CASE STUDY

CEREBROVASCULAR DISEASE, HYPERTENSION STAGE 2, T/C COMMUNITY ACQUIRED PNEUMONIA- MODERATE RISK

By: Group 3B Asingho, Ma. Theresa

GORDONS FUNCTIONAL HEALTH PATTERNS Health Perception/ Health Management Pattern 1. Kindly Describe any health concerns that you would like to improve? 2. What do you do to improve/maintain your health? 3. Do you have any preexisting conditions, surgeries, procedures in the past? What and When? 4. Are you exposed to any communicable disease within the past year?

Nutritional-Metabolic Pattern 1. Do you have a special diet? ( )No ( )Yes. If yes, kindly indicate Prior to admission 1st day 2nd day 3rd day

2. When was the last time you ate? 3. Did you receive some instructions from the medical team to increase/restrict your fluid intake? ( )No ( ) Yes Prior to admission 1st day Kindly describe 2nd day 3rd day

4. Dentures?
5. Appetite

( ) Upper

( ) Lower

( )Partial

(Normal,Increased,Decreased) 1st day 2nd day 3rd day

Prior to admission

6. Do you have difficulty with ( )No ( )Choking ( )Swallowing Related to :

( )Smell ( )Tasting

( )Chewing ( )Following diet

7. Do you have?

( )No ( )Nausea ( )Vomiting ( )Indigestion ( )Weight loss/ gain kg/lbs ( )Mouth Sores ( )Persistent fever 8. Skin/ mucosa(color, temperature/moisture, turgor, edema) Prior to admission 1st day 2nd day 3rd day

9. Wounds/ Drains/ Tubes/ Catheters/ Dressings:

( )None

10. Oral mucous membrane (intact, moist, lesions, dry, color) 1st day 2nd day 3rd day Prior to admission

Elimination Pattern 1. Do you have any problems with bowel/bladder elimination? ( )No ( )Yes Describe: Prior to admission 1st day 2nd day 3rd day

2. Abdomen (soft, firm, nontender, tender, nondistended, distended, ostomies/tubes-type) 1st day 2nd day 3rd day Prior to admission

3. Bowel sounds (present, absent, other) 1st day Prior to admission

2nd day

3rd day

4. Bladder (nondistended, distended) Prior to admission 1st day

2nd day

3rd day

Activity-Exercise Pattern 1. Do you have enough energy for your daily activities? ( )No ( )Yes 2. Desired/Required Activities? ( )Yes ( )No 3. Activities Performed Prior to admission

1st day

2nd day

3rd day

4. Do you need assistance with ADLs? ( )Not applicable (eating, drinking, walking, sitting , toileting ,bathing, dressing, getting up from bed/chair, stair climbing, turning, preparing meds, shopping) Prior to admission 1st day 2nd day 3rd day

5. Do you have mobility problems? ( )none ( )history of falling ( )dizziness ( )unsteadiness/ balance ( )amputation ( )impaired limb ( )unable to assess ( )tremors/spasms ( )paralysis ( )decreased function ( )numbness, tingling, burning Prior to admission 1st day 2nd day 3rd day

6. Gross motor movement (gait, posture, ROM) Prior to admission 1st day 2nd day

3rd day

7. Do you have any assistive devices at home? ( ) No 8. Muscle Strength ( )not applicable Prior to admission 1st day Left arm: Right arm: Left leg: Right leg: 2nd day

( )Yes

3rd day

9. Respiratory Assessment Prior to admission 1st day Respiratory effort: Respiratory pattern: Breath sounds (right, left) Cough, Sputum 10. Cardiovascular assessment Prior to admission 1st day Rhythm Heart sounds Neck veins (flat, distended) Peripheral pulses (absent,weak, normal, bounding)

2nd day

3rd day

2nd day

3rd day

SLEEP-REST PATTERN ( )Not applicable ( )Deferred 1. Have you had difficulty sleeping? ( )No 1st day Prior to admission ( )Yes Describe 2nd day 3rd day

2. Difficulty falling asleep? ( ) No ( )Yes Describe Prior to admission 1st day 2nd day

3rd day

3. Early awakening? ( )No Prior to admission

( )Yes 1st day

2nd day

3rd day

4. Abnormal cycle of sleeping a. Daytime sleeping b. Awake at night Cognitive-Perceptual Pattern

( )No ( )No

( )Yes ( )Yes

1. Orientation (not oriented, oriented to person, oriented to person and place, Oriented to person, placeand time) 1st day 2nd day 3rd day Prior to admission

Level of Consciousness ( Conscious,Lethargic, sleepy, drowsy Stupor, Light coma, Deep coma) 1st day 2nd day 3rd day Prior to admission

2. Pupils ( )Not applicable

Describe :

3. Clarity of Speech (clear, slurred, aphasic) Primary language if not English: Prior to admission 1st day 2nd day 3rd day

4. Thought process (logical, illogical (confused), flight of ideas, deferred) 1st day 2nd day 3rd day Prior to admission

5. What is the highest grade in school you have completed? Occupation: Do you have problems with your memory? ( )No ( )Yes Hearing aid ( )No ( )Right ear ( )left ear Glassess/Contacts ( )No ( )Yes Do you have any problem with your ability to feel pain, temperature? Describe: Have you ever had a seizure? ( )No ( )Yes Describe your seizure When was your last seizure? Do you have pain? ( )No ( )Yes If yes ( type, duration, location) Describe How do you get relief from pain? What do you need to learn to be able to care for yourself after discharge?

Self- perception pattern 1. Mood (calm, agitated, angry, anxious, sad, other) Prior to admission 1st day 2nd day

3rd day

2. Affect (normal, labile, flat) Prior to admission

1st day

2nd day

3rd day

3. Verbal style (interactive, quiet, talkative, guarded) 1st day 2nd day Prior to admission

3rd day

Role-Relationship pattern 1. Lives ( )alone ( )with

2. Who will assist you with your care after discharge? 3. Resides ( )house ( )apartment ( )assisted ( )living

4. Environmental/Safety concerns (stairs, inaccessible bathrooms, etc) Describe: 5. Any current family difficulties of concern to you? ( ) none Descibre: Sexuality-Reproductive Pattern 1. Do you have any questions/concerns about the effects your physical condition or medications may have on your sexual activity? ( )No ( )Yes

Coping-Stress Pattern 1. Have you had any recent major-lifestyle changes? ( )No ( )Yes, describe

2. How do you deal with stressful situation?