PROF: SONIA DIGNADICE
Data Base: PHYSICAL EXAMINATION
Family Member: Emmanuel Sagun
Age: 49
Gender: Male
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
Health Perception and Health Management
Nutrition and Metabolism
Elimination Pattern
Activity and Exercise Pattern
Cognition and Perception
Sleep and Rest Pattern
Self Perception and Self Concept
Roles and Relationship
Sexuality and Reproduction
Coping and Stress Tolerance
Values and Belief
He only goes the Municipal Health Center for
minor illnesses and checkups; if the condition is
severe, he seeks a hospital.
Eats three meals a day but only eats a small
amount of rice every morning. regularly
consumes 2 liters of water.
Mr. Sagun has no issues with his stools, and his
urine is a yellowish color. He claims that today's
water intake caused him to urinate more than 10
times and pass stool twice.
Exercises every day by doing a morning walk for
30 min before going to work or during work.
Fluent speech, no sensory deficits, situation-
appropriate expression on the face
He had insomia back then but for 1 month the
insomia passes, but he still has trouble sleeping if
he is facing problems and if he is tired.
He is still in good shape and grooms himself
everyday, as well as he take good care of his
health daily.
His the head of the family as well as the decision
maker of the family. He checks the health of his
family and provides their family income.
He is still sexually active
Cope up with stress by praying and by singing
gospel songs
Religion: Born Again Christian, Goes to church
every Sunday then Wednesday only if they have
church meeting. Attends online bible study.
 DOCUMENTATION
1st interview

2nd interview

Indoors

Link for video:

https://drive.google.com/drive/folders/1EQiZPxq3VeB_rm7vJJL7A0UxvlBtqajx?usp=sharing
 FIRST LEVEL OF ASSESSMENT
Identifying health threats, health deficit, and foreseeable crisis / stress points
A. Health threat conditions that promote disease or injury and prevent people from realizing health
potential. (Conductive to disease)

Improper balanced diet. Consider it a health threat because it could result in a person being sick or
developing a disease.

Red and processed meat have been linked in several studies to inflammation, which may exacerbate
the symptoms of arthritis. Interleukin – 6 (IL – 6), C – reactive protein (CRP), and homocysteine levels are
elevated in diets high in processed and red meats. Red meat was observed to frequently make RA
symptoms worse according to a study. In addition, a study of 25,630 adults found that eating a lot of red
meat may increase your chance of developing inflammatory arthritis.
Poor nutrition and an unbalanced diet have been related to stroke, which is caused by plaque that
builds up in a blood artery, then breaks free as a clot and goes to the brain and causes blockage. Strokes
harm the brain, limit functioning, and can even be fatal. Stroke risk is increased by foods heavy in salt,
fat, and cholesterol.
It's best to limit the intake of meals with a lot of saturated fat because cholesterol seems to play a
function in the development of gallstones. Poor eating habits are the cause of a lot of gallbladder
diseases. This typically denotes a diet heavy in refined white foods, processed foods, and unhealthily
greasy foods.
B. Health deficits occur when there is a gap between actual and achievable health status.

Gallstone is considered as a health deficit because it is already present to a person.

Gallstones are calcified collections of gastrointestinal fluid that can develop in your
gallbladder. On the right side of your belly, beneath your liver, is a little, pear-shaped organ called
the gallbladder. The small intestine receives bile, a digesting fluid, which is secreted from the
gallbladder. Gallstones can in sizes ranging from a grain of sand to a golf ball. One gallstone may
form in some persons while many stones may form simultaneously in others.

Gallbladder removal surgery is typically necessary for those who have symptoms related to
their gallstones. According to doctors, having too much cholesterol in your bile may lead to
gallstones. Normally, the molecules in your bile are sufficient to break down the cholesterol your
liver excretes. However, if your liver excretes more cholesterol than your bile can break down, it
may crystallize and eventually turn into stones.
 Being female, being over 40, eating a diet heavy in fat, cholesterol, and fiber, having a family
history of gallstones, having diabetes, having a son, and other factors may all raise your risk of
developing gallstones.

If you don't skip meals, you can lower your risk of developing gallstones. Try to eat at the same
times every day. Fasting or skipping meals both raise the risk of gallstones. eat more foods high
in fiber. Increase your intake of fiber-rich foods like fruits, vegetables, and whole grains. keep a
healthy weight. Gallstones are more likely to form in people who are overweight and obese. By
consuming less calories and engaging in more exercise, you can work toward achieving a healthy
weight. Once you reach a healthy weight, attempt to keep it off by sticking to a balanced diet and
exercising regularly.

Arthritis is considered as a health deficit because it is already present to a person.

Arthritis is one of the most prevalent diseases that affects a significant portion of the
population, according to Dr. Parate P. (2017). People over the age of 40 frequently experience it.
Among the most prevalent signs of arthritis are acute joint pain, difficulty moving, and weakening
bones. One of the most feared illnesses of the present time is arthritis because of how severely
it has impacted modern living.
 Depending on the individual, arthritis may have different causes. Some foods, particularly red
meat and goods derived from animals, can raise uric acid levels, which raises the risk of both gout
and arthritis. Rheumatoid arthritis, one of the immune system's issues, is brought on by the
body's immune system attacking the lining of the joints.

Many health problems that a person encounters in general are brought on by eating the
incorrect meals. That this is also the case when it comes to the issue of arthritis should not be at
all surprising. As a result, someone with arthritis should avoid fried, hot, and spicy foods because
they have a high potential for harm.

C. Foreseeable crisis / Stress point

Anticipated periods of unusual demand on the individual of family in terms of adjustment
or family resources.

Sagun Family does not currently have any known Foreseeable crisis or Stress Points.
 SECOND LEVEL OF ASSESSMENT
LIST OF PROBLEM IDENTIFIED

SUBJECTIVE CUES AND DATA FAMILY NURSING PROBLEM

“Mostly meat and frozen foods, Vegetable is
bihira, Fish is also bihira. Ang mga vegies minsan
kasama nalang sa meat sometimes and fish kapag
nag tola,” as quoted by one if the member of
family
Inability to maintain a balanced diet due mainly
to ignorance of the issue as well as lack of or
inadequate understanding of health education

The Sagun family primarily consumes frozen

meals and red meat. They frequently eat fish,
vegetables, and fruits. Depending on the dish,
some of their food solely contains vegetables
when paired with meat.

Imbalanced Nutrition (Health Threat)

Name: Rachelle Sagun Inability to prevent the existence of the health

Age: 41 issue as a result of:
- Eats meat and Frozen foods
a.) ignorance about the effects of the diet
BP: 100/90 mmHg that should be followed based on the
health issue.
- Sometimes eats fruits and vegetables
depending on the dish prepared
- Needed a Gallstone operation b.) not fully understanding the underlying
- “Meron ako Gallstone na need ng cause of the health issue
opeartion kasi last nov.12 nasa 2.3 lang
sya but now 6.0 nasya. Kanina nag
undergo nako sa mga labs xray and Ecg 3
to 5 days parw results .after nito need
kopa magpa checkup sa I.M and
Anesthesiology for clearance if makpasa
na tska ako bigyan ng date for Surgery”, as
stated by her.

Gallstone (Health Deficit)

Name: Emmanuel Sagun Inability of the patient to exercise self-control due
Age: 49 to:
BP: 120 / 80 mmHg
- Eats meat and frozen foods a.) knowledge deficit
- “Arthritis minsan sa Fam pero bihira pag
nasobrahan lang sa mga pagkain na b.) insufficient expertise in preventative
bawal..nawawla pag nainuman na ng measures
gamut”, as quoted by one if the member
of family.
- The Sagun family does not take prescribed
medication to a doctor if the health
problem is not that severe.
- Takes naproxen /Planax 500 mg if arthritis
occurs.

Arthritis (Health Deficit)

List of Health Problems Ranked According to Priorities

HEALTH PROBLEMS SCORE

1. Gallstone 3.66

2. Imbalanced Nutrition 3.16

3. Arthritis 3
 SCALE FOR RANKING
A. IMBALANCED DIET

CRITERIA SCORE JUSTIFICATION

2 x 1 = 0.66 It is viewed as a threat to health

1. Nature of the problem 3 since it may complicate or
negatively affect the family's
health condition due to their
Health Deficit unbalanced diet, which may
Health Threat lead to various health issues
Foreseeable Crisis such as gallbladder problems
from constantly consuming too
many high-cholesterol, high-fat
foods.
1x2=1 Because we told the family how
2. Modifiability 2 important it was to eat properly,
especially when it came to foods
Easily to avoid when they had a
Intermediate particular health issue, it is
Not modifiable intermediately modifiable.
Through our nutritional health
education, the family
understood the dangers of
eating an unbalanced diet for
their current health status.
3. Preventive / potential 3x1=1 It is highly preventive since,
3 based on my observations of the
High family I chose, they were aware
Moderate of the foods that are high in
Low cholesterol and that they ate
more meat than vegetables. This
will allow the family to practice
being more mindful of their
dietary needs.
4. Salience of the problem 1 x 1 = 0.5 Despite being aware of the issue
2 with consuming unhealthy
Problem needing urgent foods, the family still views it as
attention a problem not needing an
Problem not needing urgent attention.
urgent attention
 Not perceive as a
problem

TOTAL SCORE: 3.16

B. Gallstone

CRITERIA SCORE JUSTIFICATION

1. Nature of the problem 3x1=1 It is considered as a health

3 deficit since that there is a
Health Deficit presence of problem.
Health Threat
Foreseeable Crisis

2. Modifiability 1x2=1 Because the family will still be

2 able to practice balanced
Easily nutrition now that I have
Intermediate provided additional information
Not modifiable on how to handle our health
education, it is modifiable to an
intermediate level.
3. Preventive / potential 2 x 1 = 0.66 Because the family continued to
3 practice healthy balanced
High nutrition by eating fruits,
Moderate vegetables, and fish, it is
Low regarded as a moderate
preventive.
4. Salience of the problem 2x1=1 The family understood that this
2 was a problem needing an
Problem needing urgent urgent attention because they
attention would need a surgery and
Problem not needing medical care in order to recover.
urgent attention
Not perceive as a
problem.
TOTAL SCORE: 3.66
 C. Arthritis

CRITERIA SCORE JUSTIFICATION

1. Nature of the problem 3x1=1 It is considered as a health

3 deficit since that there is a
Health Deficit presence of problem.
Health Threat
Foreseeable Crisis

2. Modifiability 1 x 2 = 0.5 It is intermediate because Mr.

2 Emmanuel Sagun is cooperative
Easily in engaging in conversation with
Intermediate me to prevent the health issue
Not modifiable from going worse. He also takes
supplements to minimize his
arthritis and avoid having a poor
diet.
3. Preventive / potential 3x1=1 Since Mr. Emmanuel takes
3 medication to prevent it from
High getting worse and takes his
Moderate health seriously, it is seen as a
Low high preventative.
- naproxen / Planax 500
mg
4. Salience of the problem 1 x 1 = 0.5 Since Mr. Emmanuel Sagun is
2 taking medication to treat this
Problem needing urgent issue, the family understood
attention that this is a problem not
Problem not needing needing attention.
urgent attention
Not perceive as a
problem

TOTAL SCORE: 3
 FORMULATE THE OBJECTIVES
Health Problem Family Nursing Goal of Care Objective of Care
Problem
HEALTH THREAT Inability to maintain a Sagun Family will be The Sagun family will
Improper Balanced balanced diet due able to practice the be able to recognize
Diet mainly to ignorance of importance of proper nutritious foods like
the issue as well as lack balance nutrition. fruits and vegetables
of or inadequate and follow sensible
understanding of eating habits to avoid
health education nutritional imbalances.
HEALTH DEFICIT Inability to prevent the Mrs. Rachelle Sagun Mrs. Rachelle Sagun
Gallstone existence of the health will be reminded of the will be able to:
issue as a result of: significance of getting
routine checkups as a.) Educate her
a.) ignorance well as of having good family measure
about the diet, avoiding greasy about the
effects of the and high-cholesterol importance of
diet that should foods. regular check-
be followed up.
based on the b.) Explain
health issue. importance of
proper diet or
food intake.
not fully understanding
the underlying cause of c.) Educate on the
the health issue do’s and don’ts
of Gallstone.
HEALTH DEFICIT Inability of the patient Mr. Emmanuel Sagun Mr. Emmanuel Sagun
Arthritis to exercise self-control will take the required will be able to identify
due to: steps to manage and and demonstrate
reduce the risk factors interventions to relieve
a.) knowledge for arthritis. pain.
deficit The patient will be
provided with the
b.) insufficient necessary information
expertise in about healthy eating
habits that can lessen
preventative
arthritis symptoms and
measures
stop them from getting
worse, as well as the
ability to take medicine
as needed.