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Gordon’s Functional
  Health Pattern
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
•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
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
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
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
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
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
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
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
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.”
•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
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
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
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
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
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
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
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
Problem List
           Problem                    Date       Time       Date
                                   Identified             Resolved
1. Constipation r/t obstruction     12-13-10    8:30 AM    12-13-10
    as manifested by difficulty
    and inability to defecate,
    abdominal distention, result
    of diagnostic test, and
    vomiting
2. Acute Pain r/t obstruction as    12-13-10    8:35 AM    12-13-10
    manifested by pain rate of
    8, from a pain scale of 1-
                                                          (Monitori
    10, 10 as the highest                                   ng)
    possible pain perceived,
    claims     of   intermittent
    radiating pain on the
    abdomen, and abdominal
    distention
3. Altered Health Maintenance      12-13-10   9:30 AM     12-13-10
    r/t   choice      of  health
    practices as manifested by
    not     seeking      medical
    assistance if ill
4. Health-Seeking Behavior r/t     12-13-10   9:35 AM     12-13-10
concern for health status as
manifested by healthy lifestyle
and desire to be treated and to
recover
5. High Risk for Injury r/t        12-13-10   10:00 AM    12-13-10
developmental        age      as
manifested      by    decreased
strength,    weakening,     and
limited range of motion
6. Acute pain r/t surgical         12-14-10   8:30 AM     12-14-10
incision as manifested by
verbalization of perceived pain                          (Monitorin
around the surgical site, and                               g)
slight facial grimacing
7. Altered comfort secondary to   12-14-10   8:35 AM    12-14-10
pain as manifested by frequent
sighing and complaints of pain
8. Fatigue r/t post-operative     12-14-10   9:00 AM    12-14-10
    experience as manifested by
    evidence of weakness and
    deep sleep
9. Impaired Skin Integrity r/t    12-14-10   9:15 AM     Not yet
surgery as manifested by                                resolved
presence of surgical incision
and colostomy
10. Readiness for enhanced        12-14-10   10:30 AM   12-14-10
    ability to eliminate waste
    products r/t post-operative
    experience as manifested by
    proper management and
    cooperation
Prioritization

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Gordon's Health Issues and Recovery Plan

  • 1. Gordon’s Functional Health Pattern
  • 2. 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
  • 3. •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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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.”
  • 12. •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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. Problem List Problem Date Time Date Identified Resolved 1. Constipation r/t obstruction 12-13-10 8:30 AM 12-13-10 as manifested by difficulty and inability to defecate, abdominal distention, result of diagnostic test, and vomiting 2. Acute Pain r/t obstruction as 12-13-10 8:35 AM 12-13-10 manifested by pain rate of 8, from a pain scale of 1- (Monitori 10, 10 as the highest ng) possible pain perceived, claims of intermittent radiating pain on the abdomen, and abdominal distention
  • 21. 3. Altered Health Maintenance 12-13-10 9:30 AM 12-13-10 r/t choice of health practices as manifested by not seeking medical assistance if ill 4. Health-Seeking Behavior r/t 12-13-10 9:35 AM 12-13-10 concern for health status as manifested by healthy lifestyle and desire to be treated and to recover 5. High Risk for Injury r/t 12-13-10 10:00 AM 12-13-10 developmental age as manifested by decreased strength, weakening, and limited range of motion 6. Acute pain r/t surgical 12-14-10 8:30 AM 12-14-10 incision as manifested by verbalization of perceived pain (Monitorin around the surgical site, and g) slight facial grimacing
  • 22. 7. Altered comfort secondary to 12-14-10 8:35 AM 12-14-10 pain as manifested by frequent sighing and complaints of pain 8. Fatigue r/t post-operative 12-14-10 9:00 AM 12-14-10 experience as manifested by evidence of weakness and deep sleep 9. Impaired Skin Integrity r/t 12-14-10 9:15 AM Not yet surgery as manifested by resolved presence of surgical incision and colostomy 10. Readiness for enhanced 12-14-10 10:30 AM 12-14-10 ability to eliminate waste products r/t post-operative experience as manifested by proper management and cooperation