Gordons Level of Functions

Health Pattern Health MaintenanceHealth Perception Pattern

Before Hospitalization Prior to admission: The patient perceived that his own health is in good condition. He does not smoke but drinks occasionally. No allergy was reported. Practices healthy lifestyle like having proper exercise, etc. Dont usually take medication when sick. Prior to admission: Patient loves to eat vegetables and fruits. Eats the usual breakfast meal like longganisa, hotdog and sinangag. Also eats his usual favorite dish during lunch & dinner with 1 cup of rice. He drinks at least 6 glasses of water and 1 can of softdrinks daily. Does not like drinking juices. He also stated that he has a good appetite and loves to eat spicy food. He does not have any allergy on food. He experienced gum bleeding 2 days before admission. Ht: 5 ft & 4 inches Wt: 53 kg BMI: 34.98 kg/m Body Temp: 37.4

During Hospitalization The patient perceived that his own health is not in good condition for almost a week now. He is worried about not getting better because of his consistent high fever for 6 days.

Interpretation Patient is aware of his present condition and verbalized that he experiencing weakness and body pain. Patient is compliant to the treatment and procedures that is being done. The patient was not able to eat what he usually eats because of loss of appetite. He also lost 3 kg due to lack of nutrition.

NutritionalMetabolic Pattern

Due to his present condition, patient lost his appetite and having a difficulty in eating. He eats only small portion of food. Ht: 5 ft & 4 inches Wt: 50 kg BMI: 28.89 kg/m Body Temp: 39.0

Activity and Exercise Pattern

Patient attends Wushu and Yoga lessons every weekend. He also plays basketball during his free time or sometimes once a week. Usually go out with friends after school. Able to bath himself.

Elimination

Weak and lethargic due to his fever and lack of nutrition. Also experiencing body malaise because of his high fever for six days. Needed assistance in simple activities like walking or standing up. Decrease in muscle movements and limited range of motion. Patient voids at least 5 Patient experienced times a day with light difficulty in yellow to yellowish in urinating and color. No burning defecates with soft sensation or pain felt blackish stool. when urinating. He sweats a lot due He defecates usually in to high fever. the morning before going Patient also had to school; with brown continuous nose and formed stools. Did bleeding followed not experience difficulty by vomiting in defecating. episodes. No problems either in perspiring. Usually sleeps around 10pm-7am during school days. His sleep varies during weekends . Always making sure that he sleeps almost or more than 8hrs daily; straight hours of sleep. No difficulty in sleeping. Does not use any medications to promote sleep. Rarely takes an afternoon nap. Patient can hardly sleep straight. Maximum of hrs of sleep is only less than 5hrs. He wakes up easily everytime nurses or hospital personnel would come and monitor him. Requested dim light to promote better sleep.

Patients daily activity was affected. He was not able to perform strenuous Activities. He was not able to bath himself because of limited muscle movement due to his present condition.

Due to his present condition, patients regular elimination was affected. His urinalysis appeared normal. But his Fecalysis shows that patient is experiencing gastro intestinal bleeding. Administered Plasil for anti-emetic. The patients sleeping pattern was affected by his present condition. Experienced difficulty to sleep because of his his fever. Advised to have complete bed rest with bathroom privileges.

Sleep and Rest Pattern

Cognitive And Perceptual

Well oriented with people, places, etc. No signs of forgetfulness. Both visual acuity and hearing are in good condition. Responds to stimuli verbally and physically.

Though weak & lethargic, patient was able to understand and hear comprehensively all our question and was able to answer it. Felt pain in the right lower quadrant. Gave an 8 pain score out of 10. Though the patient is weak, he still manages to appear calmed and relaxed. His major concern is to have a fast healing. Takes a nap and rest when tired. Verbalized the desire to get better.

Self-Perception and SelfConcept

Manages to practice healthy lifestyle. Perceived himself as a good person. Doesnt have a problem with his body image nor personal abilities. Copes up with stress by playing basketball with friends, watching movies and television and sometimes by jogging around their neighborhood. No traumatic events experienced before. Patient chose not to answer questions about sexuality and reproductive.

Still coherent even though patient is experiencing weakness. Administered Nubain as per doctors order to treat moderate to severe pain. Can respond to stimuli verbally and physically with weakness noted. No signs of sensory deficits. Patient shows anxiousness about health status but remained hopeful to get better soon inspite of his present condition. Patient shows ineffective coping because of his present illness.

Coping and Stress Tolerance

Sexuality and Reproductive

Patient chose to be private in this matter.

RoleRelationship Pattern

States that he is a family-oriented person. No conflicts with family, friends or other people. Considers himself as responsible son and a brother to his siblings. Loves his family. The patient believes in God but goes to church often.

Patient is being taken care of by his mother. Well supported by his family members.

Relationship with family members remained intact especially with his mother.

Value and Beliefs

No restrictions to any procedure (BT) or treatment because of religion. Prays a lot.

Procedures did not interfere to any spiritual practices.