D.S.E.

B
Patient’s Initials

Submitted by:
Josiah David P. Maraat
Kyrah Mae Nerez

Submitted to:
Asst. Prof. Zorrina Luague

Date:
10/24/2022
 ASSESSMENT OF MARJORY GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Student’s Name: Josiah David P. Maraat, Kyra Mae Nerez Level: III - A2

Biographical Information

● Patient’s Name : Delos Santos, Edilberto Bandiala

● Age : 55 Years Old Gender: Male Insurance: PhilHealth
● Marital Status : Married Birthdate: Dec. 16, 1966
● Address : Dampalad, Dapitan City Occupation: Farmer

● Race : Filipino Religion: Filipiniana

● Educational Level : Primary Language Spoken: Bisaya

● Date of Admission : October 17, 2022 at 8:18 AM Ward/ Bed: NEM 3

● Mode of Admission : Elective Medical Dx. On Admission: Sacral Decubitus Ulcer Stage 4

Reason for Seeking Care: CC: Bed Sores, sacral area

History of Present Illness: 8 weeks PTa, patient had incomplete Spinal Cord Compression sec to Burst Fracture, S/P posterior decompression T12, instrumental spinal
fusion T10 - L2 (8/18/22). G weeks PTA, onset of blisters on sacral region 5 weeks PTA, follow up check up at SUMC, advised Flammazine on
blisters BIDA BIO on blisters. 4 weeks PTA, blisters progressed to ulceration ~2 cm deep. Worsening of symptoms prompted consult &
subsequent admission at a local hospital in Dapitan. Transferred with 7 units PRBC, confined for 3 weeks. In the interim, symptoms now with
urinary & bowel incontinence & numbness on R leg. On the day of admission, worsening of symptoms prompted consul in this institution &
subsequently admitted.

General Impression: Pt lying in bed, on his side. Pt is non-ambulatory and is with the company of his wife and niece who take care of the pt while admitted. Pt
responded well and clearly to all questions
 Nursing Diagnosis

● Priority
○ Electrolyte imbalance related to excessive loss of potassium
○ Impaired Skin Integrity related to immobility as evidenced by stage 4 sacral ulcer
○ Risk for infection due to presence of stage 4 sacral ulcer
● Other
○ Disturbed sleep pattern
○ Self care deficit
○ Altered comfort
○ Impaired physical mobility
 USUAL FUNCTIONAL PATTERNS INITIAL APPRAISAL ONGOING APPRAISAL
10/ /2022 10/ /2022
1. Health-perception – Health –management pattern

● No food or drug allergies

● No comorbidities, no maintenance medication
● Doesn’t use any herbal/traditional remedies
● No COVID vaccines given. Stated “mahadlok man
gud kog dagom.”
● verbalized “naa man ko gina tumar nga vitamins
man siguro to pero di ko ka hinumdom sa ngalan”
● does not smoke or do drugs, occasionally drinks
when invited
● stated “na ingani ko kay wa ko ga pangingkamot
maayo mao na aksidente ko.”
● Niece verbalized “ nagka sugod na siyag ka ulcer
sukad atong gi operahan na siya unya wala na siyay
lihok lihok sa iya higdaanan kay sakit man kung mo
lihok siya.”
● verbalized “wala man ko tagda sa mga doctor
didtos amo kay murag ma hadlok sila mo tandog
nako mao sige ra ko higda sa ako likod sukad na
operahan ko.”
● experienced fever last October 17, 2022

Examination

● Vital Signs (10/24/2022 - 6:15 PM)

○ T: 36.5 ºC, RR: 16 cpm, BP: 125/70 mmHg;
PR: 81 bpm; SaO2: 99%
● Urinalysis (10/17/2022)
○ few dysmorphic RBC’s seen
● CBC (10/21/2022)
○ Hgb: 9.60 g/dL
○ Hct: 29.80%
○ Mean Corpuscular Hgb: 26.20pg
○ Mean Corpuscular Concentration: 32.2%
○ creatinine serum: 1.50 mg/dL
○ potassium: 2.30 mEq?L
● 10/23/2022
○ potassium: 2.90 mEq/L

2. Nutritional-metabolic pattern

● Eats three meals a day

● Each meal consisting of vegetables, fish, and rice
● Has no problem with appetite
● Has no eating disorder
● Drings 2 L of water everyday
● Has multiple missing teeth but does not affect his
ability to eat
 3. Elimination pattern

● Defecates 1-2x a day

● Stool is of normal characteristic but has difficulty
passing due to the bed sores in the sacral area
● Use of condom catheter
● Urine is light yellow, slightly hazy

Examination

● 10/17/2022
○ Chemical Examination
■ Blood: Trace
○ Urine Flow Cytometry
■ RBC: 40 /uL
○ Other
■ Few Dysmorphic RBCs seen. Please
correlate clinically.

4. Activity-exercise pattern

● wakes up at 5:00am in the morning and prepares to

feed his carabao’s
● tends to his farm by 6:00am
● goes home by 3:00pm after tending to his carabaos
and making “sug-angan” and clay pots with his son
● generally active and enjoys doing work verbalizing
“ganahan ko magpa singot.”
● talks to neighbors and friends during leisure time
● has not reported any dizziness or fainting spells
prior to accident
 ● Perceived ability according to functional levels
code below:
○ feeding: 2
○ grooming:2
○ bathing:2
○ general mobility:4
○ toileting:4
○ bed mobility:4
○ home maintenance:4
○ dressing:4

grade description

0 Independent

1 Requires use of equipment or device

2 Requires assistance or supervision of another

person

3 Requires assistance or supervision of another

person and equipment or device

4 A dependent and … participate

Examination

● Pulse: 81bpm, regular, 2+ normal

● BP: 125/70 mmHg
● SaO2: 99%
● motor function impaired on both lower legs
● unable to move independently on bed
● to be turned every 2 hours with a flat, left, flat, right
pattern
5. Sleep-rest pattern

● Sleep is inconsistent every night

● Every 2 hrs PT has to move from side to side
● Wakes up throughout the night, “Kay init ako
lawas” on the side lying upon
● Snores occasionally but not loud as to disturb
others

6. Cognitive-perceptual pattern

● Patient main complaint is that his body gets warm

● Does not experience much pain and rarely asks for
pain medication
● Responded well to all answers and is oriented to
location, time, and date
7. Self-perception-self-concept pattern

● Patient main worry is his inability to walk and use

his legs verbalizing “ang ako ra jud maam ug sir
maka lakaw ra ko balik ug maka trabaho kay ako
ang breadwinner sa among pamilya.”
● Is hopeful to get well and regain ability to walk
after a successful spinal surgery
● Niece said that before the fall, patient was very
active and healthy

8. Role-relationship pattern

● Has a wife and one son

● Arguments are resolved by talking and
communication
● Wife verbalized, “talagsa mi mag away”
● 22 year old son is typically the mediator of
arguments between parents

9. Sexuality-reproductive pattern

● Wife verbalized that their son is a miracle child as

they tried five times before had to have a child
before their son was born
● After the birth of their son, they continued to try to
have a second child, but at the 3 month mark wife
had a miscarriage.
10. Coping stress tolerance pattern

● Talks to his “kompare” when feeling stressed and

feels that he cannot tell his feelings to his wife

11. Value-belief pattern

● Wife is Roman Catholic

● Patient practices Filipiniana with his son

Nursing Diagnosis #1: Electrolyte imbalance related to excessive loss of potassium
CUES / EVIDENCES OBJECTIVES
Subjective: At the end of our 8 hour nursing
● “di nako ma lihok akong
care, the patient will:
mga tiil”
● Verbalize understanding
Objective:
of causative factors and
● Low potassium results in
blood chemistry test purpose of interventions
○ 2.30 mEq/L
and medications
● To demonstrate behaviors
to monitor and correct
deficit
● To achieve fluid volume
at a functional level as
evidence by laboratory
results of patent
Nursing Care Plan
INTERVENTIONS
Independent
● Monitor heart rate/rhythm
● Maintain accurate record
of urinary, gastric, and
wound losses
● Monitor rate of IV
potassium administration
using microdrop or pump
infusion devices. Provide
an ice pack as indicated.
● Encourage intake of foods
and fluids high in
potassium, e.g. bananas,
oranges, dried fruits, leafy
vegetables, peast, baked
potatoes, tomatoes
● Watch for signs of
digitalis intoxication when
RATIONALE EVALUATION
● Changes associated with
hypokalemia include
abnormalities in both
conduction and
contractility. Tachycardia
may develop , and
potentially
life-threatening atrial and
ventricular dysrhythmias
● Guide for calculating
fluid/potassium
replacement needs
● Ensures controlled
delivery of medication to
prevent bolus effect and
reduce associated
discomfort, e.g. burning
sensation at IV site
● Potassium may be
replaced/level maintained
through the diet when
patient is allowed oral
food and fluids
● Low potassium enhances
effect of digitalis, slowing
 used, e.g. report of cardiac conduction
nausea/vomiting, blurred
vision, increasing atrial
arrhythmias, and heart
block

Collaborative

● Monitor laboratory ● Levels should be checked

studies, e.g. serum frequently during
potassium replacement therapy,
especially in the presence
of insufficient renal
function. Sudden
excess/elevation may
cause cardiac arrythmias

● ABGs ● Correction of metabolic

alkalosis raises serum
potassium level and
reduces replacement
needs. Acidosis drives
potassium back into cells,
resulting in decreased
serum levels and
increased replacement
needs.
Dependent

● Administer electrolyte
replacement as prescribed
Nursing Diagnosis #2: Impaired Skin Integrity related to immobility as evidenced by stage 4 sacral ulcer

CUES / EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: At the end of our 8 hour nursing Independent

● Niece verbalized “ nagka care, the patient will:
sugod na siyag ka ulcer
sukad atong gi operahan
na siya unya wala na
siyay lihok lihok sa iya
higdaanan kay sakit man
kung mo lihok siya.”
● Patient verbalized “wala
man ko tagda sa mga
doctor didtos amo kay
murag ma hadlok sila mo
tandog nako mao sige ra
ko higda sa ako likod
sukad na operahan ko.”
Objective:
● presence of stage 4 sacral
ulcer on left and right
butocks
● Have reduced risk of
additional skin integrity
degradation
● reduce risk for infection
● verbalize in his own
words the importance of
proper wound care
● provide privacy and cover ● to protect patient’s
unnecessary exposed body integrity and dignity
parts when assessing
● determine, document and ● establish comparative
assess dimension and baseline data and early
depth of pressure ulcer, detection of possible skin
exudates noting its color, deterioration or healing
odor and amount,
evidence of necrosis
(color gray or black) or
healing (pink or red
granulation tissue)
● Maintain head of bed at ● elevating head of bed can
the lowest elevation distribute weight to the
lower region of the body
causing more pressure to
the ulcer
● follow isolation ● to reduce risk for infection
precaution when cleaning
 and dressing wound

● keep bed linens dry and ● wrinkles and wet bed

wrinkle free and use linens can cause put
appropriate padding or pressure to the already
pressure reducing devices existing ulcer
● paddings or pressure
reducing devices such as
egg crate foam can reduce
pressure on sensitive areas
and enhance circulation to
compromised tissue
● develop regularly timed ● to reduce stress on
repositioning schedule pressure points and
promote proper
circulation to tissues

Dependent
● administer piperacillin + ● treats bacterial infection
tazobactam sodium, 4.5g in many parts of the body
infusion Q 8H as
prescribed
Nursing Diagnosis #3: Risk for infection due to presence of stage 4 sacral ulcer
CUES / EVIDENCES OBJECTIVES
Subjective: After 8 hours of nursing
intervention, the client with the
● help of the significant others will
be able to:
Objective: ● Perform independently
proper wound care
● presence of stage 4 sacral
ulcer on left and right ● Take in foods/diet that
butocks would promote faster
wound healing
● Identify interventions that
could prevent or reduce
the risk for infection
● Achieve timely wound
healing, free from signs of
infection
● Verbalize feelings of
understanding, recovery
and comfort
INTERVENTIONS
Independent
● Monitor vital signs
● Assess the patient’s
knowledge about
condition. In addition, the
significant others
knowledge since the
patient may be unable to
do such because of
neurologic disturbances
● Assess adequacy of blood
supply and innervations of
the affected tissue
● Assess changes of wound
site for depth, width,
color, smell, location,
temperature, texture, and
discharges
RATIONALE EVALUATION
● This would determine if
there has been systemic
infection occurring inside
the body
● Determine patient’s ability
to perform independent
interventions together
with her significant others
● Determining the blood
supply for proper
oxygenation of the tissues
which would aide in the
progress of healing of the
affected tissue
● Provides a comparative
baseline for future
assessment and promote
timely nursing
intervention and revision
of care plan. It also
determines the risk or
degree of infection of the
wound
 ● Provide good nutrition by
giving diet rich in protein
and calories, and vitamins
and/or minerals
● Promote mobility by
providing position
changes, active or passive
exercises and assistive
exercises
Dependent
● Maintain adequate
hydration by proper
regulation of IVF and
giving fluids as indicated
● Promotes faster wound
healing and provide the
patient adequate source of
energy for recovery
● Promote better circulation
at body parts and prevent
excessive tissue pressure
thus promoting faster
wound healing and
recovery
● Prevent dehydration and
provide electrolytes and
minerals needed by the
body to recover