Chapter VIII Gordons 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

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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 200cc Packed RBC at 25cc/hr On NPO

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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 hasnt move her bowel all throughout the 8 hour shift

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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

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Decreased strength; becomes weak in prolonged activities Bradykinetic 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

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

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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
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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
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Acts as a housewife and does household chores 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

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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

A colostomy is present and gives foul odor 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
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During: No restrictions in the procedure brought by religion The admission and surgery dont 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

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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 Doesnt uses any medication to promote sleep

During:
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Sleeps at 8:00 PM Wakes up at 6:00 AM Can sleep for 10 hours Sometimes, she is distracted and sleep is interrupted due to pain, administration of medication and visitors

With rest intervals, usually 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

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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 200cc Packed RBC at 25cc/hr

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 Comvibent q80

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Problem List

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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 2. Acute Pain r/t obstruction as manifested by pain rate of 8, from a pain scale of 110, 10 as the highest possible pain perceived, claims of intermittent radiating pain on the abdomen, and abdominal distention 3. Altered Health Maintenance r/t choice of health practices as manifested by not seeking medical assistance if ill 4. Health-Seeking Behavior r/t concern for health status as manifested by healthy lifestyle and desire to be treated and to recover 5. High Risk for Injury r/t developmental age as manifested by decreased strength, weakening, and limited range of motion

12-13-10

8:30 AM

12-13-10

12-13-10

8:35 AM

12-13-10 (Monitoring)

12-13-10

9:30 AM

12-13-10

12-13-10

9:35 AM

12-13-10

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 7. Altered comfort secondary to pain as manifested by frequent sighing and complaints of pain 8. Fatigue r/t post-operative experience as manifested by evidence of weakness and deep sleep 9. Impaired Skin Integrity r/t surgery as manifested by presence of surgical incision and colostomy 10. Readiness for enhanced ability to

12-14-10

8:30 AM

12-14-10 (Monitoring)

12-14-10

8:35 AM

12-14-10

12-14-10

9:00 AM

12-14-10

12-14-10

9:15 AM

Not yet 123 resolved

Prioritization

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Health Pattern 1.Health Perception and Management

Cue Cluster >Rarely visits a doctor to have a check-up and seek for medical assistance >When sick, she goes to the manghihilot or just waits for the sickness to heal

Inference >Altered Health Maintenance

Diagnostic Statement >Altered Health Maintenance r/t choice of health practices as manifested by not seeking medical assistance if ill

Priority LOW 3

Rationale >The patient only needs to know the proper basic health practice and correct misconceptions. This will be resolved since the patient already knows how to seek for health to assist needs and prevent further problems. >This is important for the patient to always remind that prevention is better than cure. This also needs support health teachings to practice it all the time. If that happens, diseases will be prevented and if not, atleast recovery will be prompt.

>Practices healthy lifestyle and depends on fruits and vegetables >Uses herbal medicines such as oregano, guava, bitter gourd, and ginger >No vices since young such as drinking alcoholic beverages and smoking cigarette >After experiencing difficulty in defecating, she decided to see a physician >Concerns for her surgical site after incision and repair >Willing to accept and listen to health teachings >Shows interest to recover easily

>Health Seeking Behavior

>HealthSeeking Behavior r/t concern for health status as manifested by healthy lifestyle and desire to be treated and to recover

LOW 2

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