Gordon’s Functional Health Pattern

1. ABDULLA MZEE
HOSPITAL INFECTIOUS RN,BScN..
 RN, BSc,N. ABDULLA K
NGWALI
 PHONE:+255779766230
 EMAIL:ibinkhair120@hot
mail.com

2. Gordon’s Functional Health
Pattern

3. A. Health Perception and Management
Prior to admission:
•Can only recall being immunized with BCG
and DPT
•Rarely visits a doctor to have a check-up and
seek for medical assistance
•Uses herbal medicines such as oregano,
guava, bitter gourd, and ginger
•Buys and takes over the counter drugs such
as Solmux, Neozep, Biogesic, Mefenamic acid,
Diatabs, and Loperamide.
•Stopped taking multivitamins Enervon
•When sick, goes to the manghihilot or just
waits for the sickness to heal

4. •Practices healthy lifestyle and depends on
fruits and vegetables
•No vices since young such as drinking
alcoholic beverages and smoking cigarette
•After experiencing difficulty in defecating,
she decided to see a physician
During hospitalization:
•Oriented
•Conscious and coherent
•Concerns for her surgical site after incision
and repair
•Willing to accept and listen to health
teachings
•Shows interest to recover easily and fast
•Always prays to God

5. B. Nutrition/ Metabolism
Prior:
•Eats more of fruits and vegetables
•Eats her meals 3x a day with snack in
between
•Can drink up to 1.5L of water or 4-5 glasses
a day
•Drinks coffee in the morning and in the
afternoon
•Claimed to be allergic on shrimps and
claimed to have good appetite

6. During:
•Weight: 41 kg
•Height: 4 ft and 10 in
•Normal Body Mass Index; BMI = 18.89 kg/m2
•Average Body Temperature is 360 C
•Able to fast in preparation for surgical procedure
•Before operation, being infused with an IVF of
D5NM 1L x 160 hooked at her left cephalic vein
•After operation, being infused with an IVF of PLR 1L
x 8 hours as main line hooked at her left cephalic
vein with a side drip of PNSS 500mL + 2 ampules
Voltaren at 20cc/hr and an IVF of PNSS 1L x KVO
hooked at her right cephalic vein with a side drip of
2units PRBC
•On NPO

7. C. Elimination
Prior:
•She voids 4-5 times a day
•Her urine color is yellow which is dark most of the
times
•There is no burning sensation/ pain felt during
urination
•She usually moves her bowel every morning
•With brown and formed stools. But recently, she is
having difficulty in defecating
•The impression to the result of the ultrasound of
her whole abdomen is to consider ileus; partial
obstruction and fecal stasis

8. During:
•No pain or burning sensation during urination
•Before operation, she experienced vomiting with
yellowish vomitus and hasn’t move her bowel all
throughout the 8 hour shift
•After undergoing the surgical procedure, a
nasogastric tube is used which is attached to a
drainage bottle; a colostomy is present attached
to a colostomy bag
•After operation, a foley catheter was used which
is attached to the uro bag draining well with dark
yellow urine with an output of 175 cc was taken
after the shift

9. D. Activity/Exercise
Prior:
•The patient ambulates within the house
•She does household chores
•She takes a walk at their subdivision to visit
the neighbors and buy at the store
•She does simple exercises on the upper and
lower extremities by means of shaking and
stretching
•Able to bathe herself

10. During:
•Reaction to stimuli are slower
•Decreased strength; becomes weak in prolonged
activities
•Decreased speed of movement
•Limited range of motion
•Radial pulse rate easily palpable and heard
•PR: 70 bpm
•RR:18 cpm
•BP: 110/80 mmHg
•Before operation, patient can turn to sides with
slight discomfort and can ambulate with assistance
•After operation, patient is on bed rest; flat on bed
and shows evidence of weakness
•Steady and in deep sleep for 4 hours

11. E. Sexuality/ Reproductive
•Married
•A mother of 4 children
•Menarche was on the year 1938 when she
was 11 years old
•On her menopausal stage
•She has no history of Sexually Transmitted
Disease or any disease affecting her genitals

12. F. Cognitive/Perceptual
Prior:
•No sensory deficits but functions are diminished
due to age
•Oriented to people, time, and place
•Responds to stimuli verbally and physically
•Pain felt radiating on the abdomen
During:
•Pre-operative Phase
•Before operation, she verbalized, “Sakit kaayo
akong tiyan tapos butod ko. Magbalik-balik ang
sakit.”

13. •She rated pain as 8, from a pain scale of 1-10, 10
as the highest possible pain perceived
•She claimed that pain starts at the right upper
quadrant and radiates all throughout the abdomen
•Claimed pain to be intermittent
•In normal thought process
Post-operative Phase
•“Akong tahi, nagasakit pa.”, as verbalized
•Felt pain around the surgical site
•Slight facial grimacing
•Can respond to stimuli verbally and physically with
weakness noted
•Believes that pain felt is due to post-operative
experience

14. G. Roles/Relationship
Prior:
•Married
•With 4 children
•Lives with the youngest child
•Close to her grandchildren
•Loves her family so much
•Well – supported and loved by her family with close
relationship
During:
•Well – supported by the family
•Still plays the role of a mother despite condition by
means of reminding important matters to her
children

15. H. Self-Perception/Self-Concept
Prior:
•Manages to practice healthy lifestyle so as not to seek medical
assistance
•Recently, she believed that admission will be helpful to assist
her in her needs, to alleviate the pain she felt, and to correct
her bowel
•Hopeful to be relieved and treated
During:
•Though weak, she still manages to appear calm and relaxed
•Agreed to be operated and undergo surgery and gives her
trust to the surgical team
•Hopeful and positive to have a successful operation
•Before operation, she prays all the time
•She desires that no complications will arise after the surgery
•Major concern is her recovery

16. I. Value/Belief
Prior:
•A Roman Catholic
•Have strong faith in God
•She always brings with her the rosary and always
prays at night
•She goes to the church with her youngest child and
her grandchildren to attend the mass every Sunday
During:
•No restrictions in the procedure brought by religion
•The admission and surgery don’t interfere with
spiritual practices

17. J. Coping/Stress
Prior:
•Copes up with stress by doing household chores
and by taking a nap or sleep
•Copes up with problems by talking about it with
the family and finds ways to resolve it together
•No traumatic events experienced before
•Reason for admission is to alleviate the pain and
correct her bowel
•Went to hospital and sought for medical assistance
after experiencing inability of defecating
During:
•Takes a nap and rests when tired
•Verbalizes desires to recover
•Able to accept situation by cooperating with the
medical advices and procedures

18. K. Sleep/Rest
Prior:
•Can sleep for 7-9 hours per night
•Straight hours of sleep
•Her earliest time in going to sleep is at 9:30 PM
•Latest time in waking up is at 6:30 AM
•She sometimes takes a nap at noon for about 1-3 hours
•No difficulties in going to sleep
•Doesn’t uses any medication to promote sleep
During:
•Sleeps at 8:00 PM
•Wakes up at 6:00 AM
•Can consume 10 hours of sleep
•Sometimes, she is distracted and sleep is interrupted
due to pain, administration of medication and visitors
•With rest intervals, usually naps for 4 hours

19. L. Medication History
Prior:
•Took Bentyl and Loperamide
During:
•Pre-operative Phase
•IVF of D5NM 1L x 160
•Completed 6 doses of Kalium Durule 1 tab
TID
•Completed 3 doses of Senokot Forte 2 tabs
BID
•Administered with Motillium 10 mg 1 tab TID
•Nexium 40 mg 1 tab OD
•Lactulose 30 cc

20. Post-operative Phase
•IVF of PLR 1L x 8 hours as main line with a side
drip of PNSS 500mL + 2 ampules Voltaren at
20cc/hr
•PNSS 1L x KVO with a side drip of 2units PRBC
•On NPO
•Administered with Cefuroxime 750 mg q80 IVTT
•Metronidazole 500 mg q80 @ am
•Omepron OD 40 mg IVTT
•Voltaren 20 cc/hr
•2nd dose of 12 doses Nalbuphine 5 mg q60 IVTT
•Nebulized with Convibent q80

21. Problem List
Problem Date
Identified
Time Date
Resolved
1. Constipation r/t obstruction
as manifested by difficulty
and inability to defecate,
abdominal distention, result
of diagnostic test, and
vomiting
12-13-10 8:30
AM
12-13-
10
2. Acute Pain r/t obstruction as
manifested by pain rate of
8, from a pain scale of 1-
10, 10 as the highest
possible pain perceived,
claims of intermittent
radiating pain on the
abdomen, and abdominal
distention
12-13-10 8:35
AM
12-13-
10
(Monitor
ing)

22. 3. Altered Health Maintenance
r/t choice of health
practices as manifested by
not seeking medical
assistance if ill
12-13-10 9:30 AM 12-13-10
4. Health-Seeking Behavior
r/t concern for health status
as manifested by healthy
lifestyle and desire to be
treated and to recover
12-13-10 9:35 AM 12-13-10
5. High Risk for Injury r/t
developmental age as
manifested by decreased
strength, weakening, and
limited range of motion
12-13-10 10:00 AM 12-13-10
6. Acute pain r/t surgical
incision as manifested by
verbalization of perceived
pain around the surgical
site, and slight facial
grimacing
12-14-10 8:30 AM 12-14-10
(Monitorin
g)

23. 7. Altered comfort
secondary to pain as
manifested by frequent
sighing and complaints of
pain
12-14-10 8:35 AM 12-14-10
8. Fatigue r/t post-
operative experience as
manifested by evidence
of weakness and deep
sleep
12-14-10 9:00 AM 12-14-10
9. Impaired Skin Integrity
r/t surgery as manifested by
presence of surgical incision
and colostomy
12-14-10 9:15 AM Not yet
resolved
10. Readiness for enhanced
ability to eliminate waste
products r/t post-
operative experience as
manifested by proper
12-14-10 10:30 AM 12-14-10

24. Prioritization