SILLIMAN UNIVERSITY

COLLEGE OF NURSING
DUMAGUETE CITY

GORDON’S FUNCTIONAL HEALTH PATTERNS

B.T.R

Patient’s Initials

(First Name, Middle Initial, Last Name)

Submitted by:

Ma. Fermi Gleam P. Bajado

John Kenneth B. Zason

S.Y. 2022-2023
 SILLIMAN UNIVERSITY
COLLEGE OF NURSING
DUMAGUETE CITY

Student’s Name: Ma. Fermi Gleam P. Bajado & John Kenneth B. Zason Level: III - A2 Date: October 24, 2022

Biographical Information

● Patient’s Name: Rivera, Bartilitico Tomias

● Age: 69 years old Gender: Male Insurance: PhilHealth
● Marital Status: Married Birthdate: 08/19/1953 Birthplace: Dumaguete City
● Address: Habitat Cantil-e, Dumaguete City Occupation: N/A (Retired Security Guard)

● Race: Filipino Religion: Roman Catholic

● Educational Level: College Graduate Primary Language Spoken: Cebuano

● Date of Admission: 10/23/2022 Ward/Bed: NEM-2

● Mode of Admission: Elective Admission Medical Dx. On Admission: T/C Varicocele vs Indirect Inguinal Hernia, Right

Reason for Seeking Care: Pain at right groin when moving

History of Present Illness: 1 year PTA, patient noticed onset of flaring feeling on R inguinal area and sought consult w/ AP due to persistence of symptoms and was diagnosed w/
R inguinal hernia and not advised for surgery. Medications were unrecalled pain relievers. In the interim, tolerated symptoms. 1 day PTA, increase in severity of the symptoms and
prompted consult.

General Impression: Pt received lying on bed, awake and relaxed. Pt is ambulatory and is with the company of his wife who supplemented the pt’s information. Alert, coherent,
and active when asked questions during the interview. Cooperative, responsive and was able to answer questions appropriately.
Functional Health Pattern
HEALTH PATTERNS USUAL FUNCTIONAL PATTERNS
Health Perception & Health
Management
Nutrition & Metabolism
● Patient is diagnosed with diabetes at
age 40
● Had a history of stroke at age 30
● Started experiencing swelling of
prostate 3 years ago
● No allergies
● Uses herbal medications such as
Xanthone Plus Herbal Capsule
500mg
● Does not smoke
● Does not use illicit drug
● Does not drink alcohol
● Usual meal: rice, fish, chicken,
vegetables, and fruits
● Has good appetite, eats 3x a day
● No difficulty in chewing and
swallowing
● He has no problem with appetite
nor has eating disorders.
● Wounds heal well despite being
diabetic
INITIAL APPRAISAL ONGOING APPRAISAL 
● Admitted on October 23, 2022 @ 05:50 pm due
to pain at right groin when moving
● Verbalized “Okay okay na man ko”
● Claimed no herbal medications taken when
experiencing pain
Medications:
● Atorvastatin Ca (ITORVAZ) 40mg tab
● Clonidine Hydrochloride 75Mcg tab
● Ketorolac Trometamol 30Mg/Ml, 1Ml ampule
● Losartan K + Amlodipine Besilate (Amlife)
50Mg/5Mg , FC tab
● Metformin Hcl (GLUMET) 500Mg tab
● Tamsulosin + Finasteride 400mcg 1 cap
● Ketoconazole 2% cream
CBC:
● WBC: 13180 /cumm
○ Monocyte: 7%
Clinical Chemistry:
● Fasting blood sugar: 155.70 mg/dL
● SGPT/ALT: 19.00 U/L
Urinalysis:
● Glucose: 1+
● Protein: Trace
● Meal: rice, meat, and vegetables
● Diet: full as tolerated
● Drunk 1000ml of water 3x since morning
Examination:
● Temperature: 36.2 C
● No lesions and discoloration noted
● No visible perspiration
● Skin is normal
 ● No skin dryness ● No bruises noted on skin
● No dry mouth noted ● Normal oral mucous membranes (pink in color,
● Drinks 8-10 glasses of water not dry, no lesions)
everyday
● Avoids drinking soft drinks
Elimination Pattern ● Defecates every other day ● Has not defecated yet
● No discomfort while defecating ● Urinated 5x
● Stool character: Brown, not soft and ● verbalized “naka ihi ginagmay ra”
not too hard ● Urine character: Yellow to clear in color
● Does not use laxatives ● Does not have trouble holding urine
● Urinates frequently about 5-6x a ● No excessive perspiration noted
day ● No odor problems
● Does not have trouble holding urine
● Urine character: Yellow to clear in
color
● No excessive perspiration noted
● No odor problems
Activity and Exercise ● Activity level: Very Active ● Activity level: Mostly Sedentary
● Has sufficient energy for home ● Needs assistance and supervision when getting
activities out of bed
● Feeding ______ ● Able to move without pain ● No dizziness, faintings, and fall experiences
● Grooming ______ ● Watches tv with family as leisure while admitted in the hospital as claimed
● Bathing ______ activities
● General mobility ● No dizziness, faintings, and fall Examination:
______ experiences while admitted in the ● Pulse Rate: 75 bpm
● Toileting ______ last few months ● Blood Pressure: 140/98 mmHg
● Cooking ______  ● Affected gait due to right lateral ● Respiration: 18 cpm
● Bed mobility ______ buttocks pain ● Bed mobility: Can turn to side-to-side and
● Home maintenance ● Patient’s perceived ability for daily position the body
______ living (code 1 to 4 according to ● Ambulatory
● Dressing ______ Functional Levels Code below):
● Shopping ______ ○ Feeding 0
○ Grooming 0
○ Bathing 0
Functional Levels Code ○ General mobility 0
○ Toileting 0
Level 0: Full self-care ○ Cooking 0
Level I: Requires use of ○ Bed mobility 0
equipment or device ○ Home maintenance 0
Level II: Requires assistance
or supervision from another
person
Level III: Requires assistance
or supervision from another
person or device
Level IV: Is dependent and
does not participate
Sleep-Rest Pattern
Cognitive & Perception
○ Dressing 0
○ Shopping 0
● Generally feels well rested after
sleeping
● Ready to do activities after sleeping
● Does not have sleeping problems
● Does not use sleeps aids
● Snores when sleeping but not loud
● Does not doze off
● Usual sleeping pattern is from 8pm
to 9am
● Watches tv as a form of relaxation
● Does not wear glasses nor use
contact lenses
● No difficulty in hearing
● Not exposed to loud noise or music
● No changes noted in the sense of
touch
● Has short term memory, usually
forget things easily
● No changes in the sense of smell
● Verbalized, “Nausob gyud ang
panlasa nako, dili na pareha sauna
nga lami pa kaayo ang mga
pagkaon. Pero mukaon lang
gihapon ko, murag naa lang gyuy
kulang”
● No problems in concentrating; not
easily distracted
● No problems in making decisions
● Has trouble sleeping due to hospital
environment
● Slept for 5 hours
Examination:
● Sleep pattern: 11pm sleeping time, wakes up
often when there’s a nurse or doctor
● Looks tired; sleepy eyes noted
● Patient experience discomfort and pain at
inguinal area, right
● Verbalized “mag halang”, pointing at right
inguinal area
● Rates pain 5/10 (0 as no pain and 10 as the most
pain)
● Verbalized “Mawala dayon mubalik”, referring
to duration and onset of pain
● Does not wear glasses nor use contact lenses
● No difficulty in hearing
● Not exposed to loud noise or music
● No changes noted in the sense of touch
● Has short term memory, usually forget things
easily
Examination:
● Oriented to time, day, date, and place currently
in
 ● No difficulty in learning
● College graduate
Self-Perception & ● Most of the time feels good about ● Verbalized “Gidawat nako unsay sunod
Self-Concept himself mahitabo sunod” to describe himself
● Does not frequently angry, annoyed, ● Most of the time feels good about himself
fearful, or anxious
● Does not frequently angry, annoyed, fearful, or
● Does not feel depressed
● Does not lose hope anxious
● Prays when feeling stressed about ● Does not feel depressed
something ● Verbalized “Dili mawala ang paglaum kay naa
ang Ginoo” when ask if he lose hope

Examination:
● Consistent eye contact during interview
● Confident while speaking
● Mood: 1 (1 being relaxed and 10 being nervous)
● Response Style: 1 (1 being assertive and 10
being passive)
● Interacts with family members while in bed

Roles & Relationships ● Lives with wife, nephew, and son ● Lives with wife, nephew, and son
● Problems are handled by admitting ● Have a great relationship with family
mistakes and by communicating
well with each other Examination:
● No recent losses ● Family members are present and supportive
● Has 4 children, no problems
between them
● Feels safe in his second marriage
and relationship partner
● Does not belong to any social
groups
● Have a great relationship with
family
● Feels part of the neighborhood
Sexuality and Reproduction ● No problems with sexual ● No problems with sexual relationship
relationship ● Does not use any medications to enhance sexual
● Does not use any medications to performance
enhance sexual performance
 ● No plans on having children
anymore because of his age
Coping & Stress Tolerance ● Talks to his wife when he has
problems
● His wife is always available if he
needs someone to talk to
● Relaxed and calm most of the time
● Does not use any medicine, drugs,
or alcohol to help in relaxation
● No big changes happened recently
● When big problems occur in life, he
handles them by having a relaxed
mind and praying
Value-Belief ● Patient is Roman Catholic
● Religion is very important in his
family and his life personally
Examination:
● Plans on not having anymore child because of
his age and his wife
● Talks to his wife when he has problems
● His wife is always available if he needs
someone to talk to
● Relaxed and calm most of the time
● Does not use any medicine, drugs, or alcohol to
help in relaxation
● No big changes happened recently
● When big problems occur in life, he handles
them by having a relaxed mind and praying
● Claimed if stressed during hospitalization he
thinks of happy thoughts
● Examination:
● Anxiety scale: 1
● Has no difficulty concentrating during the
interview
● No voice quivering noted
● Pulse Rate: 75 bpm, regular
● BP: 140/98 mmHg
● Religion is very important in his family and his
life personally
● Considers God an important figure in his life
● Patient has a Bible and Rosary.
 COLLEGE OF NURSING
Silliman University
Dumaguete City

NURSING CARE PLAN

NURSING
CUES / EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain r/t Within our 8-hour nursing Independent: Independent:
● Verbalized, inguinal hernia care, the patient will be able to ● Build rapport with the ● To build trust and a
“Sakit gyud siya experience lesser pain as patient and family. comforting environment
dayon evidenced by: to the patient and
maghalang, ● Satisfactory pain improve the cooperation
mawala dayon control from 5/10 to among the patient and its
mubalik, mao ng 2/10 pain scale. ● Assess reports of pain family.
nagpa admit ko ● Uses and sensory alterations,
kay dili nagyud nonpharmacological noting location, ● To differentiate and know
nako kaya.” pain-relief strategies duration, and intensity if the treatment and
● Pain scale: 5/10 such as positioning (0 to 10 scale). procedures had improved
and exercises. the patient’s pain level.
Objective: ● Demonstrates the use ● Provide basic comfort
● Right inguinal of diversional and diversional
hernia activities such as activities. ● To divert their attention
walking and relaxation onto the activities instead
techniques such as ● Encourage ambulation of the pain.
deep breathing and use of relaxation
exercises. techniques. ● Ambulation and
● Able to move without relaxation techniques are
assistance from others. non pharmacological
pain-relief strategies that
● Provide appropriate can help alleviate the
pain medication on a pain.
regular schedule before
pain is severe and ● Timing of medications
before activities are are needed so that when
scheduled. the patient is said to do
activities, it can help
them achieve it fully.
 Dependent:
● Administer pain
medications as ordered.
Dependent:
● To provide pain relief
and comfort.
NURSING OBJECTIVES
CUES / EVIDENCES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Activity Within our 8-hour nursing Independent:
● Verbalized, intolerance care, patient will be able to ● Assess the patient's ● Provides baseline
“Sakit gyud siya related to pain perform physical activity as present level of activity information for
dayon from inguinal evidenced by: and tolerance to activity. formulating nursing goals
maghalang, hernia when during goal setting.
mawala dayon moving ● Demonstrate ● Monitor the patient's vital
mubalik, mao ng techniques in resuming signs. ● To track changes on
nagpa admit ko usual activities of daily patient’s condition
kay dili nagyud living ● Assess the patient’s
nako kaya.” emotional and ● Patients might often be
● Verbalized, ● Understands the motivational status. depressed or frustrated
“Makalihok ra importance of increase over their situation and
man kog akoa. activity tolerance condition. Performance
Makaadto lang strongly depends on the
pud kos CR pero ● Actively participates patient’s mental state and
di pa jud kaayo in activities mood.
ko kabakod nga ● Provide adequate rest for
ako ra usa.” the patient. ● To provide comfort on
patient
Objective: ● Assist patient in self-care
● Right inguinal activities
hernia ● Assisting the patient with
ADLs allows
conservation of energy.
Carefully balance
provision of assistance;
facilitating progressive
endurance will ultimately
Dependent: enhance the patient’s
● Administer pain activity tolerance and
medications as ordered. self-esteem.
 Dependent:
● To provide pain relief
and comfort.

NURSING OBJECTIVES
CUES / EVIDENCES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Disturbed Within our 8-hour nursing Independent: Independent:
● Has trouble sleeping care, patient will as evidenced
sleeping due to pattern related by : ● Assess data on the ● To get baseline data and
hospital to hospital ● Verbalization of patient’s usual sleeping observe if there are any
environment setting significance of hours before changes or improvement
● Wakes up often adequate rest hospitalization including
when there’s a ● Verbalization of length, depth, quantity of
nurse or doctor feelings of being sleep and other
as claimed well-rested circumstances.
● Normal sleeping ● To have data to evaluate
Objective: pattern at the right ● Identify and monitor the if the goals are met.
● First night of sleeping time. patient's sleep-wake
hospitalization ● Having at least 7-8 pattern including the
● Slept for 5 hours hours of sleep possible reasons for
● Sleep pattern: waking up. ● Napping can disrupt
11pm sleeping normal sleeping patterns
time ● Discourage the pattern of unless it's part of the
● Looks tired; daytime naps unless patient's usual pattern.
sleepy eyes noted necessary or if part of
one's usual pattern.
● Milk contains tryptophan
● Promote drinking of and melatonin which can
warm milk before going help promote sleep.
to bed.
● To avoid the need to void
during night time which
● Discourage intake of large can also be a factor of
fluid before bedtime. sleep disturbance.

Collaborative:
Collaborative:
● Provide ● To provide the services to
nonpharmacologic the patient that can help
interventions such as back in promoting relaxation
rub, bedtime care, pain without
relief, comfortable
position, and relaxation
techniques.