You are on page 1of 6

Gordons Pattern of Health November 29, 2011 Health Pattern Health Interpretation and Maintenance Past Condition Patient

is a 72 years old male. The client rated his health status as 6 out of 10, 10 being the highest and 1 being the lowest. Present Condition The patient is conscious, coherent and oriented to time, place and person. He stated, Di ko During his childhood, he acquired diseases including measles, chickenpox, and mumps. He didnt have any serious illness so he doesnt visit the doctor often. He became more aware of the things that he needs to He has no known allergy. avoid like drinking alcoholic According to him he smoke 10 cigarette sticks per day and started at the age of 17 years old. With his current condition, he And he drinks alcoholic beverages with his friends and neighbors for about 1-2 bottles of Ginebra Gin. eagerly complies with the doctors orders for his immediate recovery and feels dependent to his family. (Basic Nursing 6th Edition by Potter and Perry p.4) beverages and smoking cigarette. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 32 na magawa yung mga ibang bagay na nagagawa ko noon, may limitasyon na ngaun. A: Because of his condition, the client feels that his illness is will eventually become severe if he will not compliant with his medications and doctors advice. He assumes total responsibility for decision-making and selfcare.not Reference: Fundamentals of Nursing; The Art and Science of Nursing Care, 6th edition page 70 Analysis and Interpretation I: With clients condition, he is eager to stop smoking because he perceptive that it is the major factor of his illness.

Nutrition and Metabolic pattern

He usually eats bread or pandesal and drinks coffee for breakfast.

Patient is on a DAT

I: Clients doesnt have any problem in appetite.

Has good appetite. Claims that she A: The nutritionalmetabolic pattern focuses on food and fluid intake, the bodys use of this intake, and problems that might The patient influence intake. doesnt have any problems in eating.

For lunch, he eats variety of dishes but mostly, its fishes and vegetables.

He consumes 1-2 cups of rice for lunch. For dinner, he eats the same dish from lunch which is mostly left-over. Drinks 1000cc-1500 of water a day.

consumed 1 cup of rice per meal. The patient eats dishes with pork and vegetables. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 120

Drinks 800cc-1000 of water a day.

Weighs 103lbs. Elimination pattern According to patient he has no problem in defecating and urinating. He usually defecates once a day with a consistency of soft to hard and a color of brown to dark brown stool. Claims that he has Has no difficulty in defecating. Still eliminates 1-2 times a day, defecates brown moist stool. Waste products of digestion is a natural process, healthy fecal elimination usually requires 2-3L of daily fluid intake and high fiber diet. One third to of ingested food waste is normally excreted in the stool within 24hrs, and the remainder will be on the next 24 and 48hrs.

He usually urinates about no problem in 4-7 times a day with light. urinating. Reference: Coxs Clinical Applications of Urinates 4-6 times a day. Nursing Diagnosis 5th edition, page 230

Activity and Exercise pattern

Patient does not require any help and is completely independent in performing activities such as feeding, bathing, dressing, toileting and ambulation and driving.

Patient is unable to perform activities of daily living due to easy fatigability.

I: During the hospitalization the client needs assistance when performing daily living activities.

A: Because of his condition, the client was unable to do his tasks alone. A problem in the activity exercise pattern may be the

He usually performs stretching in the morning as a form of his daily exercise.

primary reason for the patient entering the health-care system or may arise secondary to problems in another functional pattern. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 270

Sleep and Rest pattern

Sleeps 8hrs daily, from 12mn until 8am, takes afternoon naps around 2pm.

As verbalized by the patient he has a difficulty sleeping throughout the day due new environment (hospital) and complaints of noisy environment.

I: During hospitalization the client is experiencing discomforts. He prefers to rest in his bed and more secure environment. Client expressed his anxiety towards sleep pattern and rest insufficiencies.

A: The client could not sleep well because of new environment. He is also uncomfortable to his hospitalization Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 425

Cognitive and Perceptual pattern

The patient claimed he has problem with his eye sight, hes experiencing blurring of his vision or decreased in vision because of his age.

Patient experiences decreased of vision.

I: The client experiences eye problems but he has good memory and has no problem in hearing, touch and smell.

However, he is cooperative in A: Decreased in vision or difficulty in reading and seeing is one of the signs of senile degeneration. Delmars Geriatric Nursing Care Plans 3rd edition

He also stated that he doesnt have any

answering my questions and has

problem in hearing, taste, no signs of touch, smell, and pain perception. looseness of association or any flights ideas. The patient can recall memories and can relate or communicate with people even though he is only a elementary graduate. Self Perception and Self Control pattern The client would then view himself as someone who regards life to the fullest. During the assessment the client was calm and answered every question with Even without much to offer, he then perceives himself as someone to openly accept. ease and depth. He defined that his hospitalization caused a lifestyle change with some His daughter states that even when faced with hardships, client would say, Kaya natin yan. bodily changes. A: The patients behavior is affected not only by experiences prior to interactions with the health-care system, but also by interactions with the health-care system. I: The client has positive views on his condition. He thinks that his hospitalization only affected his body and lifestyle. He is still calm and positive about things.

He views himself as a person of positivity. The client does not exhibit rude behavior and remains respectful. Role and Relationship pattern The patient would view himself as a kind, loving and responsible father to his children. The relationship of his family remains strong. They remain firm and gather strength When they have problems in the family they solve it by talking between the members. from each other. They support each other and exude strength to the client. He was living with his wife in Masbate and his children were all living in Manila. 1 month ago he and his wife settled in manila with their children Sexual and Reproductive pattern Client has been in a He and his wife

Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 520 I: The clients relationship with his family is strong. A: The clients hospitalization made their family become stronger. They used each as a source of energy and hope. Each of us has several roles in family with the related responsibilities. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 606

I: The client had no sexual activity. A: Sexuality patterns involve sex role behavior, gender identification, physiologic and biologic functioning and the ability to express sexual feelings but the aging altered the sexual drive of person. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 715

romantic relationship with dont have any his wife. sexual acts but they remain He is not sexually active. intimate with each other by always looking after him specially in his condition right now

Stress and Coping pattern

His major stress occurred when a family member died. However, he was able to cope well because of his familys support. He wasnt problematic with his family in terms of finances because of children, was able to provide for their familys needs.

His illness is his biggest problem and a major source of stress. However, he is able to cope with this because of the continues love and support he gets from his family.

I: The client copes because of his children. Whenever he experiences stress, the client would take time to rest. He also talks to his children about his problems.

A: His ability to respond to stress is affected by a complex interaction of physical, social, and emotional reactions.

Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 741

Values and Belief pattern

The client is Roman Catholic. He considers his family as the most important thing in his life.

During hospitalization the clients responses was really hard to validate but the

I: During hospitalization the clients responses was really hard to validate but the relatives was very much consistent to mention that he has strong faith in his God especially during times of conflict or suffering. A: The patient finds great solace in their spirituality and the values and beliefs they have formed through a lifetime.

Whenever problems arise, they support each other. He also values the practices that he had acquired from his parents. So, he also applies them to his own family. Some of these are celebrating fiesta and Christmas.

relatives was very much consistent to mention that he has strong faith in his God especially during times of conflict or suffering.

Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 803