COLLEGE of NURSING

Silliman University
Dumaguete City

Gordon’s Functional Health Pattern

USUAL PATTERN INITIAL ASSESSMENT ON GOING

January 4, 2011 ASSESSMENT
I. HEALTH
PERCEPTION/HEALTH
MANAGEMENT
 Health has been good as claimed for the past year.  Admitted: January 1, 2011; 06:00 PM at SMC.  Patient was discharged on the
 Does not exercise regularly but considers jogging as  Vital signs: same day January 4, 2010 at
her exercise to keep herself healthy. She walks for at  T= 36.5 C 1:00 pm.
least once a week for 1 hour.  PR= 70 bpm
 Does not smoke.  RR= 19 cpm
 Occasionally drinks alcoholic beverages.  BP = 110/70 mmHg
 Does not do breast self examination.  Rated pain felt upon urination as 5on a scale of 1-10, being
 Finds it easy to follow nurse’s or doctor’s order. 0 as the lowest and 10 as the highest.
 Diabetes Mellitus is the heredo familial disease  Client verbalized that she has been experiencing coughs
identified. and colds.
 Medications:
 Paracetamol = 500mg 1tab q4h
 Cefalexin = 500mg 1cap q8h
 Amnum= BID
 Prenatal Vitamins Rejuvon OB= 1 cap daily.
 Blood type: 0
 G1 P0
II. NUTRITIONAL METABOLIC
PATTERN
 Eats three times a day and sometimes takes her
 Doesn’t lose her appetite upon hospitalizations.
snacks in between meals.
 Does not need assistance upon consuming food.
 Daily Food Intake:
 Client appears well nourished and not emaciated.
 Breakfast
Amount  Diet: DAT
 Without IV line. IV line was removed at January 3,
Kind of Food
2011 around 9:00PM
Cereals 1 bowl
Bread 1-2 pieces  Eats foods that are routinely served in the hospital.
(ward)
 Lunch
 Supplements: prenatal vitamin, Rejuvon OB (1 capsule
Amount
daily)
Kind of Food
 Claimed that she had gained a little weight because of
Rice 1 cup her pregnancy.
Fried Meat 1piece
 Client stated that the doctor prohibited her to drink
Vegetables 1 bowl
acidic drinks and instead increase her water intake to at
 Dinner least 8-10 glasses a day.
Amount
Kind of Food
Rice 1cup
Meat 1 piece
Fish 2 pieces
 Daily Fluid Intake
 Breakfast
Amount
Kind of Fluid
Milk 1 glass
 Lunch
Amount
Kind of Fluid
Juice 1 glass
Water 1 glass
  Dinner
Amount
Kind of Fluid
Milk 1 glass
Water 1 glass
 Often drinks soft drinks and junk foods when in
school.
 Generally has a good appetite.
 No food allergies noted.
 Weighs 98 lbs.
 Claimed that she gained weight because of eating
large amount of food at night.

III. ELIMINATION PATTERN

 Eliminates bowel everyday or once a day.
 Urinates 3-4x a day.  Bladder:
 Sometimes experienced discomfort during bowel  Client complains of pain upon urinating, client rated
eliminations as claimed. pain as 5 on a scale of 1-10; 1 being the lowest and 10 being
the highest.
 Does not have any discomfort voiding.
 Urinated 8-9x per day since admission.
 Stool formed is soft and brownish in color.
 Bowel:
 Skin: no noticeable problems; intact and smooth, no
rashes noted.  Already defecated yesterday.
 Stool was soft and slightly brown in color.
 Skin: soft; minimal sweating noted, no foul odor
noted.
IV. ACTIVITY EXERCISE
PATTERN
 Has sufficient energy for completing desired
activities.
 Leisure activity: watching TV, reading, going out  Can fully ambulate but sometimes she requests the
with friends. assistance of her mom when she needs to go to the
bathroom.
 Activity Pattern:
 Talks frequently to her “bantay”, who is also her mom,
 5:30- 6:00 am – wake up and prepare for
when no one visited her yet.
school.
 6:00-6:0 am - eat breakfast
 6:10- 6:25 – travel and proceed to school.
 6:25 or 7:00 am – 8:00 pm –school
 8:00-8:15pm – dinner
 8:15-9:00pm – watch TV, surf the net.
 9:00 – 12:00am – study
 12:00am – sleep

V. SLEEP REST PATTERN

 Usual sleep pattern
 Onset: 12mn  Usual sleep pattern
 Awakening: 9 am  Onset: 7pm
 Sleep interruptions: none  Awakening: 6:00 am
 Sleeps with the lights off and with two pillows  Sometimes sleep was interrupted due to nurse’s
 Number of sleeping hours: 6-7 hrs. procedures like vital signs taking, and administration of
 Does not use mosquito net. medications. (part of nursing procedure)
 No sleeping problems and aids.

VI. COGNITIVE PERCEPTUAL

PATTERN
 Oriented to time and place.
 Does not have hearing problems.  Experiences minimal/moderate pain upon urination.
 Memory is still good.  Rates pain as 5 as a scale of 0-10.
 College graduate.  When in pain, minimal sweating is noted.
 Finds it easy to learn regardless of teaching  Doesn’t use any visual aids.
method.  Near Visual Acuity:
 Can read 1 ft. away without moving
it closer.
 Far Visual Acuity:
 Cannot read letters in a 20 feet
distance.
 Hearing Acuity:
 Hear ticking of the watch and
whispered voice.
 Speaks well, and it is clear and understandable; not
stuttering.

VII. SELF PERCEPTION PATTERN

 She perceives herself as simple and as claimed “ok”.
 Claimed that she only has problems within her  Claimed to be happier now because her mother has
family very often. accepted her pregnancy.
 Does not get angry easily.  Doesn’t blame herself for what happened or her
hospitalization anymore.(reason)

VIII. ROLE RELATIONSHIP

PATTERN
 Lives with her mother and her brother.
 They are 3 living in their house.  Speech is clear and relevant; easy to understand.
 Client claimed that there are no house problems in  Her mother is at her bedside and is ready to attend to all
 the house that she is living. of her needs.
 Language spoken at home: Cebuano  Relatives frequently drop by to visit her.
 Her mother and her father are both Dumaguetenos.  Close friends have not yet visited her.
 Turns to her boyfriend and her mother when she
needs help with anything.
 No difficulties in relating with the family and future
in laws.
 Has close friends.

IX. SEXUALITY REPRODUCTIVE

PATTERN
 Does not use any contraceptives.
 Menarche: 13 years old.
 Lasts for 7-9 days or more.
 G1P0
 LMP: August 4, 2010
 Her mother is very attentive to her needs ever since she
 Sometimes feels dysmenorrhea upon menstruating. got pregnant.
 Used to have regrets of having a child.

X. COPING STRESS
MANAGEMENT PATTERN
 Share her problems to her boyfriend and mother.
 Does not go to church regularly.
 Always find ways to solve her problems.
 When under stress she watches TV, or reads in order  She feels that her hospitalization is slightly stressful.
to relax herself.  She has been administered with analgesics to relieve her
 When she knew she got pregnant she had attempts pain.
to get rid of the child.  No longer feels so much regret on getting pregnant.
 Client verbalized that she used to be suicidal.  No longer has the urge to get rid of the baby.

XI. VALUE BELIEF PATTERN

 Does not have a strong faith in God.
 Seldom goes to church.
 Roman Catholic  No religious materials on bedside table.