XII.

GORDONS HEALTH PATTERN OF FUNCTION

A. Health perception and management

Before hospitalization
She knows about her health and knows how to take care of herself specially her family

During/After hospitalization
Is aware of her health condition

Analysis: Aware and concern about her health and the health of her family Interpretation: the patient knows how to manage her health Problem Identification
B. Nutritional/Metabolic Pattern

Analysis: The patient is well oriented about her current condition Interpretation: the patient is aware and accepts her health condition Problem Identification

Before hospitalization
She eats everything that is on the table. She eats vegetables the most

During/After hospitalization
Has diet restrictions

Analysis: She wasnt able to monitor a balance diet Interpretation: The patient was able to eat what she wants Problem Identification
C. Elimination Pattern

Analysis: the patient is able to eat everything she needs to eat Interpretation: the patient is in a diet restriction so she wasnt able to eat everything she want Problem Identification

Before hospitalization
Defecates twice a day, urinates 5-7 times a day

During/After hospitalization
Defecates ones a day, urinates 5 times a day

Analysis: Normal bowel movement Interpretation: She can urinate and defecate regularly Problem Identification
D. Activity/Exercise Pattern

Analysis: Normal bowel movement, Urine output is measured Interpretation: She became more careful when doing toilet activities Problem Identification

Before hospitalization
Does household chores, serves as her exercise

During/After hospitalization
Limited movement due to her condition

Analysis: the patient is physically active

Interpretation: she do exercise regularly

Analysis: the patient needs some assistance because it will be dangerous to her womb Interpretation: needs limited assistance

by doing chores Problem Identification

E. Sleep/Rest Pattern

but can act on her own Problem Identification

Before hospitalization
Sleeps 7-8hrs every day

During/After hospitalization
Sleeping hours increased

Analysis: the patient gets enough sleep Interpretation: the patient has enough sleep Problem Identification
F. Self-Perception/Concept Pattern

Analysis: the patient can sleep well due to her confinement Interpretation: the patient has enough sleep. Problem Identification

Before hospitalization
She perceives herself as a healthy individual and care provider for her family.

During/After hospitalization
She thinks of her condition as okay and no problem and wants to return home to her children.

Analysis: as the familys care provider she perceives herself as a healthy person Interpretation: the patient thinks of herself as a provider of care in the family so she always sees herself as healthy Problem Identification

Analysis: eager to see her family and return to her role as a mother to her children Interpretation: the patient is always thinking of herself as a healthy individual Problem Identification

G. Cognitive/Perceptual Pattern(Jean Piagets Theory)

Stage of Development STAGE FOUR: The Formal Operational Stage.

Definition
Person at this stage acquire the ability to think hypothetically and outside the box. Logical conclusions can be inferred from verbal information, and concrete, physical objects are no longer necessary

Clients Behavior The patient knows that she is needed by her children so shes trying to recover as soon as possible to unite with her children

Analysis
The patient can give appropriate solution to some problem she encounter in life

Interpretation
The patient is able to think deep into situations and provide actions that may benefit her family

H. Role and Relationship Pattern(Erik Erikson/Harry Stack Sullivans Theory)

Stage of Development
Intimacy vs. Isolation

Definition
This stage covers the period of early adulthood when people are exploring personal relationships. It was vital that people develop close, committed relationships with other people.

Clients Behavior
Patient is having a good relationship with her husband and other patient that she encounters.

Analysis
The patient fulfilled the intimacy with other people and specially her husband and family members

Interpretation
The patient is okay even if her husband is away. She spends most of her time talking with other patient and watching movies in laptop

I. Value and Belief Pattern

Before hospitalization Shes Roman Catholic and believes about God but cant go to church regularly because of working Analysis: The patient has faith in God Interpretation: She cant go to church regularly because shes working for her family Problem Identification

During/After hospitalization Shes always praying that she recovers from her condition and protect the baby inside her womb Analysis: Her faith becomes more stronger and more active due to her current condition Interpretation: The patient cannot go to church because of current conditions. Problem Identification

J. Sexuality Pattern(Sigmund Freuds Theory)

Stage of Development Genital Stage

Definition
The individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of a person's life.

Clients Behavior Patient is always accompanied by her husband and taking care of her and they are happy with each other

Analysis Patient is happy with her sexual life and her family.

Interpretation Patient is happy with her partner and they are supporting each other.

K. Coping/Stress Pattern

Before hospitalization
Shes much more irritable due to her current condition. To cope up with her stress, she rest and relax her mind by watching television.

During/After hospitalization
She experience boredom because of the environmental setting. She misses her siblings in house and copes by communicating with them and watching movies in laptop.

Analysis: She knows how to manage stress by resting and watching television Interpretation: she tries to rest whenever she feels tired and stressed or relax herself by watching Problem Identification

Analysis: She knows how to manage stress by diverting her attention Interpretation: she is trying to relieve her stress by diversion and rest and communicating to her siblings Problem Identification

XIII. PHYSICAL ASSESSMENT

A. General Appearance HEENT Anicteric sclerae, pink palpebrae conjunctivae, no nasoaural discharge. Neck: No lymphadenophaties CHEST / LUNGS Symmetrical chest expansion, clear breath sounds HEART Adynamic pericardium, distinct heart sounds ABDOMEN fabby, FH 25cm FHT 145 bpm RLQ INGUINAL / Essentially normal GENITAL RECTAL Essentially normal EXRTEMITIES Full and equal pulse B. Head to Toe Assessment

Area Assessed
Head and Face

Normal Findings
Skull is proportionate to body, no tenderness, hair evenly distributed. Face is symmetrical with symmetrical facial movement.

Actual Findings
Skull is proportionate to the body, no tenderness, hair evenly distributed

Analysis
Normal

Interpretation
Normal

Skin

Nails

Eyes

Nose

Mouth

Neck

uniform in color hair evenly distributed Pinkish nail bed and clean capillary refill 23seconds Client has straight normal eye condition. Pupil is black on color and equal in size, have thin eye brows Nasal septum is in the midline, mucosa is moist Symmetrical, tongue is in midline, lips pinkish and symmetrical Skin is uniform in color No masses and tenderness upon palpation, Uniform in color No deformities

Skin of patient uniform in color and intact Nail beds are pinkish. Capillary refill 23 seconds Pupil is black on color and equal in size

Uniform in color, Normal skin intact Normal Normal

Equal in size of pupil.

Normal

Nasal septum is in the midline, mucosa is moist Lips pinkish and moist, tongue is in midline

Aligned to face

Normal

Lips and mucosa are moist

Normal

Breast and Axilla Abdomen Upper Extremities

No palpable mass, skin is uniform in color No pain and tenderness, symmetrical Uniform in color Full and equal pulse

Normal

Normal

Symmetrical

Normal

Normal Normal Patients pulse are Normal normal

XIV. COURSE IN THE WARD A. Laboratory and Diagnostic Procedures

Hematology
CBC Hemoglobin Hematocrit RBC Count WBC Count Result 120 gms/L 0.35 gms/L 3.94 x10 9/L 10.30x109/L Normal 123-153 gms/L 0.34-0.45 gms/L 3.93 -5.22 x10 9/L 5.0-10.0x109/L Interpretation Decrease Normal Normal Increase

Differential Count Neutrophils bonds Segments Lymphocytes Eosinophils Monocytes Basophils Atypical Cells MCV MCH MCHS RDW Platelet Count

0.58 0.31 0.03 0.08 0.00 89.1 30.5 34 12.80 415

0.55-0.65 0.25-0.35 0.02-0.04 0.02-0.10 0.00-0.01 80-100 27-31 31-36 11.0-15.0 130-500

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Oral Glucose Tolerance Test

Oral Glucose Tolerance Test OGTT FBS OGTT 1hr OGTT 2hrs Result 85 208 148 Normal 70-105mg/dL 90-160 80-140 Interpretation Normal Increase Increase

Urinalysis
Urinalysis Color Transparency Reaction Yellow Cloudy Acidic Result Interpretation Normal Not normal Not normal

Chemical Exam
Chemical Test Albumin Sugar Findings Positive(+) Positive(+) Interpretation Positive Positive

Microscopic Exam
Microscopic Pus cell Epithelial Cells RBC Mucus threds Findings 2-3/HpL Many Interpretation -