manifested by
presence of darkening on the periorbital area.
G. Sensory – cognitive – perceptual pattern
S> Patient verbalizes: “Malabo na ang paningin ko pero hindi ako gumagamit
ng salamin kase dahil sa komplikasyon ng diabetes na mas nakakalabo ng mata.
Mahina na rin ang pandinig ko dahil nga siguro matanda na ko. Sumasakit yung
leeg ko kasi nangangawit. Nakakapagdesisyon pa naman ako.”
O> Patient is oriented to time, place and person. Patient’s speech is
understandable. Conjunctiva is pale in color. Right and left auricles are aligned
with outer canthus of the eyes. There is no presence of lesions on both external
ears. Her nose is symmetric and straight with no presence of lesions.
A> Disturbed sensory perception: visual and auditory r/t environmental
stimuli as manifested by aging
H. Role relationship pattern
S>Patient verbalizes: “Maayos naman ang pakikitungo ko sa mga anak ko.
Hindi naman ako nagkakaroon ng problema sa kanila. Tumitira ako kasama ang
pamilya ko. Namatay na ang asawa ko. Ginagawa ko na lang nung nasa bahay pa
ako ay manuod ng tv, humiga, matulog. Matanda na rin ako, kaya wala akong
masyadong ginagawa na mabigat at nakakapagod.”
O> Patient communicates with family members with understandable speech
pattern. Smiling when talking to her daughter. Shows a cheerful face during the
interview. No dysfunctional family interactions. Exhibits closeness to her child
and granddaughter.
A> Therapeutic regimen: Readiness for enhanced family process.
I. Self-perception pattern
S> Patient verbalizes: “Iniisip ko na lang sa ngayon ang mga anak ko at mga
apo ko. Tingin ko naman makakabuti ang pagtagal ko dito kung para din sa
kalusugan ko. Ganun pa rin naman ang tingin ko sa aking sarili. Hindi ko na lang
masyado iniisip ang problema.”
O> Patient is comfortable lying on the bed. Appears calm, soft voice and clear
speech pattern, no negative emotions observed. Patient is not irritated during
interactions.
A> Therapeutic regimen: “Readiness for enhanced selft-concept.
J. Coping – stress pattern
S> Patient verbalizes: “Masaya na ko kapag nakakasama ko ang pamilya ko.
Kapag nakakausap ko sila. Binabantayan nila ako. Masaya na ako sa pagaalagang
ginagawa ng mga anak ko at apo ko. Madalas din akong manuod ng tv sa gabi ng
teleserye. Dito sa ospital, natutuwa ako kapag kasama ko ang anak ko.”
O>Patient has no observed altered behaviors and thought processes. No overt
signs of crying, wringing of hands.
A> Therapeutic regimen: Readiness for enhanced coping-stress pattern
I. Value-Belief pattern
S> Patient verbalizes: “Nawawala na pagod ko kapag nandyan ang anak at apo
ko. Hindi naman ako masyadong problemado kapag may mga naiisip na bagay.
Sapat na sa akin ang pagaalagang binibigay sa akin ng pamilya ko. Mas
nakakabuti talaga sa kalusugan ko kapag alam kong andyan sila para alagaan
ako.”
O>Patient is Catholic. There is no presence of religious objects in the patient’s
room. The patient did not show any religious actions or routines during
assessment, does not show any signs of alterations like anger or crying.
A> Readiness for enhanced spiritual well- being
