GORDON’S

FUNCTIONA NURSING HISTORY PHYSICAL

LAB NURSING
EXAMINATION
L HEALTH SUBJECTIVE RESULTS DIAGNOSIS
OBJECTIVE

PATTERN
(+) sudden weight changes;

Health Quite puzzled as to how she Cardiac rate: 50 Decreased cardiac

Perception and got cancer and complications beats per minute (on output related to

Health such as heart block; pacemaker) decreased cardiac

Management Does not usually do breast RR: 27 rate and rhythm

self-examination; cycles/minute

Not compliant with

prescribed treatment;

Delays consultation until

condition is not tolerable

anymore
Single meal consists of 1-2 Slight pallor Hgb = 102 Activity

Nutrition and cups of rice, 1 cup of viand Skin slightly dry (low) intolerance related

Metabolism (vegetables, chicken and Capillary refill time Hct = 0.302 to imbalance

seafood); of 5 seconds (low) between oxygen

Prefers to consume tea, Slightly pale Glucose = 7.46 supply and

coffee and carbonated palpebral and bulbar (high) demand as

beverages; conjunctiva Sodium = 134, evidenced by

Weight loss from 75 to 49 Slight pallor in lips 130, 130 (Low) cardiorespiratory

and mucus distress

GORDON’S

FUNCTIONA NURSING HISTORY PHYSICAL

LAB NURSING
EXAMINATION
L HEALTH SUBJECTIVE RESULTS DIAGNOSIS
OBJECTIVE

PATTERN
membranes

Impaired gas

exchange related

to altered oxygen-

carrying capacity

of the blood
Elimination BUN = 2.30

Pattern (Low)
(+) easy fatigablity; (+) Acute Ineffective

Activity- Energy level was observed to Cardiorespiratory metabolic breathing pattern

Exercise be not the same as before; (-) distress alkalosis with related to

Pattern exercise; (+) episodes of Comfortable in full respiratory decreased lung

shortness of breath sitting up rather than compensation expansion

lying down Chets UTZ: (+) secondary to

Assymetrical chest pleural presence of

expansion effusion ® pleural effusion

Decrease breath lung

sounds at right base

(+) subcostal and

intercostal

retractions
 GORDON’S

FUNCTIONA NURSING HISTORY PHYSICAL

LAB NURSING
EXAMINATION
L HEALTH SUBJECTIVE RESULTS DIAGNOSIS
OBJECTIVE

PATTERN
Decreased vocal Risk for infection

fremitus at right base related to a

Grade 3/6 murmur disruption in skin

(+) with pacemaker integrity

inserted in the right secondary to

subclavian vein with pacemaker

intact dressing insertion

(+) difficulty of breathing Sleep Pattern

Sleep-rest when lying down Disturbance

Pattern (+) difficulty sleeping related to

(+) reduction of sleep and rest abnormal

period to 4-5 hours physiologic status

Verbalized that she is worried as evidenced by

and bothered with her health difficulty of

condition breathing
(+) tendency to forget things

Cognitive- which are not familiar to her

Perceptual

Pattern
Fear of complications make (-) right breast due

Self-Perception her more anxious and to MRM

 GORDON’S

FUNCTIONA NURSING HISTORY PHYSICAL

LAB NURSING
EXAMINATION
L HEALTH SUBJECTIVE RESULTS DIAGNOSIS
OBJECTIVE

PATTERN
and Self- stressed. (+) surgical scar

Concept Pattern chest area

Role- Maintained constant

Relationship communication with family

Pattern members
Menopause at the age of 45

Sexuality-

Reproductive

Pattern
Does not resort to drinking

Coping- Stress and smoking in times of

Tolerance problems

Pattern
Active member of the church

Value Belief where she belongs to

Pattern