Assessment

Date: February 11, 2012

Vital Signs Temperature Pulse Rate Respiratory Rate Blood Pressure Weight Height : 38C : 98 b.p.m. : 48 c.p.m. : 160/90mmHg : kg : feet inches BEFORE HOSPITALIZATION Gordons Functional Health Pattern Subjective He graded his health 10 over 10 for the reason that he sees himself as having a strong wellbeing. He drinks Paracetamol or Alaxan whenever he is sick. He doesnt consult a doctor for regular check-ups and does not perform testicular examination. He had fever for the past months. He had no accidents for the past Subjective He graded his health 3 out of 10 because he sees himself weak. He is complying with his medications. He is afraid of his condition right now because he has 5 kids and he is still young. When asked what he thinks caused his illness, he answered that Objective General: He has an I.V. of 0.9% NaCl 1L x KVO at his left arm. He is well groomed. The patient is calm. DURING HOSPITALIZATION Route : Axillary Site : Radial Diaphragmatic Left arm

Health Perception Health Management Pattern

years. He drinks beer once a week, 1 mucho bottle. He smokes everyday, 1 pack. He started when he was 14 years old. He eats meal 3 times a day. He has normal and good appetite. He likes eating fatty and sweet foods. He eats vegetables and fruits. He doesnt take vitamins or any other supplements. He drinks more than 8 glasses of water a day. He also drinks milo or coffee. He has no difficulty in swallowing. Hes not constipated or had no problems in elimination of stool. He defecates once a day. He has normal color of stool. He urinates 8 times a day. His urine color was yellow. He doesnt use any laxatives.

he dont have an idea.

He eats meal 3 times a day. He has normal and good appetite. He consumes his food. He avoids sweet food. He eats vegetables and fruits. He doesnt take any vitamins and supplements. He drinks more than 8 glasses of water a day. He has no difficulty in swallowing. He can eat independently. Hes not constipated and has no problems in elimination of stool. He defecates once a day. He has normal color of stool. He urinates 8 times a day. His urine color was yellow. He doesnt use any laxatives. He has companion when going to the comfort room.

Nutritional Metabolic Pattern

Integumentary: No dentures. He is warm to touch. Lips are moist. Hair color is black and equally distributed. Skin turgor is normal. Skin is not dry. Oral mucosa is moist and pinkish. Braden scale of 19. DM diet.

Genitourinary: Bladder not distended. Urine color is yellow. Urine frequency is 8 times a day. Genitointestinal: He has no constipation. Stool color is normal. Defecation frequency is 1 time a day.

Elimination Pattern

 Every morning, he regularly does push-ups. He does not play any sports. He does household chores and farm activities.

He ambulates himself. He doesnt want to be lying on bed the whole day.

Musculoskeletal: Muscle tone is normal. He has proper posture. Gait is normal. Patient has Active Range of Motion. Lovett scale with grade of 5 ; Complete ROM against gravity with full resistance. Respiratory: He has tachypnea. Normal chest expansion. No chest pain. Has history of smoking (27 years). Cardiovascular: Pulse rate of 98 c.p.m. Nailo color is pink. Capillary refill is less than 2 seconds. Negative for Homans sign. No jugular vein distention. No swollen varicose vein. No edema.

Activity Exercise Pattern

Sleep Rest Pattern

His longest hour of sleep is usually 9 hours and his shortest is usually 4 hours.

He usually wakes up every now and then.

 He has no sleeping problems. He didnt have any nightmares for the past months. He feels refreshed whenever he wakes up in the morning. He usually awakes early. He takes a nap in the afternoon. He can feel pain. He has no hearing problems. He has eyeglasses with a grade of 500. He doesnt have any problems with his taste. He doesnt have any problem with talking.

He cant have a deep sleep and cant sleep well. He didnt have any nightmares or dreams. He feels stressed whenever he wakes up in the morning. He usually awakes early. He sleeps every now and then. He can feel pain in his left eye. He has no hearing problems. He cant wear his eyeglass.

GCS of 15. Pain scale of 7/10. He is oriented with the date, place and people.

Cognitive Perceptual Pattern

Self- Perception SelfConcept Pattern

He described his physical condition as healthy and believes in the saying Mas malakas pa sa kalabaw. Some things that can make him feel depressed is when his children has problems and when there is flack money which can be a problem in buying milk for his kids. His wife, brother and mother help him whenever these problems come. He has a positive outlook in life.

He doesnt have any problems with his taste. EENT: He doesnt have any problem with Pupils are equally round, talking. reactive to light and accommodation. Pale conjunctiva. White sclera. Left swelling of the eyes. He described his health as weak; he thinks the environment contributes to it. One thing that can make him feel angry is when a person doesnt do what he wants.

He has a positive outlook in life.

Role Relationship Pattern

Sexual Reproductive Pattern

He has a wife and 5 kids (1 girl and 4 boys) His mother lives with them. They have a second floor in their house. For him, its normal to have a problem with his children or any family member. He said that his family can bear with their condition. They help each other to afford what they need. Patient said that he was sexually active but his wife is not anymore. He is satisfied with his sexual relationship. He has no problem regarding sexual or reproductive organ. He didnt use any contraceptives. His mother, father and brother are the ones that he talks to whenever he has problems. They are always available for him. He said that whenever he feels any tension, he just drinks 1 bottle of beer. He feels relaxed whenever he drinks beer and smokes. He prays to handle some of his problems.

He said that his family is having a He has interaction with difficult time because of his his mother. condition. His family is supportive to him and visits him always.

He is satisfied with his sexual relationship.

Coping Stress Tolerance Pattern

His mother, father and brother are the ones that he talks to whenever he has problems. They are always available for him. He feels tense about the hospital bills and medications.

Value Belief Pattern

He is a Roman Catholic. His religion is important to him. He thinks that this helps him whenever he is faced with difficulties in life. He goes to mass every Sunday but not consistent. He formerly reads the Bible. He prays every night.

He always prays. He believes that his prayer helps because many supports or help are coming.