VIII.

G ORDON ’S 11 FUNCTIONAL HEALTH PATTERN

A. Health Perception

Mr. YK don’t do regular workout, however, he is active in basketball sports. He doesn’t have a strict diet but
he always prefer vegetables over processed foods. He consumes a great amount of sugar and he drinks caffeine often
times. Mr. YK maintains good hygiene; thus, use the shower 2 times a day. He wants it clean and neat, and he likes the
smell of fragrance. These are all important for him because it provides relaxation and eases his stress and discomfort.
Mr. YK believes that a clean environment is the key for having a good health.

B. Nutritional-Metabolic

Mr. YK has a great appetite for sweets but he always make sure that he consumes a balance amount of nutrients, too.
He is not a picky eater according to him, and he eats whatever that is served on the table.

MEAL

MEAL July 26, 2021 JULY 27, 2021 JULY 28, 2021
Breakfast 1px Pancit canton 1bowl sopas N/A
3pcs Pandesal 1glass coffee
1glass coffee
AM Snacks N/A N/A N/A

Lunch 2 cups rice 2 cups rice 1 cup rice

591ml Water 443 ml water 443 ml water

Sinigang na Hipon Tinola Sinigang na Bangus

PM Snacks N/A 1px Pancit canton N/A

1glass coffee

Dinner 3 cups rice 1 cup rice 1 ½ cup rice

296ml water 591ml water 591ml water

Adobong Manok 1 Canned tuna Sinigang na Bangus

Total Caloric Intake

Date BREAKFAST LUNCH DINNER

JULY 26, 2021 660 calories 356 calories 778 calories
JULY 27, 2021 384 calories 396 calories 294 calories
JULY 28, 2021 N/A 359 calories 654 calories
Total k/cal 1,044 k/cal per day 1,111 k/cal per day 1,726 k/cal per day
Total Fluid Intake 354ml 1,477ml 1,478ml

Interpretation

Mr. YK is a 21 year-old, weighing 52kg, and 164 cm tall. He is categorized sedentary with little or no
exercise. The number of calories required to maintain his weight is 1,734k/cal per day. Upon observation of
Mr. YK’s diet in 3 consecutive days. Mr. YK has consumed a total 1,794 k/cal in July 26, 2021, total of 1,074
kcal in July 27, 2021, and total of 1,013 k/cal in July 28, 2021. In correlation with required k/cal a day for Mr.
YK, his total calories intake is not met. In conclusion, Mr. YK’ chart shows that he has a poor diet.

C. Elimination
 Mr. YK has not complained any problem with defecation and urination. He claimed that the stool
appears brown, soft, and well-formed in consistency. Mr. YK urinates in total of 5 to 8 times per day. In
conclusion, everything is normal with regards to M. YK’s elimination.

I. Activity Exercise

Mr. YK is a basketball player and once played as a varsity before pandemic happen. Although he is active in sports,
he does not do any regular workout. However, since the beginning of the pandemic and together with some of his
cousins, they do joggings in the morning and sometimes, Mr. YK do some push-ups, too.

TIME 07/19/2021 07/20/2021 07/21/2021 07/22/2021 07/23/2021 07/24/2021

1 AM
2 AM
3 AM
4 AM
5 AM
6 AM
7 AM
8 AM
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
11 PM
12 MN

Legends:

SLEEP
WAKE UP TIME PREPARING
BREAKFAST
DRESSING UP/PREP
ONLINE SCHOOL
BREAKFAST
LEISURE TIME
LUNCH
DINNER
ONLINE HOMEWORK
BASKETBALL
 Interpretation:

Mr. YK wakes up in the morning at 6am and prepares and eats his breakfast at 7 to 8am. In some days
like Tuesday and Thursday, he plays basketball as his exercise, but this only happens seldom due to
pandemic. During 8 to 9 am is when Mr. YK prepares for his day. He takes a shower and dress himself for
the day. In days like Friday, he has online school in which he attends from 7 until 4pm in the afternoon.
During the days where he has no classes is when he accomplish all his academic requirements, this
happens mostly during 10 to 11 am and 9 to 10 pm. Mr. YK takes his lunch from 11 to 12noon and eats his
dinners during 7 to 8 pm. Mr. YK also has a time to enjoy for himself. He takes leisure from 2pm until 6 pm.
He spent this mostly streaming and playing mobile legends. He prepares for bed mostly during 11pm.

I. Sleep and Rest

Mr. YK gets a good; if not great, amount of sleep because of the pandemic and on-going online classes gives him
enough time to rest and sleep. He claimed that he hasn’t experience any trouble sleeping. Although he confessed that in
some mornings he wakes up tired, but that is all. Upon thorough inspection of Mr. YK’s skin appearance, he’s not pale
and with normal pinkish skin color and no signs of wakefulness.

II. Cognitive-Perceptual Pattern

Mr. YK appears to be alert and oriented. He is able to think clearly and stays logically with his words. He
has not shown any signs of memory problem, in fact, he claimed that his decisions were all rationale. Mr. YK also
showed good understanding skills. However, it is obvious that he has minor problem with concentration in which
he tells me that he is trying to address and fix the issue.

III. Self- Perception

Mr. YK mentioned that he notices his improvements with his academics. This makes him feel good about
himself. Although there are few complications with study, he remained positive and confident with his skill and
knowledge. Mr. YK is self-conscious and likes to keep himself clean at all times, he believes that this contributes
positively with his self-confidence. Upon observation, Mr. YK appears to be happy and contented with his life. There
are no signs of sorrows or depression.

IV. Roles-Relationships

Mr. YK lives with his extended family. He stays under the same roof with his unties and his cousins. As a
part of their family, Mr. YK contributes with expenses and doing household chores. He has shown great
accountability in taking up his responsibilities in their family. Mr. YK also has a girlfriend, as a boyfriend he makes
sure that his girlfriend is fed with love and attention. This is his way of keeping their relationship strong and striving.

V. Coping-Stress Tolerance

The client admits that he is not good at keeping his temper in control. He is sometimes impulsive and irritates
quickly. However, Mr. YK said that he always stays polite and avoid hurting other people’s feelings. When MR. YK
is sad he turned to his friends or his girlfriend. This way he releases some stress and reducing the weight of his
feelings and emotions. He mentioned, too, that he always practice thinking of happy thought whenever he is stress
and irritated.
 IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs

VITAL SIGNS July 26, 2021 July 27, 2021

Blood Pressure 110/80 100/90
Temperature 36.5 C 36.7 C
Pulse Rate 90 86
Respiratory Rate 15 15
Pain Scale 0 0
ANTHROPOMETRIC MEASUREMENTS
Height 5’4”
Weight 52 kg
BMI 19.3kg/m2: NORMAL BMI

X. FOCUSSED ASSESMENT

ASSESMENT FINDINGS
INTEGUMENTARY
SKIN The client’s skin is uniform in color,
unblemished and no presence of any foul
odor. He has a good skin turgor and skin’s
temperature is within normal limit.

HAIR The hair of the client is thick, silky hair is

evenly distributed and has a variable
amount of body hair. There are also no
signs of infection and infestation observed.

NAILS The client has a light brown nails and has

the shape of convex curve. It is smooth
and is intact with the epidermis. When
nails pressed between the fingers (Blanch
Test), the nails return to usual color in less
than 2 seconds.

HEAD
HEAD The head of the client is rounded;
normocephalic and symmetrical.
SKULL There are no nodules or masses and
depressions when palpated.
FACE The face of the client appeared smooth
and has uniform consistency and with no
presence of nodules or masses.
EYES AND VISION
Eyebrows Hair is evenly distributed. The client’s
eyebrows are symmetrically aligned and
showed equal movement when asked to
raise and lower eyebrows.
Eyelashes Eyelashes appeared to be equally
distributed and curled slightly outward.
Eyelids There were no presence of discharges, no
discoloration and lids close symmetrically
with involuntary blinks approximately 15-20
times per minute.
Eyes  The Bulbar conjunctiva
appeared transparent with few
capillaries evident.
 The sclera appeared white.
 The palpebral conjunctiva
appeared shiny, smooth and pink.
 There is no edema or tearing of
the lacrimal gland.
 Cornea is transparent, smooth
and shiny and the details of the iris
are visible. The client blinks when
the cornea was touched.
 The pupils of the eyes are black
and equal in size. The iris is flat
and round. PERRLA (pupils equally
round respond to light
accommodation), illuminated and
non-illuminated pupils constricts.
Pupils constrict when looking at
near object and dilate at far object.
Pupils converge when object is
moved towards the nose.
 When assessing the peripheral
visual field, the client can see
objects in the periphery when
looking straight ahead.
 When testing for the Extra
ocular Muscle, both eyes of the
client coordinately moved in unison
with parallel alignment.
 The client was able to read the
newsprint held at a distance of 14
inches.

EARS AND HEARING

EARS The Auricles are symmetrical and has the
same color with his facial skin. The
auricles are aligned with the outer canthus
of eye. When palpating for the texture, the
auricles are mobile, firm and not tender.
The pinna recoils when folded. During the
assessment of Watch tick test, the client
was able to hear ticking in both ears.
 NOSE AND SINUS
NOSE The nose appeared symmetric, straight
and uniform in color. There was no
presence of discharge or flaring. When
lightly palpated, there were no tenderness
and lesions
MOUTH  The lips of the client are
uniformly pink; moist, symmetric
and have a smooth texture. The
client was able to purse his lips
when asked to whistle.
 The buccal mucosa of the client
appeared as uniformly pink; moist,
soft, glistening and with elastic
texture.
 The tongue of the client is
centrally positioned. It is pink in
color, moist and slightly rough.
There is a presence of thin whitish
coating.
 The smooth palates are light
pink and smooth while the hard
palate has a more irregular texture.
 The uvula of the client is
positioned in the midline of the soft
palate.

TEETH AND GUMS There are no discoloration of the

enamels, no retraction of gums, pinkish
in color of gums

NECK  The neck muscles are equal in

size. The client showed
coordinated, smooth head
movement with no discomfort.
 The lymph nodes of the client
are not palpable.
 The trachea is placed in the
midline of the neck.
 The thyroid gland is not visible
on inspection and the glands
ascend during swallowing but are
not visible.

LUNGS AND THORAX

LUNGS/CHEST  The chest wall is intact with no
tenderness and masses. There’s a full
and symmetric expansion and the
thumbs separate 2-3 cm during deep
inspiration when assessing for the
respiratory excursion. The client
manifested quiet, rhythmic and
effortless respirations.
  The spine is vertically aligned. The
right and left shoulders and hips are of
the same height.

HEART There were no visible pulsations on

the aortic and pulmonic areas. There
is no presence of heaves or lifts.

ABDOMEN
ABDOMEN  The abdomen of the client has an
unblemished skin and is uniform in
color. The abdomen has a symmetric
contour. There were no movements
seen during inspection.

 Observation: scaphoid Θ scars, striae

 Auscultation: nl bowel sounds, Θ bruits
 Palpation:
 Superficial-Θ tenderness, masses,
guarding
 Deep- Θ tenderness, masses
 Liver: Palpation- liver edge not palpable

 Spleen:
 Palpation- non palpable

 Kidneys:
 Left- non palpable
 Right- non palpable

EXTREMITIES
EXTREMETIES The extremities are symmetrical in size
and length.

MUSCLE The muscles are not palpable with the

absence of tremors. They are normally firm
and showed smooth, coordinated
movements.

BONE There were no presence of bone

deformities, tenderness and swelling.

JOINTS There were no swelling, tenderness and

joints move smoothly.

NEUROLOGICAL
MENTAL STATUS The patient is alert and oriented to person,
place, time, and event with normal
speech. Memory is normal and thought
process is intact.
CRANIAL NERVES  (II, III, IV, VI) Visual acuity 20/20
bilaterally.
 Visual fields normal in all quadrants.
Pupils are round, reactive to light and
 accommodation.
 Extra ocular movements are intact without
ptosis.
 (V) Facial sensation is intact to bilaterally
to dull, sharp and light touch stimuli.
 (VII) Facial muscle strength is normal and
equal bilaterally.
 (VIII) Hearing is normal bilaterally.
 (IX, X) Palate and uvula elevate
symmetrically, with intact gag reflex.
Voice is normal.
 (XI) Shoulder shrug strong, and equal
bilaterally.
 (XII) Tongue protrudes midline and moves
symmetrically. 
REFLEXES: Biceps, brachioradialis, triceps, patellar,
and Achilles are 2/4 bilaterally. No clonus.
Plantar reflex is downward bilaterally.

SENSATION Sensation is intact bilaterally to pain and

light touch. Two-point discrimination is
intact. 

MOTOR Good muscle tone. Strength is 5/5

bilaterally at the deltoid, biceps, triceps,
quadriceps, and hamstrings. 

CEREBELLAR: Finger-to-nose and heel-to-shin test

normal bilaterally. Balances with eyes
closed (Romberg). Rapid alternating
movements normal. Gait is steady with a
normal base. Coordination is intact as
measured by heel walk and toe walk.