Gordons case

1. Health perception
Nutrition
Typical daily food intake? Supplements (vitamins, type of snacks)?
 Not mentioned
Typical daily fluid intake?
 Not mentioned.
Appetite?
How has general health been?
 She is pregnant.
 Has Lumbar pain
 She’s afraid of CS.
 Pitting edema
 G5T4P4A0L5
Any colds in past year that hindered your work?
 Had no colds or fever.
Most important things you do to keep healthy? Think these things make a diff
erence to health?
 Not mentioned
Use of cigarettes, alcohol, drugs? Breast self-examination?
 Not mentioned
Experience any accidents in the past (home, work, driving)?
 Not mentioned
In past, been easy to find ways to follow suggestions from physicians or nurs
es?
 Marni follows the order of her family doctor but worried to her other
children so she’s eager to get back home
Do you have regular check-ups with your physicians or specialist?
 Not mentioned

2.  Not mentioned.
Do you have any food or eating discomfort? Swallowing? Any diet restrictions?
 Has had no nausea and vomiting
Skin problems: Lesions or Dryness?
 Not mentioned
Dental problems?
 Not mentioned
Elimination
Activity- exercise
Sufficient energy for desired or required activities?
 Not mentioned if she is doing the required activities for pregnant
woman
Exercise pattern? Type? Regularity?
 Not mentioned
Bowel elimination pattern? (Describe) Frequency? Character? Discomfort? Problem in control? Laxatives?
 Not mentioned
Urinary elimination pattern? (Describe.) Frequency? Problem in control?
 Not mentioned
Excessive perspiration? Odor problems?
 Not mentioned
d. Body cavity drainage, suction, and so on? (Please indicate and specify.)
- not mentioned
Does the food you eat affect your excretory pattern?
 Not mentioned

3.  Regularity: not mentioned
Spare-time (leisure) activities? What sport do you actively participate in?
 Not mentioned
Perceived ability (code for level) for:
Functional Level Codes:
• Level 0: full selfcare
• Level I: requires use of equipment or device
• Level II: requires assistance or supervision from another person
• Level III: requires assistance or supervision from another person and equip
ment or device
• Level IV: is dependent and does not participate
Sleep Rest
Generally rested and ready for daily activities after sleep?
 Not mentioned
Sleep onset problems? How well do you fall asleep? Do you use any aids? Dre
ams (nightmares)? Early awakening?
 Not mentioned
Rest-relaxation periods? How many hours of sleep do you get in a day?
 Not mentioned
Cognitive
Hearing difficulty? Do you use hearing aid?
 Marni has no hearing problems
Vision? Do you wear glasses? The last time you got checked? When was the last changed?
 Normal vision

4. Are you currently in pain? Any discomfort? Pain? When appropriate: How do you manage it?
 Lumbar Pain
 Hospitalized for assessment
 Pitting edema
Any change in memory lately?
 Not mentioned
Important decision easy or difficult to make?
 To stay in the hospital or get back home because she is worried for her other
children
Easiest way for you to learn things? Any difficulty?
 Not mentioned
Self-Perception
How do you describe yourself? Most of the time, feel good (not so good) about self?
 Not mentioned
Changes in body or things you can’t do? Problem to you?
 Physical changes because of pregnancy
 No problem since she is normal and can do her normal activities
Changes in way you feel about self or body (since ill- ness started)?
- Not mentioned
Things frequently make you angry? Annoyed? Fearful? Anxious?
 Not mentioned
Ever feel you lose hope?
 Not mentioned
Are you pleased with your current place in life?
 Not mentioned

5. Role Relationship
Live alone? Family? Family structure (diagram)?
 Living together with her children
 Other relatives or family are not mentioned
Any family problems you have difficulty handling (nu- clear or extended)?
 Not mentioned
Family or others depend on you for things? How managing?
 Other 4 children depending on her
When appropriate: How family or others feel about ill- ness or hospitalization?
 Not mentioned
When appropriate: Problems with children? Difficulty handling?
 Not mentioned
Belong to social groups? Close friends? Feel lonely (how often)
 Not mentioned
Do things generally go well at School?
 Not mentioned
When appropriate: Income sufficient for needs?
 Not mentioned
Do you feel part or isolated in the neighborhood where you are living?
 Not mentioned
Sexuality
When appropriate to age and situations: Sexual relationships satisfying? Changes? Problems?
 Yes, it is satisfying
 No changes
 No history of miscarriage during pregnancy

6. When appropriate: Use of contraceptives? Problems?
- Not mentioned
Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida?
 Menarche: Not mentioned
 Para: 4
 Gravida: 5
Coping
Any big changes in your life in the last year or two? Crisis?
 Being pregnant
Who’s most helpful in talking things over? Available to you now?
 Not mentioned
Tense or relaxed most of the time? When tense, what helps?
 Not mentioned
Use any medicines, drugs, alcohol?
 Insulin to control blood sugar
When (if) have big problems (any problems) in your life, how do you handle them?
 Not mentioned
Most of the time is this (are these) way(s) successful?
 Not mentioned
Value
Generally, get things you want from life? Important plans for the future?
 Expecting a new baby
 Her children to be good all the time
Religion important in life? When appropriate: Does this help when difficulties arise?

7. - Not mentioned
When appropriate: Will being here interfere with any religious practices?
- Not mentioned
Are there ever instances where you go against your beliefs or values?
- Not mentioned