A.

NURSING HISTORY AND GORDON’S

FUNCTIONAL HEALTH PATTERN
A. NURSING HISTORY

CLIENT INITIALS: MR. M DATE ADMITTED: SEPT. 30, 2010

AGE: 36 SEX: M NATIONALITY: FILIPINO RELIGION:

CATHOLIC

ADMISSION COMPLAINT/S: ABDOMINAL CRAMPING

ADMISSION DIAGNOSIS: GI ACIDITY

HISTORY OF PRESENT ILLNESS: ON AND OFF ABDOMINAL PAIN LEADING TO

PERSISTENT PAIN

PAST MEDICAL HISTORY: CURRENT HOSPITALIZATION WAS LAST FEBUARY 21st UPTO
MARCH 1st OF 2010 DUE TO NOSE BLEEDING AND ON AND OFF HIGH FEVER W/C IS
DIAGNOSED AS DENGUE.

:CHILHOOD ILNESSESS OF THE PATIENT WAS CHICKEN

POX, MUMPS, AND FEVER.

FAMILY HISTORY: NO MEDICAL PROBLEM ON BOTH FATHER SIDE AND MOTHER SIDE
OF THE PATIENT.

SOCIAL HISTORY: THE PATIENT DRINKS OCCASIONALLY, A HEAVY SMOKER WHICH

RANGES FROM 10 TO 15 STICKS OF CIGAR PER DAY. HE WAS A JEEPNEY DRIVER
WHICH IS HE IS EXPOSED TO POLLUTION. AND FOR THE LIFESTYLE OF THE PATIENT
THERE IS NO CERTAIN ACTIVITY OR EXERCISE BEING DONE BY THE PATIENT AND AT
THE SAME TIME THERE IS NO FOOD RESTRICTIONS WHEN IT COMES TO PATIENT’S
DIET.

B. GORDON’S FUNCTIONAL HEALTH PATTERN

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

1.1 CLIENT’S DESCRIPTION OF HER/HIS HEALTH:

BEFORE ADMISSION:

- EXPERIENCED ABDOMINAL PAIN WHICH IS ON AND OFF THEN SUDDENLY

TURNED INTO A PERSISTENT PAIN.

AT PRESENT:

- STILL ILL.
1.2 HEALTH MANAGEMENT

SELF:

- HE DO MANAGES HIS HEALTH BY SIMPLY TAKING UP SUPPLEMENTARY VITAMINS

AND EATING NUTRIOUS FOODS.

FAMILY:

-SAME THING AS HOW HE MANAGES HIS HEALTH.

1.3 HISTORY OF PRESENT ILLNESS

- GI ACIDITY

1.4 PAST ILLNESS

-DENGUE

1.5 HISTORY OF HOSPITALIZATION

WHEN: 2010 WHY: DENGUE

WHERE: PANGASINAN HOSPITAL

1.6 HISTORY OF ILLNESS IN THE FAMILY:

-NONE

1.7 EXPECTATION OF HOSPITALIZATION

-TO HEAL, TO BE CURED & TO GET WELL.

2. NUTRITION & METABOLIC PATTERN

2.1 USUAL FOOD INTAKE (BEFORE ADMISSION)

BREAKFAST: MORE ON FRIED FOODS (HOTDOGS, EGG, CORN BEEF), JUICES, AND
VEGGIES

LUNCH: KANIN, AVAILABLE VIAND (VEGGIES, MEAT), WATER

SNACKS: LIGHT SNACKS (MIRIENDA), SOFT DRINKS

SUPPER: KANIN, AVAILABLE VIAND (VEGGIES, MEAT), WATER

PREFERENCES: MATAMIS AND OTHER TYPES OF FOODS BECAUSE HE DON’T HAVE
ANY FOOD RESTRICTION
2.2 USUAL FLUID INTAKE

TYPE: JUICES, WATER, SOFT DRINKS

PREFERENCES: WATER

AMOUNT: 8-10 GLASS

2.3 ANY FOOD RESTRICTION? NONE

2.4 ANY PROBLEMS WITH ABILITY TO EAT? NONE

2.5 ANY SUPPLEMENTS? – SUPPLEMENTARY VITAMINS

3. ELIMINATION PATTERN

3.1 BLADDER

USUAL FREQUENCY/DAY: 3-4X

COMPLAINS THE USUAL PATTERN OF URINATION: NONE

HOME REMEDIES: NONE

3.2 BOWEL:

USUAL PATTERN/DAY

TIME: MORNING AND SOMEIMES IN THE AFTERNOON

FREQUENCY: 2X

COLOR: BROWNISH

CONSISTENCY: INTACT

3.3 ANY ASSERTIVE ADVICE?

-NONE

3.4 SKIN CONDITION- DRY

4. ACTIVITY EXERCISE PATTERN

4.1 USUAL DAILY/ WEEKLY ACTIVITIES

EXERCISE LEISURE

-NONE -NONE

4.2 ANY LIMITATIONS OF PHYSICAL ABILITY?

-NONE

4.3 HISTORY OF DYSPNEA OR FATIGUE

-NONE

5. SLEEP-REST PATTERN

5.1 USUAL SLEEPP PATTERN

BEDTIME: PERMANENT

HOURS SLEPT: 8-10 HRS

NO. OF PILLOWS: 2 PCS.

SLEEP ROOUTINE: NONE

5.2 ANY PROBLEMS REGARDING SLEEP? RECENTLY THE CLIENT WAS EXPERINCING
DISTURBANCE IN SLEEP DUE TO IRRITATION LIKE ENVIRONMENT (EXTREME HEAT),
AND OFTEN COUCHING

6. COGNITIVE-PERCEPTUAL PATTERN

6.1 ANY DEFICITS IN SENSORY PERCEPTION?

HEARING: NONE

SIGHT: NONE

TOUCH: NONE

6.2 ABILITY TO READ & WRITE ANY DIFFICULTY IN LEARNING

-THE PATIENT IS LITERATE

6.3 ANY COMPLAINTS (e.g PAIN) – SLIGHTLY (ON AND OFF) ABDOMINAL PAIN

7. SELF PERCEPTION PATTERN

7.1 WHAT THE CLIENT IS MOST CONCERNED ABOUT

-TO GET WELL

7.2 PRESENT HEALTH GOALS

-TO GET WELL

7.3 EFFECT OF PRESENT ILLNESS TO SELF

-SUDDEN WEIGHT LOSS AND FEELING OF WEAKNESS

HOW DOES THE CLIENT SEE/FEEL ABOUT SELF?

-ILL

8. ROLE-RELATIONSHIP PATTERN

8.1 LANGUAGE SPOKEN: -KAPAMPANGAN

8.2 MANNER OF SPEAKING: CALM

8.3 SIGNIFICANT PERSON TO CLIENT: FAMILY AND HIS GIRLFRIEND

8.4 COMPLAINTS REGARDING FAMILY: NONE

8.5 LIVING WITH(MEMBERS OF FAMILY): YES (YOUNGER BROTHER)

9. SEXUALITY-SEXUAL FUNCTION

9.1 ANTICIPATED CHANGE IN SEXUAL RELATIONS BECAUSE OF ILLNESS:

-NONE

9.2 KNOWLEDGE OF SEXUAL FUNCTIONING

-KNOWLEDGEABLE

10. COPPING-STRESS MANAGEMENT PATTERN

10.1 DECISION IN MAKING ABILITY: -OWN

10.2 ANY SIGNIFICANT STRESS IN THE PAST YEAR: -NONE

10.3 MANAGEMENT OF STRESS: - SLEEP OR REST

II VALUE OF BELIEF SYSTEM

1. SOURCE OF STRENGH OR MEANING : - FAMILY AND GOD

2. IMPORTANCE OF GOD TO CLIENT: - VERY IMPORTANT