UNIVERSITY OF NEGROS OCCIDENTAL RECOLETOS

COLLEGE OF NURSING
RELATED LEARNING EXPERIENCE
2nd Semester, A.Y. 2022-2023

HEALTH 12I

Name: Montero, Sheridan Lei E. Year and Section: BSN1 – N05

GENERAL INSTRUCTION:
1. Read and analyze the case scenario. Use Gordon’s Health Assessment Pattern and
correlate the case scenario according to individual health functions.
2. Fill-in the respective information for demographic data of the patient.
3. Identify the following medical history of the patient: Past, Present, Family and
Medication.
4. Create your own chief complaint base on your understanding in this case
scenario.

Health Perception – Elimination Cognitive – Self-perception Sexuality – Value –

Health Management Pattern Perceptual Pattern – Self-concept Reproductive Belief
Pattern Pattern Pattern Pattern

Nutritional – Metabolic Activity – Sleep – Rest Role – Coping – Stress

Pattern Exercise Pattern Pattern Relationship Tolerance Pattern
Pattern

SITUATION:

Ryan Liman, 38 years of age, male, single and still living with his parent’s house. Born with
privileges, his mother came from Cuneta clan, and his father rooted with political dynasty under
the Pangilinan family. He graduated with BSN degree and knew how to take V/S on his own.
Using a manual sphygmomanometer, thermometer, analogue watch, and stethoscope he
immediately took his own vital signs and records the following: T=37.8 degrees Celsius, PR=78
bpm, RR=15cpm and BP=180/110mmHg. Paracetamol 500mg 1 tab PRN taken to manage
hyperthermia.

After a couple of days, Ryan felt sore throat and difficulty of swallowing when eating. At
this point, he lost appetite and consumes soft diet instead of solid foods. Then, a sudden loss of
weight from kicks in from 54 kgs changed into 52 kgs. During the onset of his health problems,
he has an irregular bowel movement due to less consumption of foods that is rich in fiber. Then,
constipation kicked in due to irregularity of intake and output. In year 2008, he was rushed to the
hospital due to appendicitis and he directly admitted to OR for appendectomy. After the surgery,
the doctor prescribed him Metformin 500mg 1 tablet TID as maintenance due to his HbA1c test
with result of 20%. During his childhood, he had a severe chicken pox that last three weeks before
healing.
At this moment, he worked as probationary Nurse at a private hospital, he prefers himself
as the goddess of rookie in their station, he knew that he is smart and reliable in his work. Always
oriented to time and date. His senses are intact and functional. As time goes by due to his recent
condition, his senses are fluctuating especially the sense of taste. He is not productive in terms of
his assigned task and obligation, he lessens to communicate with his co-workers as he opted to
be alone. As time goes by, he cannot immediately cope to his conditions yet choose not to seek
medical attention as he is obliged to perform his duties at work. He prioritizes the needs of his
patients rather than solving his own health problems.

Meanwhile, Ryan is still able go to the gym as he always set his scheduled gym activity on
his DPA. He worked out religiously despite suffering from sore throat and difficulty of swallowing
for almost 14 days. He sleeps like a baby and prefer a dim light in his room while sleeping.

Finally, Ryan decided to visit for consultation in their family doctor, as his grandmother
convinced him to his health problems. Ryan has a warm bond with His Lola. He is a good provider
and a responsible son with his parents. He is also a choir member in their Baptist church and
actively attending every Sunday. After the consultation, the Private Physician prescribed him
Azithromycin 500mg 1 tab OD good for 3 days. Paracetamol 500mg 1 tab as needed. Increase
fluid intake and to have small frequent feeding with soft diet until swallowing is not in pain.

RGDA
 UNIVERSITY OF NEGROS OCCIDENTAL RECOLETOS
COLLEGE OF NURSING
RELATED LEARNING EXPERIENCE
2nd Semester, A.Y. 2022-2023
I. Gordon’s Eleven Functional Health Patterns
Gordon’s Health Assessment
Pattern
Health Perception – Health
Management Pattern
Elimination Pattern
Cognitive – Perceptual Pattern
Self-perception – Self-concept
Pattern
Sexuality – Reproductive
Pattern
Value – Belief Pattern
Nutritional – Metabolic Pattern
Activity – Exercise Pattern
Sleep – Rest Pattern
Role – Relationship Pattern
Coping – Stress Tolerance
Pattern
RGDA
Situation
The patient took over the counter drug, specifically Paracetamol 500mg 1 tab as
needed to manage hyperthermia. However, two days after, he experienced sore
throat and difficulty swallowing which prompt him to consume soft diet rather
than solid food because he believed hard food will further irritate his throat.
After the consultation, the patient is prescribed with Azithromycin 500mg 1 tab a
day good for 3 days.
The patient suffered from irregular bowel as a result of decreased intake of fiber-
rich food. Then, constipation presented due to lack of appetite.
There is no sensory deficit in the patient but functions are diminished due to his
condition, especially his sense of taste. He became unproductive in terms of his
task and obligations prior to him claiming he is the rookie in their station
because he knew he is smart and reliable in his work. Additionally, he is oriented
to people, time and location, and responds physically and verbally to stimuli.
Recently, the patient came to realize that admission would be beneficial for him
to help him with his needs, to relieve him from sore throat and difficulty
swallowing as well as to have a regular bowel again. He is optimistic about being
relieved and receiving treatment.
The patient hasn’t had any sexual encounters for the past couple of months due
to his strict schedule, and he actually took an STD test three weeks ago which
yield a negative result for syphilis, chlamydia, and gonorrhea.
The patient is a choir member in their Baptist church and actively attends every
Sunday mass. The admission to the hospital and administration of health care
plan will not disrupt any religious or spiritual practices that are already underway.
Prior to hospitalization, the patient claimed to have lost his appetite because of
difficulty swallowing brought upon by the sore throat he has been experiencing
for almost 14 days already. He had a sudden weight loss from 54kgs changed
into 52kgs, and lean into soft diet that are easy to swallow instead of solid food.
After the consultation, the patient is ordered to increase fluid intake and to have
small frequent feeding with soft diet until swallowing is not in pain.
The patient is able to have full function of both his upper and lower extremities.
His range of motion is not limited and he is still able to go to the gym and work
out religiously despite the sore throat and difficulty swallowing.
The patient doesn’t have any difficulty in terms of falling asleep, and doesn’t
need any medications to help him sleep, however he prefers a low light setting
on his bedroom.
The patient currently lives with both his parents and has a close relationship with
them, and claimed being a good provider and responsible son. He also has a
good relationship with his grandma, with his grandma being the one who forced
him to seek medical help.
Despite the concern on his health, the patient still chooses to attend to his duties
as a nurse rather than seek medical intervention. He copes to the stress of his
recent condition by keeping himself busy as he tends to the needs of his
patients, and opted to be alone by lessening the communication between him
and his co-workers.
 UNIVERSITY OF NEGROS OCCIDENTAL RECOLETOS
COLLEGE OF NURSING
RELATED LEARNING EXPERIENCE
2nd Semester, A.Y. 2022-2023

II. Demographic Data

Full Name: Ryan Liman

Age: 38 years old
Sex: Male

III. Medical History

Present: Patient presents for evaluation of sore throat and dysphagia with
fever for almost 14 days.

Past: Patient experienced irregular bowel movement and in year 2008, patient
was diagnosed with appendicitis, which resolved after STAT OR
(Appendectomy). During childhood, patient was diagnosed with chicken pox,
which resolved after three weeks. Additionally, the patient describes no
history of cancer, lung disease or previous heart disease.

Family Hx: Both of the patient’s parents are alive and well. No brothers or
sisters. There is no positive family history of hypertension, diabetes or cancer.

Medication:

- Occasional OTC Paracetamol 500mg

- Metformin 500mg 1 tablet TID as maintenance
- Azithromycin 500mg 1 tab OD good for 3 days

Previous Illnesses: The patient experiences constipation or irregular bowel

movements due to a lack of fiber intake. With the previous injury due to
inflammation of his appendix, he also experiences slightly elevated blood
sugar levels, or hyperglycemia; hence, he is taking Metformin 500mg as
prescribed by his physician, and with experience with previous chicken pox in
his early childhood days.

IV. Subjective Cues: Ryan verbalizes, “My throat is dry and itchy, which has
made it difficult for me to swallow solid food for almost 14 days now.” and
“I’ve also been feeling hot, and my skin is flushed.”

V. Objective Cues:

Temp: 37.80C
BP: 180/110 mmHg
W: 52 kgs
The patient is noted to have poor skin turgor
Has a redden or swollen tonsils
Dry and cracked lips

VI. Chief Complaints:

- swollen tonsils
- loss of appetite
- fever 37.8

RGDA
 UNIVERSITY OF NEGROS OCCIDENTAL RECOLETOS
COLLEGE OF NURSING
RELATED LEARNING EXPERIENCE
2nd Semester, A.Y. 2022-2023
- hypertensive 180/11

RGDA