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1. Health Perception/Health Management Pattern
Consult Health facility in times of health crisis.
Diagnosed with PTB last 2008 and had undergone a
series of treatment and the medications prescribed to
him are INH, rifampin, ethambutol and pyrazinamide
daily for 8 weeks and continuing for up to 6 to 7 months
but after three months he stopped taking these
medications without consulting his physician.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
Medications like over-the-counter drugs.
During admission patient complies with the
medicines needed.
Does not take any food supplement or
vitamins.
Patient has no allergies to food, and drug.
Do not practice regular exercise.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
2. Nutrition and Metabolism PatternWeight: 72 kgHeight: 5’6 ftVital signs: ( July 31,2010 12pm) BP- 120/70 PR- 73 bpm
RR- 21 cpm T- 36.4°C
PTA, the patient eats 3 times a day with a serving of 1-2 cup of rice, viand and a glass of waterPatient experience acute pain in the right upper chest. Presence of stabbed wound at the upper right portion of his back.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
Post operative incision at the upper right portion of
his chest.
IVF D5 LR 1000cc x 10 hours hooked at right
metacarpal vein regulated at 10 gtts per minute.
Occasional drinker, drinks alcohol atmost 2-3
times/week but drinks in lager amounts.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
3. Elimination Pattern
Prior to admission, the patient has a bowel
habit of 1-2 times a day
During the admission, the patient able to
urinate 2-3 times a day and a bowel movement
of 3 times within 5 days of hospitalization.
no observed blood during urination.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
4. Activity and Exercise Pattern
During the admission patient needs assistance in ADL.
Patient has slowed and cautious movement due to
CTT attached
Able to ambulate with limited movement on left arm
due to IV infusion and upper right extremities due to
the CTT attached ranging from the chest to the hands
left arm due to IV infusion.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
5. Sexuality/ Reproductive Pattern
Male, married, 5 children
Reported no use of contraceptives both artificial and
natural methods.
The patient has been married for 20 years, currently
staying with his children but is away from his wife for
almost a year due to work assignments.
Patient does not have questions or concerns about how
his illness will affect the sexual aspect of his life.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
6. Cognitive/ Perceptual PatternNo sensory deficits.PERRLAOriented to time, place and person.Responds appropriately to verbal and physical stimuli.Recent and remote memory intact.Patient states pain on the right upper chest with pain scale of 7 out of 10, 10 as the highest.Patient verbalized “Okay naman ang akong samad, kining tubo lang medyo sakit malisdan ko mag lihok maong kelangan jyud nay mag tabang”
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
No hearing, visual and memory difficulties noted.
Patient does not have difficulty understanding,
answering questions and following directions.
Patient has clear and appropriate responses to
questions.
Patient talks in “Bisaya”
Patient is able to participate in decision making for his
health.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
7. Roles and Relationship PatternStates good relationship with family but always in trouble and argument when he is intoxicated with alcohol.The patient’s parents are still alive.Family is supportive financially and emotionally.Patient verbalized “Maayo man among relasyon sa among balay, okay pud mi sa akong asawa, pirmi man siya naga tawag sa amua. Makakita lang man ko og away didto sa amu kanaang naka inom na lage, unya magkainitan, magkabiklanay dira jud”
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
Client works as a tricycle driver.
Positive interaction with watchers/significant others
observed.
Does not have difficulty in relating to staff and nurses;
complies with the instructions provided by the health
care givers.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
8. Self-Perception / Self- Concept Pattern
Patient expresses understanding and recognition of
his present condition and does not verbalize signs of
hopelessness; “Okay naman ko, pwede naman gani
mudagan.”
Patient talks with eye to eye contact with clear voice.
Patient manages to smile and conversant with others.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
Patient is properly groomed: Clean fingernails,
toenails and hair is well commed.
Patient expresses concern with his illness and work
“Basig madugayan ko diri sa hospital,obserbahan pa
man gud daw ko ingon sa doctor unsaon nalang ang
mga bayarin kelangan jud mag trabaho”.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
9. Value/ Belief Pattern
Patient is Roman Catholic by faith.
Attend mass whenever possible.
Prays by himself.
Values family relationships.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
10.Coping/ Stress Tolerance PatternFamily members are supportive to patient’s needs.Patient verbalized “Maau gani naa akong asawa, sige gani to padala og kwarta kay hurot na jud akong kwarta diri naga bisita man pud akong mga parente diri, nag llisod pud lage to sila maong maulaw pud ta mangayo og tabang”.Sleeps, listening to music, playing of cards and drinking of alcoholic beverages as a form of relaxation.He asks questions about his vital signs.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
11.Sleep/Rest Pattern
Usually the patient sleeps at around 8:00-9:00 in the
evening and wakes up at 5:00 in the morning.
During hospitalization, he experiences discomfort due
to the CTT attached to him. He tries to take a nap of
about two hours in the afternoon.
Patient does not have any sleeping routines or
sleeping aids.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
12. Medication History
Takes pain relievers and OTC drugs for common illnesses.
Patient verbalized “Gapalit nalang kog tambal sa botika,
mga over-the-counter, para mayo dayun ang akong mga
sakit, sama sa ubo, sip-on o hilanat”
No stated childhood illness.
Unreported presence of allergies as stated by patient
“Wala man koy allergies”.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
Diagnosed with PTB last 2008 and had undergone a
series of treatment and the medications prescribed to
him are INH, rifampin, ethambutol and pyrazinamide
daily for 8 weeks and continuing for up to 6 to 7 months
but after three months he stopped taking these
medications without consulting his physician.
Gordon’s Functional Health Gordon’s Functional Health PatternPattern
Medicines:
1. Ampicillin 100 gm IVTT q 6hours PRN
2. Ketorolac 30 mg IVTT q 8hours, ANST
3. Cefuroxime 500 mg 1tab PO, TID
4. Cefuroxime 750 mg IVTT q 8hours
5. Ambroxol 75 mg 1tab PO, TID
6. Myrin-P 3 tabs 30 minutes before breakfast
Gordon’s Functional Health Gordon’s Functional Health PatternPattern