GORDONS FUNCTIONAL HEALTH PATTERN

Name: Yap, Kenneth Age: 16 Address: Basak, Cebu City A. Health perception Health Management Pattern The client believes that self-discipline and selfresponsibility is the key to good health secondary to any environmental factors. I usually consult my mother whenever I am not feeling well, since I believe my mothers credentials as a registered nurse. As verbalized by the client. B. Nutritional Metabolic Pattern The client stated that he loves to eat junk foods and fruits as well, but doesnt prefer to eat vegetables. Usually take his breakfast at 6:30 am, take his lunch at 11:30 am and takes his dinner at 7:00 pm. He said that he usually bring with his a bottle of water because he easily get thirst. He believe that he drink enough volume of water needed for a day. C. Elimination Pattern The client said that he defecate every morning, and urinate more often. He said that he was once admitted to hospital because of Urinary Tract Infection (UTI). D. Activity Exercise Pattern The client usually stays at his room and frequently goes out to have some exercise. Since everyday he walks along stairs for his class this become some sort of his exercise. E. Sleep Rest Pattern The client said that since his studies requires more time; he usually goes to bed at 11:00 pm sometimes at 12:00 am. He wakes up at 6:00 am. Sometimes I experience troubles in sleeping at night, I dont know why but I hate it. As verbalized by the client. F. Cognitive Perceptual Pattern Client doesnt have any sensory deficit. The client reacts easily to any pain and sensitive enough to emotional circumstances. He is mentally and physically aware of what is going on around him. G. Role Relationship Pattern Client is the eldest in the family. I must admit my parents somehow spoiled me as their eldest, according to the client. Often teases his sibling especially his younger brother. He admits that he is very sensitive when his parents scolded him. H. Values/Belief Pattern According to the client, they are Roman Catholic and he believes that somehow faith in God plays role in ones life and health as well. He recognizes Almighty God as the ruler of his life and his faith to Him keeps his struggling to live. I. Self-perceptual Self-concept Pattern Erik Erikson Psychosocial Theory (Identity vs. Role Confusion) The person during this stage realizes a stable sense of identity; develops devotion and fidelity. J. Coping Stress Pattern Common stressors paved his way are his studies, his family, and even his environment. He said that his way of

overcoming various stresses in his life is by verbalizing his problem and grab some food to eat. K. Sexuality and Reproductive Pattern Still on his development stage, based on Sigmund Freuds Psychosexual Theory, the client is on his genital stage. In this stage, the client attains sexual maturity.

PHYSICAL ASSESSMENT

Name: Yap, Kenneth Age: 16 Address: Basak, Cebu City

HEAD

Size: Normal size Shape: Symmetrical and contour rounded Facial appearance: Symmetrical in features and movement Head contour: No tenderness or lesions Relatively smooth with no unexpected contours or bulges TMJ: Smooth, symmetrical motion, with no pain, crepitus, or clicking Sinuses Frontal and maxillary sinuses (Palpation): No tenderness Frontal and maxillary sinuses (Percussion): No tenderness. Resonant tone.

HAIR

Scalp-hair Distribution: Evenly distributed Body Hair: Normal. Color: Normal color variation. Scalp Condition: Scalp intact and free of lesions and pediculosis.

EYES

General Appearance: Glazed eyes. Eyelashes: Present and curving outward No crusting or infestation. Eyelids: Upper eyelid normally covers one half of upper iris. Palpebral fissures symmetrical. Eyelids in contact with eyeball No lesions Eyeball: Doesnt protrude beyond frontal bone Lacrimal Gland and nasolacrimal duct: No swelling, redness, or drainage. Conjunctiva: Palpebral conjunctiva is smooth, glistening, pinkishpeach color, with minimal blood vessels visible. Bulbar conjunctiva over globes are clear, with few underlying blood vessels and white sclera visible. Sclera: Smooth, white, glistening

EXTERNAL EAR

Inspection Shape and landmarks: Helix, no pits, creases, or lesions. Condition of skin: Intact, no lesions Color: Consistent with skin color Palpation Soft and pliable, nontender.

NOSE

External Nose (Inspection): Midline placement. Shape symmetrical. No nasal flaring

No drainage External Nose (Palpation): Cartilaginous portion is slightly mobile. Nontender, no masses. Nares patent. Turbinates: Medial and inferior turbinates visible, symmetrical and shape/size consistent with general features of patient. Overlying mucosa coloring consistent with other mucous membrane.

NECK
Neck, Lymph Nodes, and Thyroid (Inspection): Neck erect, midline, no lumps, bulges or masses. Thyroid not visible. No masses, swelling, or Hypertrophy in mid to lower half of anterior neck. Neck (Palpation): Supple, nontender, no masses Cervical Nodes: No palpable nodes Thyroid: Nonpalpable

MOUTH AND THROAT

Lips (Inspection): Midline, symmetrical, skin intact, pink, and moist. No unusual odors. Teeth and Bite: Has 30 teeth, first wisdom tooth erupted. Teeth are white, not loose, with good occlusion. Oral Mucosa and Gums: Pink, moist, intact mucosa. Gums consistent in color with other mucosa and intact, with no bleeding. Hard and Soft Palate: Palate intact, smooth, pink. Bony. Salivary Ducts: Stensens duct intact at buccal mucosa at levelof second molars. Whartons duct intact at either side frenulum. Both ducts with moist and pink mucosa; no lesions, swelling, or nodules. Tongue (Inspection): Pink and moist Mucosa intact with no lesions or discolorations. Papillae intact. Tongue is freely and symmetrically mobile. Uvula: Midline, pink, moist, without lesions. Symmetrical rise of the uvula. Lips (Palpation): Soft, nontender, no masses.

NAILS
Color: Pink Shaped: Nails convex, no clubbing Texture: Firm Capillary refill: Positive capillary refill

SKIN
Inspection Color: Consistent. Odor: No usual odor. Lesions: No skin lesions. Palpation Temperature: Skin warm

Moisture: Moist