Upload
rosuelle-manalang
View
220
Download
0
Embed Size (px)
Citation preview
8/8/2019 Gordons Pa.payward
1/18
GORDONS PATTERNS OF FUNCTIONING
A. Psychological Health
The Psychological health of the child falls on Erik
Eriksons first stage of development, the Trust vs. Mistrust
where the virtue is Hope. A per observation, the child puts
everything in her mouth and if referred as the Oral
Sensory stage. The major emphasis is on the mother'spositive and loving care for the child, with a big emphasis
on visual contact and touch. Since the child is on his
infancy stage, she depends most of her needs to his
mother or to his parents, from his food (milk) to self-care
(changing diaper). It is believed that if we pass
successfully through this period of life, we will learn to
trust that life is basically okay and have basic confidence
in the future. If we fail to experience trust and are
constantly frustrated because our needs are not met, we
may end up with a deep-seated feeling of worthlessness
and a mistrust of the world in general
B. Sociocultural Health
The infant is receiving breast milk from her mother
which is obviously free and very helpful for the childs
health. The mother also uses Bona, infant milk which she
gives as substitute formula milk for her son whenever they
8/8/2019 Gordons Pa.payward
2/18
go out or if she has some chores to do like going to the
market that requires her to be gone for a while.
C. Spiritual Health
The child is not yet baptized according to her
mother. The parents are both Roman Catholic. They have
belief like, whenever their son has hiccups, they applied a
small of paper on the childs forehead; they believe that
upon doing so will make the hiccups go away. They also
believe on usog which they believe will cause their sonto become irritable and uncomfortable or sometimes will
have fever whenever someone praise their son as a
precautionary measure they will make that person put a
cross on the childs feet or forehead with a little saliva on it
that will prevent him from being irritable or be normal
again.
ACTIVITIES OF DAILY LIVING
A. Nutrition
The child receives human breast milk from her
mother and a Milk Formula Milk (Bona) which can be
bought over the counter from any stores. The child has a
good sucking reflex. According to the mother, her son
consumes a maximum of 3-4 bottle of a 4 ml bottled milk
of the formula milk whenever she has something to do +
her breast milk every 4 hours. She uses boiled water or
8/8/2019 Gordons Pa.payward
3/18
commercial mineral water to prepare the infants formula
milk.
B. Elimination
According to the mother, the child consumes 3-4
diapers a day. Defecates 1-2 times a day usually early in
the morning or late in the evening. As described by the
mother, the child has soft yellow colored stool.
C. Exercise
An infants exercise is merely his play ( Solitary
Play). Her mother said that she is able to massage the
childs body at times.
D. Hygiene
The mother has her son take his bath at 8:00 in the
morning after having him exposed to sunlight. She uses
warmed water with calamansi in bathing her son. In the
days of Tuesday and Friday, she prefers not taking her son
to bathe because of certain belief which she doesnt know
but she exercised because her mother told her so.
8/8/2019 Gordons Pa.payward
4/18
8/8/2019 Gordons Pa.payward
5/18
COMPREHENSIVE PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENT 1 (HEAD TO NECK)
BODY PARTS NORMAL FINDINGS ACTUAL
FINDINGS
ANALYSIS
GENERAL
APPEARANCE
Relaxed, coordinated
movement, clean,neat, no body odor,
healthy appearance;
cooperative, has
sense of reality
Fatigue
appearance,uneasiness,
coherent;
conscious;
labored
breathing
Abnormal
due toundergoing
disease
condition.
Pneumonia
which
compromises
that
respiratory
system of
the child.SKULL Rounded and
symmetrical, with
frontal, parietal, and
occipital
prominences;
Smooth skull contour
Rounded;
smooth skull
contour
Normal
SCALP Smooth, uniform
consistence; absence
of nodules or masses
Has no
tenderness; no
masses or
nodules
Normal
8/8/2019 Gordons Pa.payward
6/18
HAIR Evenly distributed
and covers the whole
scalp; Maybe thick or
thin, No infection and
no lice.
Evenly
distributed with
no patches of
hair loss; thick
hair; Silky and
no lice.
Normal
FACE Symmetric or slightly
asymmetric facial
features
Symmetrical
facial features
while talking or
elevating the
eyebrow.
Normal
EYES Shape depends on
the race
Mild sunken
eyes
Might be a
manifestatio
n of sleep
disturbance.EYEBROWS Symmetrical and in
line with each other;
maybe black, brown
Symmetrical
and aligned
with eachother; black;
evenly
distributed.
Movements are
symmetrical.
Normal
EYELASHES Evenly distributed;
turned outward
Turned outward
eyelashes; hair
equally
distributed
Normal
EYELIDS Upper eyelids cover
the small portion of
the iris, cornea, and
Able to close
the eyes and
has the ability
Normal
8/8/2019 Gordons Pa.payward
7/18
sclera when eyes are
open; eyelids meet
completely when the
eyes are closed;
symmetrical
to blink.
LOWER
PALPEBRAL
CONJUNCTIVA
Pinkish or red in
color; with presence
of small capillaries;
moist; no foreign
bodies; no ulcers
Red in color;
smooth in
texture
Normal
SCLERA &
CORNEA
White in color; clear;
no yellowish
discoloration; some
capillaries maybe
visible
Pale white
sclera with
some visible
capillaries.
IRIS Anterior chamber is
transparent; no
noted visiblematerials; color
depends on the
persons race
Dark brown in
color;
transparentanterior
chamber
Normal
PUPILS Color depends on the
persons race; size
ranges from 3-7 mm,
and are equal in size;
equally round
Pupil color is
dark brown;
3mm in size.
Normal
EYE
MOVEMENT
Constrict
briskly/sluggishly
when light is directed
to the eye, both
Dilates when
looking at far
objects and
constricts when
Normal
8/8/2019 Gordons Pa.payward
8/18
directly and
consensual
looking at near
objects.
Constricts when
there is light.PERIPHERAL
FIELD VISION
When looking
straight ahead, client
can see objects in
the periphery
N/A
VISUAL
ACUITY
Able to read
newsprint or small
details
N/A Normal
AURICLES Color same as facial
skin; symmetrical;
auricle aligned with
outer canthus of eye;
no tenderness
Same color as
the facial skin;
tip of auricle
aligned at the
outer canthus
of the eye; not
tender
Normal
EAR CANAL Contains hair follicles
and glands. Dry
cerumen, grayish-tan
color, sticky wet
cerumen with
various shades of
brown
Contains hair
follicles and
glands. With
sticky wet
cerumen with
various shades
of brown
Normal
HEARINGACUITY
Normal voice tonesaudible
N/A.
NOSE Air moves freely as
the client breathes
through the nares;
no tenderness
Both nares are
patent; intact;
no secretions:
no painful
Normal
8/8/2019 Gordons Pa.payward
9/18
sensation when
palpated
INTERNALNARES
Air moves freely asthe client breathes
through the nares
Both nares arepatent..
Normal
NASAL
SEPTUM
Nasal septum intact
and in midline
Nasal septum
intact and in
midline
Normal
LIPS Uniform pink color;
soft, moist, smooth
texture; symmetry of
contour; ability to
purse lips
With ulceration
on the upper
lips
Lack of Vit. C
and proper
mouth
hygiene.
GUMS Pink gums; no
retraction
With some
sores
Due to non-
cleaning of
tongue after
breastfeedin
g and bottle
feeding. TEETH 32 adult teeth;
smooth, white, shiny
tooth enamel;
smooth, intact
dentures
N/A ( no teeth)
TONGUE Central position; pink
color; smooth tongue
base with prominent
veins
Located and
positioned in
the center. With
white spots due
to milk residue.
Normal
FRENELUM pink color; moist;
slightly rough; thin
Pink and moist.
Tongue moves
Normal
8/8/2019 Gordons Pa.payward
10/18
whitish coating;
moves freely; no
tenderness
freely and no
pain felt.
BUCCAL
MUCOSA
Uniform pink color;
moist, smooth, soft,
glistening, and
elastic texture
Pink color and
moisten.
Normal.
SOFT PALATE Light pink, smooth,
soft palate
Light pink Normal
HARD PALATE Lighter pink hard
palate , more
irregular texture
Has lighter pink
than the
sof t palate
Normal
UVULA Positioned in midline
of soft palate
Positioned at
the center of
the oropharynx
Normal
TONSILS Pink and smooth; no
discharge; of normal
size
Has no
discharge;
pinkish
Normal
NECK
(gag feflux)
Present Present Normal
PHYSICAL ASSESSMENT 2 (THORAX & ABDOMEN)
BODY
PARTS
NORMAL
FINDINGS
ACTUAL FINDINGS ANALYSIS
POSTERIOR Anteroposterior to Has a anteroposterior Normal
8/8/2019 Gordons Pa.payward
11/18
THORAX transverse
diameter in ratio
1:2; Chest
symmetric
to transverse
diameter ratio of 1:2,
elliptical in shape and
symmetrical chestANTERIOR
THORAX
Skin intact;
uniform
temperature;
chest wall intact;
no tenderness; no
masses; Quiet,
rhythmic, and
effortless
respirations
Has an intact skin;
has equal warmth on
both sides. With
wheezes and effort
respirations
Because
pneumonia is
a general
term that
refers to an
infection in
the lungs,
the person
tend to have
tachycardia
because of
the effort of
the lungs to
compensate
to the
infection.
Wheezing is
an indication
of viral
invasion.
HEART With palpations With palpable
pulsations on the
apical area.
Normal
BREAST Females: round
shape, slightly
Impact skin of breast,
round shape and
Normal
8/8/2019 Gordons Pa.payward
12/18
unequal shape in
size, generally
symmetric
somewhat unequal in
shape but generally
proportion.
AREOLA Round or oval and
bilaterally the
same, colors
varies from light
pink to dark
brown
Dark brown in color
and round in shape
Normal
NIPPLES No tenderness,
masses, nodules
or nipple
discharge
Have no masses and
nodules.
Normal
ABDOMEN Pigmentation and
skin color should
be uniform; no
presence of scaror rashes; bowel
sounds: shape flat
or rounded
Even skin color and
pigmentation; free of
scar/rashes; bowel
sounds at RLQ: roundin shape; 41cm in
size.
Normal
PHYSICAL ASSESSMENT 3
(EXTREMITIES & NEUROLOGICAL ASSESSTMENT)
BODY PARTS NORMAL ACTUAL ANALYSIS
8/8/2019 Gordons Pa.payward
13/18
FINDINGS FINDINGSUPPER & LOWER
EXTREMITIES
Able to
move, followROM
N/A
FINGERS & NAILS Clean,
pinkish
Long nails with
dirt at the tip
and some in
sides of the
nails.
Abnormal
Proper
hygiene is
recommend
ed
RANGE OF MOTION OF
UPPER & LOWER
EXTREMITIES
Able to
move
without
assistance
N/A
NEUROLOGICAL
ASSESSTMENT
*MENTAL &
EMOTIONAL STATUS
LEVEL OF
CONCIOUSNESS
Apply the
Glasgow
Coma Scale:
eye
response,
motor
response
and verbal
response.
An
assessment
totaling 15
pts indicates
the client is
alert and
completely
Eye opening
8/8/2019 Gordons Pa.payward
14/18
oriented.
Comatose
client scores
7 or less.INTELLECTUAL
FUNCTION
Able to
repeat
series of
three digits
spoken
slowly and
gradually
increases
N/A
*SENSORY FUNCTION
PAIN
Able to
discriminate
sharp and
dull
sensation
N/A
LIGHT TOUCH Light
tickling or
touch
sensation
N/A
* MOTOR FUNCTION
A. COORDINATION
FINGER -TO-NOSE TEST
Repeatedly N/A
8/8/2019 Gordons Pa.payward
15/18
and
rhythmically
touches the
nose.ALTERNATING
SUPINATION &
PRONATION OF HANDS
ON KNESS
Can
alternately
supine and
pronate
hands at
rapid pace
N/A .
FINGERS TO THUMB Rapidly
touches
each finger
to thumb
with each
hand
N/A
B. BALANCE
WALKING GAIT Has upright
posture and
steady gait
with
opposing
arm swing
N/A
ROMBERG TEST Negative
Romberg:
may sway
slightly but
is able to
N/A
8/8/2019 Gordons Pa.payward
16/18
maintain
upright
posture and
foot stance.HEEL TOE WALKING Maintains
heel-toe
walking
along a
straight line
N/A
CRANIAL NERVES
CN 1 (OLFACTORY)
Able to
smell and
recognize
stimuli
N/A
CN2 (OPTIC) 20x20
vision, able
to read, 3-5
mm [pupil
size]
N/A
CN3 (OCCULOMOTOR)
CN4 (TROCHLEAR)
CN6 (ABDUCENS)
(+)
Extraoccular
Movement
(EOM);
Lateral
Upward and
downward;
pupils
reactive to
light.
Pupils react to
light. There is
constriction and
consensual
accommodation
. Able to move
the eyes in any
direction in
unison.
Normal
CN5 (Trigeminal) Able to feel
and clearly
N/A.
8/8/2019 Gordons Pa.payward
17/18
identify
stimulus,
with
bilateral
facial
sensation.
With active
corneal
reflex.CN7 (FACIAL) (+) Corneal
reflex ,
Facial
asymmetry
N/A
CN8 (AUDITORY) Able to hear
clearly, can
maintain
balance
N/A
CN9(GLOSSOPHARYNGEAL)
CN10 (VAGUS)
(+) gag
reflex, uvula
at the
center, soft
palate rises
Present gagreflex, able to
swallow.
Normal
CN11 (ACCESORY) Able to
shrug
shoulders
against
resistance
and able to
N/A
8/8/2019 Gordons Pa.payward
18/18
turn the
head side
and against
resistance.CN12 (HYPOGLOSSAL) Able to
move
tongue from
side to side
Able to extend
beyond the
tongue and
move it side to
side.
Normal