PILAR COLLEGE OF ZAMBOANGA CITY, INC.

R.T. Lim Boulevard, Zamboanga City

Tertiary Education Department
Nursing Program

Client Assessment Using Gordon’s Functional Health Patterns

Student’s Name: Clarizze Anne S. Dela Cruz, Ivy L. Villalobos, Khryssthel Eunice
Mallari, Kimhwa Jawadil, Zedrik Conde Activity #: 2
Year & Section: BSN 2-D Date: 11/03/2021

Direction: Use this form by filling in the results of your assessment. Write down
the results clearly, concisely and legibly. Use black or blue permanent
ink. Any form of alteration will not be accepted. Observe correct
spelling. Use additional sheets as needed.

PART 1. Gordon’s Eleven Functional Health Patterns

1. Health Perception – Health Management Pattern

The patient has no vices since young such as drinking alcoholic beverages and
smoking, uses over the counter drugs such as paracetamol biogesic, loperamide,
mefenamic acid, and neozep. She also sleeps 8hrs a day and has a monthly check
up and does listen to the health care provider.

2. Nutritional – Metabolic Pattern

The patient eats her meal 3 times a day with snacks in between and can drink up to
1.5 liter of water or 4 to 8 glasses a day. The patient claimed that she is allergic to
seafood and has a good appetite. She also takes immune pro as her vitamins.

3. Elimination Pattern
The patient usually moves her bowel in the morning with brown and formed stool,
she usually voids 2-5 times a day and she defecate once a day.

4. Activity – Exercise Pattern

The patient stated that she does household chores at home such as cleaning her
room, kitchen and comfort room. She also does walk with their pets and loves to go
to the park to do some exercise activities like jogging.

5. Cognitive – Perceptual Pattern

The patient has no difficulty in hearing others and doesn’t have difficulty in seeing.
She is also oriented to people, time, place, responses to physically and stimuli
verbally. She can speak and understand Chavacano, Bisaya, Tagalog, and English.
She doesn’t have difficulty in learning and usually learns the best through visual
and audio aids. Her educational attaintment is a college graduate and can read and
write.
6. Sleep – Rest Pattern
The patient usually sleeps 4-5 hours and goes to sleep at 10pm and wakes up 3am.
She cannot fall asleep easily because of her anxiety and cannot sleep straight
hours. She does not use any medication to promote sleep.

7. Self – Perception – Self – Concept Pattern

The patient is able to express her feelings about herself and she feels good and
doesn’t feel like she lost hope. She manages to practice a healthy lifestyle.

8. Role – Relationship Pattern

The client plays an important role as the breadwinner of the family, she supports
her family financially and spends her after works hours with her family and has no
conflicts among them. She also enjoys her free time with her friends and spends
time with them.

9. Sexuality – Reproductive Pattern

The patient is married and a mother of 1 child. She has no history of Sexually
Transmitted Disease or any disease affecting her genitals.

10. Coping – Stress Tolerance Pattern

The patient has traumatic events experienced before. She copes up with stress by
going out with friends and doing household chores or by taking a nap or sleep. She
also copes up the problem by talking it with her family and find ways to resolve it
together.

11. Value – Belief Pattern

The patient is a roman catholic, and have a strong faith in God. She goes to the
church with her family to attend the mass every Sunday.
Based on the assessment data gathered, identify at least 3 actual health problems
and 1 potential health problem that the client has. State the problems as nursing
diagnosis following the NANDA format. List them in the order of priority.

ACTUAL

Problem 1: Anxiety related to inability to sleep.

Problem 2: Anxiety related to threat or change in health status

Problem 3: Impaired comfort related to headache

POTENTIAL

Problem: Sleep Disorders

Now answer the question with a maximum of 5 statements:

Question:
WHAT IS YOUR BASIS IN PRIORITIZING THE ACTUAL HEALTH PROBLEMS
OF YOUR CLIENT? (Use any nursing model or theory of your choice to
justify your answer):

Based on the 11 Gordons Functional Pattern, it shown that only her sleep rest
pattern is very unstable and untidy due to anxiety related to change in health
status. A lack of sleep may affect the client’s desire or ability to maintain a healthful
lifestyle. Getting enough sleep is essential for helping a person maintain optimal
health and well-being. When it comes to their health, sleep is a vital as regular
exercise.

Criteria for Rating the Student: (100%)

30% - the data collected from an actual client are adequate, significant, valid and accurate
20% - the information are reliable and sufficient to be used for the nursing care plan
20% - the problems are identified and prioritized using valid nursing theories and models as
justification or basis
20% - all areas (health patterns) are properly filled and answered without exchange or
duplication of entries
10% - all entries are written clearly, legibly & promptly submitted

FEEDBACK Section: (Please be objective in your comments. Use an extra sheet as

necessary.)

Comments/ Concerns from the Student:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
 Comments/ Concerns from the Instructor:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Checked by: ___________________________________

Name and Signature of Clinical Instructor

Shown to me: Clarizze Anne S. Dela Cruz , Ivy L. Villalobos, Khryssthel Eunice
Mallari, Kimhwa Jawadil, Zedrik Conde
Name and Signature of BSN Student

Problem 1
Anxiety related to inability to sleep

Assessment Nursing Planning Implementation Evaluation

Diagnosis
Subjective Cues: •Impaired After 2 hours of  Provide a After 2 hours of comprehensive
"Hindi ako makatulog parenting nursing intervention quiet and nursing Intervention the patient
Ng maayos kase related to the the client will be peaceful able to:
feeling ko andami pa inability to able to:  Engages more in social
environment
dapat gawin, dapat perform •Achieve at least 5- activities.
ayusin at dapat ko pa activities of 6 hours of sleep per during sleep
 Can express her
bantayan si baby" daily living to day period
feelings and
postpartum •Show signs of  Encourage
anxiety decrease yawning at insecurities.
the client to
Objective Cues: •Assist the daytime  Sleep 5-6 hours per
express
 Dark circles Client in •be able to concerns
day
under eyes planning for maintain a normal
 Yawning at her daily sleep pattern
activities, •able to lost in
daytime
such as her shoes and be able to
 Preoccupied nutrition use relaxation
and unable to program, techniques to
think properly exercise, and minimize anxiety
sleep.
Problem 2
Anxiety related to threat or change in health status
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: "I Anxiety After the nursing •Monitor vital •To identify After 8 hours of
don't know if I related to interventions, signs (e.g, rapid physical responses nursing
can work threat or the client's or irregular associated with interventions,
already after I change in anxiety will be pulse, rapid both medical and the patient
recover." As health status eliminated. breathing) emotional appeared
verbalized by Short term goal: •Use presence, conditions. relaxed and the
the patient. After 20-30 touch, •Being supportive level of anxiety
Objectives: The minutes of verbalization, or and approachable will reduced to a
patient looks nursing demeanour to encourages manageable
pale, fatigue, interventions, remind client. communication. level.
worried. the client will be •Encourage •Taking or
able to know expressions or otherwise
some techniques clarification of expressing feeling
on how to lessen needs, concerns, reduces anxiety.
the anxiety such unknowns and •To educate the
as deep questions. patient regarding
breathing •Assist the the disease to
exercise. patient in reduce anxiety.
developing
anxiety reducing
skills.
•Allow and
reinforce clients
personal
reaction towards
the threatens to
wellbeing.
•Explain
everything
necessary
regarding the
disease.

Problem 3
Impaired comfort related to headache
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Impaired After the nursing •Note for the •To determine After 8 hours of
"I am comfort related interventions, location, scale, the nursing care nursing
experiencing to headache the patient will intensity, and to be given to interventions,
headache." As identify personal onset of pain. the patient. the patient will
verbalized by triggers to avoid •Maintain a calm •To minimize be relieved of
the patient. having headache and quiet stimulus that pain and there is
Objective: attacks and environment. could aggravate no non-verbal
The patient successfully be •Use relaxation the condition of indicators of
looks fatigue, headache free. techniques such the patient. pain or
stress, pale, and as, deep •To promote discomfort
lethargic. breathing comfort and present.
exercise. relaxation.
•Offer back rubs •To help relieve
massage, slow of pain.
rhythmic
breathing,
repositioning
and other
diversional
activity such as,
listening to
music.
•Administer pain
medications as
ordered.

TOPIC: HEALTH TEACHING FOR ANXIETY

GENERAL OBJECTIVES: The purpose of this activity is to educate the client experiencing anxiety disorders
LEARNING LEARNING CONTENT TIME STRATEGY RESOURCES EVALUATION
OBJECTIVES ALLOTTED AND
METHOD
Define the frisch & frisch defines 5 minutes Discussion Laptop for Client will
terms anxiety anxiety as a state where in PowerPoint correctly define
and anxiety a person feels a strong presentation the terms
disorder sense of dread frequently anxiety, anxiety
accompanied by physical disorder using
symptoms of increased at least two key
heart respiratory and words from
blood pressure rates each term such
without having a specific as: a state
source or reason for the where in
emotions. a person feels a
strong sense of
Anxiety disorder: This is dread
the experience of severe accompanied
anxiety to the point where by physical
it interferes with personal symptoms with
ability to function in daily a reason for the
life frisch et al 2006. emotions;
severe anxiety
to the point
where it
interferes with
a personal
ability to
function in daily
life
State the four The four stages of anxiety 10 minutes Discussion Laptop for Client will
stages of according to frisch are: Question PowerPoint correctly state
anxiety 1. Mild: This is and answer presentation the four stages
where there is the of anxiety
tension of day to
day living.
Individual has an
alert perceptual
field; this can
motivate learning.
for example,
anxiety felt when
missing the bus.
2. Moderate: Focus
is on immediate
concerns;
perceptual field is
narrowed;
individuals exhibit
selective
inattention. For
example, anxiety
felt when taking
an exam.
3. Severe: Focus is
on the specific
detail; perceptual
field is greatly
reduced. example
anxiety felt when
witnessing a car
accident.
4. Panic: A sense of
awe, dread
and/or intense
terror; individual
loses self-control;
there is a
disorganization of
the personality.
example anxiety
felt when
experiencing an
earthquake and
being unable to
cope
Describe the Frisch et al (2006) posits 15 minutes Discussion Laptop for Client was able
six major the major subtypes of Question PowerPoint to describe the
subtypes of anxiety disorders as the and answer presentation six major
anxiety following: subtypes of
disorders Generalized anxiety Pen and paper anxiety
disorder: disorders
 Anxiety is focused on a
variety of events
or activities evidenced by
restlessness fatigue
difficulty in concentrating,
sleep disturbance and so
on.

Panic disorder:
 Discrete episodes of
intense anxiety that begin
abruptly and reach a peak
within 10 minutes,
evidenced by palpitations,
sweating, trembling, chest
pain, fear of losing control,
fear of dying.

Agoraphobia:
 Acute anxiety in crowds;
fear of being alone; fear in
any physical activity where
the individual may have
trouble escaping,
evidenced by an intense
feeling of anxiety of losing
control that results in
either refraining from
going out or avoiding
situations that may bring
about anxiety.
Phobia:
 Persistent, excessive or
unreasonable fear of a
specific object or situation.
For example, elevators;
airplanes; dogs; spiders
and so on; evidenced by
fear that interferes with
life’s activities.

Obsessive compulsive
disorder:
 Occurrence of recurrent
thoughts, images and or
impulses that are intrusive
are inappropriate and
leads to anxiety; for
example, an individual
who keeps on washing his
hands over and over
although are clean, he
wishes to stop, but there is
unable to stop the
repetitive behavior.

Post-traumatic stress
disorder:
 6ccurs after a significant
life-threatening event,
there is the experience of
anxiety symptoms in which
the event is reexperienced
through recollections.

PILAR COLLEGE OF ZAMBOANGA CITY, INC.

R.T. Lim Boulevard, Zamboanga City
Tertiary Education Department
Nursing Program

Client Physical Assessment Form

Student’s Name: Clarizze Anne S. Dela Cruz, Ivy L. Villalobos, Khryssthel Eunice
Mallari, Kimhwa Jawadil, Zedrik Conde Rating: __________
Year & Section: BSN 2-D Date: 11/03/2021

Direction: Use this form by filling in the results of your assessment. Write down
the results clearly, concisely and legibly. Use black or blue permanent
ink. Any form of alteration will not be accepted. Observe correct
spelling. Use additional sheets as needed.

PART 1: General Appearance: (Describe the client’s general

appearance and response in a narrative form)
Physically the client’s nutritional status and body-built stature is appropriate with
her age. The client’s vital signs are normal with a temperature of 36.7, pulse rate of
85 beats per minute, respiration rate of 20 breaths per minute and blood pressure
of 120/90. The client physically neat and clean, has a good facial expression
without grimacing. The client is relaxed has an erect posture and coordinated by
body movements, can freely move, flex and extend her extremities, doesn’t use
any assistive device and can voluntarily move. The client showed no sign of
deformities and abnormalities.

PART 2. Cephalo – Caudal Assessment

1. Head
a. Hair, cranial bones/skull, fontanels, sutures, others
The patient has symmetric facial movements, hair is black evenly distributed and
is very thin covers the whole scalp. The skull is generally round with
prominences in the frontal and occipital. The scalp is lighter in color than the
complexion.

b. Eyes
The patient eyes are symmetrically aligned and has an equal movement. The
cornea is transparent, shiny and smooth details of iris is visible. The iris is black
flat and round. The visual acuity is normal.

c. Nose
The patient nose has a follicle hair and it is in the middle, has no discharge, both
nares are patent and also no tenderness on sinuses.

d. Ears
The external ear canal has presence of hair follicles, no pus or blood, external
ear canal is dry voice tone is audible to the patient, sound is heard on both ears.
Localized at the center of the head.
e. Mouth and Throat
The teeth are white to yellowish in color, gums are pink, firm, moist and has no
retraction of bleeding of gums. Uvula is positioned in the middle the tonsils are
pink in color and have no discharges.

f. Sinuses:
NOT ASSESSED

g. Other Observations:
NONE

2. Neck
a. Trachea
The thyroid gland is not visible in inspection, no masses palpated, glands ascend
during swallowing. The trachea is on the central placement in the middle of the
neck and spaces are both equal on both sides.

b. Thyroid glands
Smooth, symmetrical and non-tender. Smooth and it slides upward slightly when
swallowing.

c. Great vessels
NOT ASSESSED

d. Other Observations (lymph nodes):

NONE

3. Anterior Thorax
a. Clavicle, Ribs and Intercostal spaces
The clavicle has sigmoid shape long bone with a convex surface along its medial
end when observed from cephalad position. The client has 12 ribs on each side of
the body making a total of 24 ribs.

b. Heart
The client heart has no abnormal sounds and is heard like murmur. Heart has no
palpable pulsation over the aortic. No abnormal heaves and thrills felt over the
apex.

c. Breast
The client breast has a hard tender and red spot on the right outer area. Painful
to touch in the right part of the breast, pain score is 9/10 and including fullness
of the breast.
 d. Other Observations (lymph nodes): NONE

Posterior Thorax
a. Scapula
The scapula is symmetric and non-protruding. Shoulders and scapulae are equal
horizontal positions. The ratio on anteroposterior diameter is 1:2.

b. Spine
The client spine is in normal alignment with no tenderness on palpation. The
range of movement of the cervical, thoracic and lumbar spine was normal.

c. Lungs
The lungs sounds are clear. Bowel sounds are present at all 4 quadrants.

d. Flanks
The client flanks are soft and has a quality of sound elicited by percussion.

e. Other Observations:
NONE

4. Abdomen
a. Internal Organs:
NOT ASSESSED

b. Bowel sounds:
Normal bowel sounds are present, an occasional borborygmus can be heard.

c. Other Observation:
The client abdomen has no lesions, have scar, flat, rounded no tenderness noted
with smooth and consistent tension and has no muscle guarding. The skin color
is uniform.
5. Upper Extremities
a. Power
The upper arm, forearm and hand can function normally and is able to maintain
its position and has a normal power.

b. Resistance
The client cannot carry a weight in each hand.

c. Other Observations:
NONE

6. Lower Extremities
a. Power:
Hip, knee, ankle joints and bones in the thigh can function normally. Active
movement and has a normal power.

b. Resistance:
The client can move the joint it crosses through a full range of motion against
moderate resistance.

c. Balance:
The patient can balance herself and can stand in one leg.

d. Other Observations (lymph nodes)

NONE

7. Perineal and Rectal Areas (as necessary)

a. Anterior (Reproductive Organs)
NOT ASSESSED
b. Posterior:
NOT ASSESSED

8. Special Areas (attach extra sheets as necessary)

a. Neurologic Assessment (cranial nerve functions, reflexes, consciousness level,
psychomotor and balance)
NOT ASSESSED

b. Additional Information: (focusing on the current case)

NOT ASSESSED

Based on the assessment data gathered, identify at least 3 actual health problems
and 1 potential health problem that the client has. State the problems as nursing
diagnosis following the NANDA format. List them in the order of priority.

ACTUAL

Problem 1: Acute pain related to inflammation of breast tissues as evidence by

patient reporting pain in the right breast.

Problem 2: Risk for ineffective breastfeeding related to pain and inflammation

secondary to mastitis

Problem 3: Acute pain related to breast inflammation as evidence by pain score 9

out of 10, guarding sign on the affected breast and irritability.

POTENTIAL

Problem: Granulomatous Mastitis

Now answer the question with a maximum of 5 statements:
WHAT IS YOUR BASIS IN PRIORITIZING THE ACTUAL HEALTH PROBLEMS
OF YOUR CLIENT? (Use any nursing model or theory of your choice to
justify your answer):

The patient verbalizes that her baby is having difficulty at times latching on and
sometimes does not empty the breast completely. She even stated that within the
pass day she has started to develop a red, painful area on her right breast and its
making it very difficulty for her to breastfeed. The patient also denies having flu-
like symptoms at this point.

Criteria for Rating the Student: (100%)

30% - the data collected from an actual client are adequate, significant, valid and accurate
20% - the information are reliable and sufficient to be used for the nursing care plan
20% - the problems are identified and prioritized using valid nursing theories and models as
justification or basis
20% - all areas (health patterns) are properly filled and answered without exchange or
duplication of entries
10% - all entries are written clearly, legibly & promptly submitted

FEEDBACK Section: (Please be objective in your comments. Use an extra sheet as

necessary.)

Comments/ Concerns from the Student:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______

Comments/ Concerns from the Instructor:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______

Checked by: ______________________________________

Name and Signature of Clinical Instructor

Shown to me: __________________________________

Name and Signature of BSN Student