Nursing history gordons

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  • 1. A. Nursing HistoryG.T., 64 y/o, male, Roman Catholic, Filipino, born in Antipolo, presently residing inWestern Bicutan Taguig City, was admitted at TPDH on February 27, 2013.On March 5, 2013 at 1:00pm, the patient was interviewed with 100% reliability.General Data:Name: G.TAge: 64 y/oSex: MaleStatus: widowedReligion: Roman CatholicRace: FilipinoOccupation: noneDate of Birth: 11/18/1948Place of Birth: AntipoloResidence: Western Bicutan, Taguig CityDate of Admission: February 27, 2013Place of Admission: TPDH-ERNumber of Admission: 1Chief Complaint: Left sided body weaknessHistory of Present Illness:Informant/Source of Information: G.T. (patient)Date of Interview: 03/05/20134 days prior to admission, patient had a sudden onset of left side weakness of his body andno other associated symptoms. 3 days prior to admission, there was progression of his leftside weakness associated with left side body numbness and gradual blurring of vision andin addition to that, the patient also had nonproductive cough. 1 day prior to admission,same condition happened and experienced by the patient. 1 hour prior to admission,patient experienced progression of left side body weakness and suddenly fell out of balanceupon standing. The patient’s significant other was alarmed and decided to rush the patientto TPDH was admitted around 9:00 in the evening.
  • 2. Past History:Childhood Illness: The patient had no known childhood illnesses or hospitalization. Thepatient reported that he was complete of all vaccination as a child. He has no knownallergies or any foods or certain days of the season. The only medication he took wasTylenol for fever.Personal and Social HistoryThe patient is Roman Catholic living with a family of 4 people. They live in a 2 bedroomsingle story home. The patient is the only one smoker residing in their residence. Thepatient spends most of the time in their house doing nothing but taking a rest due of oldage. The patient is a smoker and alcohol user.Family HistoryThe patient’s mother has Hypertension. The patient never had the chance to meet his fathersince birth. The patient’s mother is still living and the father is unknown. The patient is theeldest among 3 siblings and the only one living. The cause of death of his sister was Bonecancer while their youngest died since birth because of Newborn complications. Thepatient does not know of smoking/alcohol use of his sister. The patient’s wife died due to avehicular accident. She is a non smoker and non alcohol user. The patient has two children,a daughter the eldest and son. The children do not have any known illnesses orcomplications during delivery.
  • 3. Gordon’s Functional Health PatternsHealth pattern Past Condition Present ConditionAnalysis andInterpretationa. HealthInterpretationandMaintenancePatient is a 64 yearsold male. He hashistory of high bloodpressure and don’ttake any medicationsfor his high bloodpressure. He is asmoker and alcoholuser. He can consume10-15 sticks ofcigarette a day anddrinks alcoholoccasionally. Heconsiders himselfvery healthy. He doesnot like going tohospitals especiallywhen he is sick.The patient is lethargic due toleft body weakness andnumbness. He states that everytime she switches position shefeel dizzy and sleepy. Thepatient is afebrile with 35-36degree temp on the right outersurface axilla arm.Patientcontinues to experiences blurryvision, headache, oriented totime, place and person. Heperceived his health is not thatwell and is aware of hiscondition. His long stay at thehospital made him realize theimportance of eating healthy byconsuming low salt low fat diet.His eldest daughter is moresupportive of his health thanbefore. The patient is incomplete bed rest.I: Client’s healthperception is notaltered.A: Because of hiscondition, thepatient feels thathis illness is notsevere. Heassumes totalresponsibility fordecision-makingand self-care.Reference:Kozier and Erb’sFundamentals ofNursing 8thedition, vol.1,page 295-307.
  • 4. b. Nutrition andMetabolicpatternPatient eats on timesince 3-5 meals a day.He loves to eatfishand chicken which hisdaughter prepares.During times whenhis daughter is atwork he enjoys eatingfried foods threetimes a week and eatssalty foods threetimes a week. Thepatient’s favorite dishis adobo. Hisdaughter states thathe has a strongertaste than her becausehe puts too many salt.He also eats heavymeals and sleeps anhour after.He drinks(250cc/8oz/glass)more than 3-4 glassesevery day. He alsoenjoys drinking sodawith his meals andconsumes 1,000 to2,000cc per day.When the patient issick he usually getsbetter the next day.Patient is currently on a low saltand low fat diet. He needsassistance in eating every time.He cannot hold his spoon andfork and his daughter is the onewho feeds him. He eats smallmeals a day at different timesand drinks 2,500ccsof waterevery day as ordered by thedoctor. He is not allowed todrink soda. Most of his dietconsists of noodles, fish,vegetables, crackers and rice.The patient displays no appetiteto eat. The patient switchesposition in bed every hourbecause he feels warm all thetime. His skin is moist but coolto touch.I: Client’snutrition ishindered becausehe needs help ineating every time.He cannot doactivities of dailyliving asimportant aseating.A: Thenutritional–metabolic patternfocuses on foodand fluid intake,however theclient hasproblems ineating and thatmight influenceintake.Reference:Cox’s ClinicalApplications ofNursingDiagnosis 5thedition, page 120c. EliminationpatternPatient has noproblem in defecatingand urinating. Heusually defecates onceThe patient has not defecatedsince he was admitted.Heurinates in approximately 500-800cc in 24 hours with smallI: Client’seliminationpattern is notaltered however
  • 5. a day at night timeand urinates 5-8times a day withyellow colored urine.Hedrinksapproximately 3-4 of250 cc each glass ofwater and 1,000-2,000cc of soda perday. Client’s stool isbrown and loose inconsistency.amounts of light yellow urine.The patient does not have anypain or difficulty urinating.client needsassistance indoing so.A: Medicationslike Methyldopaaffects the centralnervous systemthat interfereswith the normalurination andeliminationprocess and maycause retention.In addition, herwater intake isregulated at2,500cc/day.Reference:Kozier and Erb’sFundamentals ofNursing 8thedition, vol.2,page 1288-1289.d. Activity andExercisepatternPatient does notrequire any help andis completelyindependent inperforming activitiessuch as feeding,bathing, dressing,toileting andambulation. Heusually walks aroundoutside the house inthe morning as a formof his daily exercise.During spare time hePatient is unable to performactivities of daily living due toleft side body weakness. Whenthe patient moves around hefeels very dizzy which makeshim feels sleepy. He also hasdifficulty sleeping because hisblood pressure is checked everyhour. The patient is in completebad rest.Patient is a level 2: Requiresassistance or supervision fromanother person, his daughterI: The clientneeds assistancewhen performingall daily livingactivities. Hisdaughter is hisprimary caretaker.A: Because of hercondition, theclient is unable todo her tasks
  • 6. walks around thebasketball courtoutside his house. Hestates that he hasenough energythroughout the day.He has notexperienced anymusculoskeletalimpairment.Patient is Level 0: Fullself-care.alone such aseating. A problemin the activity–exercise patternmay be theprimary reasonfor the patiententering thehealth-caresystem or mayarise secondaryto problems inanotherfunctionalpattern.Reference:Cox’s ClinicalApplications ofNursingDiagnosis 5thedition, page 270e. Sleep and RestpatternPatient usually sleeps5-8 hours.During rest time, heusually walks outsideat the basketballcourt. Although mostof the time he is athome doing housework.Patient has no difficulty insleeping and usually sleeps 8-12hours at night. Throughout theday the patient also takes napsbecause of the left side bodyweakness. His rest is disturbedbecause his vital signs arechecked every hour.The patient appears weakbecause of his slow movements,drowsiness and restlessnessfrom his medications.I: The client ishaving prolongedsleep at night anddaytimesleepiness due toher dizziness andblurry visionReference:Kozier and Erb’sFundamentals ofNursing 8thedition, vol.2,page 1171-1172.
  • 7. f. Cognitive andPerceptualpatternThe patient has noproblem with hishearing and in thepast. He use to wearglasses but they were5 years ago and neverworn correctivelenses since.His memory from hispast and condition isstill accurate. He canremember names ofmost of the drugs hetook, and his regimentbefore hospitalization..When he feels sick heusually uses naturalmethods such asherbs. He rarely takesmedication because oftheir financialsituation.There are noproblems in hersenses.He is lethargicdue to hiscondition yet responds toquestions and has no signs oflooseness of association or anyflights of ideas.He does not experience anychills.I: The client iscoherent,cooperative, andalert with noproblems withhis sensors.A: Clientmanifests intactsensorymechanisms andperception.Reference:Kozier and Erb’sFundamentals ofNursing 8thedition, vol.2,page 981.g. Self Perceptionand SelfControlpatternThe client would thenview himself assomeone who regardslife to the fullest. Herarely worries abouthis problems.The patient feels thathe has enough energythroughout the dayand rarely rests.During the assessment thepatient was responsive yetanswered every question withease and depth. He defined thathis hospitalization caused a bigimpact on his life that changedthe way he viewed life. He ismore focused on eating less fatand salty foods. He Also realizesthat eating late at night andsleeping immediately is shouldI: The client haspositive views onhis condition. Hethinks that hishospitalizationonly affected hisbody andlifestyle. He isstill calm andpositive about
  • 8. He does not believethat he unhealthysince he eatfrequently andabundantly since heincorporatesvegetable and fruits inhis diet.be avoided. things.A: The patient’sbehavior isaffected not onlyby experiencesprior tointeractions withthe health-caresystem, but alsoby interactionswith the health-care system.Reference:Cox’s ClinicalApplications ofNursingDiagnosis 5thedition, page 520h. Role andRelationshippatternThe patient lives withhis two childrentogether with hismother.Most of theirproblems are financialreasons. Theymanage by savingmoney and eatingwhat they couldafford.The patient wouldview himself as akind, and responsiblefather to his childrenThe relationship of his familyremains strong. They remainfirm and gather strength fromeach other. They support eachother and exude strength to thepatient.His children is his main sourceof support. His daughter saidthat it is her turn to take care ofhim.I: The client’srelationship withhis familyremains strong.A: The client’shospitalizationmade their familybecome stronger.They used eachas a source ofenergy and hope.Reference:
  • 9. and a loving son to hismother. When theyhave problems in thefamily they solve it bytalking between themembers.He has no problemsraising his childrensince they helparound the house.She involves himselfin decision-makingfor the household andmajor decisions. .Cox’s ClinicalApplications ofNursingDiagnosis 5thedition, page 606i. Sexual andReproductivepatternThe patient ‘s wifedied a long ago.A: Sexualitypatterns involvesex role behavior,genderidentification,physiologic andbiologicfunctioning andthe ability toexpress sexualfeelings. Client isable to fulfillsexual needs.Reference:Cox’s ClinicalApplications ofNursingDiagnosis 5thedition, page 715
  • 10. j. Copping-StressTolerancePatternHe is not the type offather that gives upeasily. He viewsstresses as challengesto keep him firm andgrounded.According to thepatient, he facesstressors of life suchas financial crisis, andemotional conflicts bytalking withhischildren at alltimes.He deals with hisproblems as a familyand it makes him feelbetter..Patient tackles stress by resting.The patient’s short-term andLong-term coping strategies issupported by his conversingwith his children.I: The client’scopingmechanism is nothindered becauseof the continuedsupport ofhisdaqughter.Whenever heexperiencesstress, the clientwould take timeto rest.A: His ability torespond to stressis affected by acomplexinteraction ofsupportive socialand emotionalreactions.Reference:Kozier and Erb’sFundamentals ofNursing 8thedition, vol.2,page 1068.