Sie sind auf Seite 1von 3

1. Gordons Functional Health Pattern 2. A.

Health Perception and ManagementPrior to admission:Can only recall being immunized with BCG and DPTRarely visits a doctor to have a check-up and seek formedical assistanceUses herbal medicines such as oregano, guava, bittergourd, and gingerBuys and takes over the counter drugs such as Solmux,Neozep, Biogesic, Mefenamic acid, Diatabs, andLoperamide.Stopped taking multivitamins EnervonWhen sick, goes to the manghihilot or just waits forthe sickness to heal 3. Practices healthy lifestyle and depends on fruits andvegetablesNo vices since young such as drinking alcoholicbeverages and smoking cigaretteAfter experiencing difficulty in defecating, shedecided to see a physicianDuring hospitalization:OrientedConscious and coherentConcerns for her surgical site after incision and repairWilling to accept and listen to health teachingsShows interest to recover easily and fastAlways prays to God 4. B. Nutrition/ MetabolismPrior:Eats more of fruits and vegetablesEats her meals 3x a day with snack in betweenCan drink up to 1.5L of water or 4-5 glasses a dayDrinks coffee in the morning and in the afternoonClaimed to be allergic on shrimps and claimed to havegood appetite 5. During:Weight: 41 kgHeight: 4 ft and 10 inNormal Body Mass Index; BMI = 18.89 kg/m2Average Body Temperature is 360 CAble to fast in preparation for surgical procedureBefore operation, being infused with an IVF of D5NM 1L x160 hooked at her left cephalic veinAfter operation, being infused with an IVF of PLR 1L x 8hours as main line hooked at her left cephalic vein with aside drip of PNSS 500mL + 2 ampules Voltaren at 20cc/hrand an IVF of PNSS 1L x KVO hooked at her right cephalicvein with a side drip of 2units PRBCOn NPO 6. C. EliminationPrior:She voids 4-5 times a dayHer urine color is yellow which is dark most of the timesThere is no burning sensation/ pain felt during urinationShe usually moves her bowel every morningWith brown and formed stools. But recently, she is havingdifficulty in defecatingThe impression to the result of the ultrasound of her wholeabdomen is to consider ileus; partial obstruction and fecalstasis 7. During:No pain or burning sensation during urinationBefore operation, she experienced vomiting withyellowish vomitus and hasnt move her bowel allthroughout the 8 hour shiftAfter undergoing the surgical procedure, a nasogastrictube is used which is attached to a drainage bottle; acolostomy is present attached to a colostomy bagAfter operation, a foley catheter was used which isattached to the uro bag draining well with dark yellowurine with an output of 175 cc was taken after the shift 8. D. Activity/ExercisePrior:The patient ambulates within the houseShe does household choresShe takes a walk at their subdivision to visit theneighbors and buy at the storeShe does simple exercises on the upper and lowerextremities by means of shaking and stretchingAble to bathe herself 9. During:Reaction to stimuli are slowerDecreased strength; becomes weak in prolonged activitiesDecreased speed of movementLimited range of motionRadial pulse rate easily palpable and heardPR: 70 bpmRR:18 cpmBP: 110/80 mmHgBefore operation, patient can

turn to sides with slightdiscomfort and can ambulate with assistanceAfter operation, patient is on bed rest; flat on bed andshows evidence of weaknessSteady and in deep sleep for 4 hours

10. E. Sexuality/ ReproductiveMarriedA mother of 4 childrenMenarche was on the year 1938 when she was 11 yearsoldOn her menopausal stageShe has no history of Sexually Transmitted Disease orany disease affecting her genitals 11. F. Cognitive/PerceptualPrior:No sensory deficits but functions are diminished due to ageOriented to people, time, and placeResponds to stimuli verbally and physicallyPain felt radiating on the abdomenDuring:Pre-operative PhaseBefore operation, she verbalized, Sakit kaayo akong tiyantapos butod ko. Magbalik-balik ang sakit. 12. She rated pain as 8, from a pain scale of 1-10, 10 as thehighest possible pain perceivedShe claimed that pain starts at the right upper quadrantand radiates all throughout the abdomenClaimed pain to be intermittentIn normal thought processPost-operative PhaseAkong tahi, nagasakit pa., as verbalizedFelt pain around the surgical siteSlight facial grimacingCan respond to stimuli verbally and physically withweakness notedBelieves that pain felt is due to post-operative experience 13. G. Roles/RelationshipPrior:MarriedWith 4 childrenLives with the youngest childClose to her grandchildrenLoves her family so muchWell supported and loved by her family with closerelationshipDuring:Well supported by the familyStill plays the role of a mother despite condition by meansof reminding important matters to her children 14. H. Self-Perception/Self-ConceptPrior:Manages to practice healthy lifestyle so as not to seek medicalassistanceRecently, she believed that admission will be helpful to assist her in herneeds, to alleviate the pain she felt, and to correct her bowelHopeful to be relieved and treatedDuring:Though weak, she still manages to appear calm and relaxedAgreed to be operated and undergo surgery and gives her trust to thesurgical teamHopeful and positive to have a successful operationBefore operation, she prays all the timeShe desires that no complications will arise after the surgeryMajor concern is her recovery 15. I. Value/BeliefPrior:A Roman CatholicHave strong faith in GodShe always brings with her the rosary and always prays atnightShe goes to the church with her youngest child and hergrandchildren to attend the mass every SundayDuring:No restrictions in the procedure brought by religionThe admission and surgery dont interfere with spiritualpractices 16. J. Coping/StressPrior:Copes up with stress by doing household chores and bytaking a nap or sleepCopes up with problems by talking about it with the familyand finds ways to resolve it togetherNo traumatic events experienced beforeReason for admission is to alleviate the pain and correcther bowelWent to hospital and sought for medical assistance afterexperiencing inability of defecatingDuring:Takes a nap and rests when tiredVerbalizes desires to recoverAble to accept situation by cooperating with the medicaladvices and procedures 17. K. Sleep/RestPrior:Can sleep for 7-9 hours per nightStraight hours of sleepHer earliest time in going to sleep is at 9:30 PMLatest time in waking up is at 6:30 AMShe sometimes takes a nap at noon for about 1-3 hoursNo difficulties in going to sleepDoesnt uses any medication to promote sleepDuring:Sleeps at 8:00 PMWakes up at 6:00 AMCan consume 10 hours of

sleepSometimes, she is distracted and sleep is interrupted dueto pain, administration of medication and visitorsWith rest intervals, usually naps for 4 hours

18. L. Medication HistoryPrior:Took Bentyl and LoperamideDuring:Pre-operative PhaseIVF of D5NM 1L x 160Completed 6 doses of Kalium Durule 1 tab TIDCompleted 3 doses of Senokot Forte 2 tabs BIDAdministered with Motillium 10 mg 1 tab TIDNexium 40 mg 1 tab ODLactulose 30 cc 19. Post-operative PhaseIVF of PLR 1L x 8 hours as main line with a side drip ofPNSS 500mL + 2 ampules Voltaren at 20cc/hrPNSS 1L x KVO with a side drip of 2units PRBCOn NPOAdministered with Cefuroxime 750 mg q80 IVTTMetronidazole 500 mg q80 @ amOmepron OD 40 mg IVTTVoltaren 20 cc/hr2nd dose of 12 doses Nalbuphine 5 mg q60 IVTTNebulized with Convibent q80 20. Problem List Problem Date Time Date Identified Resolved1. Constipation r/t obstruction 1213-10 8:30 AM 12-13-10 as manifested by difficulty and inability to defecate, abdominal distention, result of diagnostic test, and vomiting2. 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 ill4. Health-Seeking Behavior r/t 12-13-10 9:35 AM 12-13-10concern for health status asmanifested by healthy lifestyleand desire to be treated and torecover5. High Risk for Injury r/t 12-13-10 10:00 AM 12-13-10developmental age asmanifested by decreasedstrength, weakening, andlimited range of motion6. Acute pain r/t surgical 12-14-10 8:30 AM 12-14-10incision as manifested byverbalization of perceived pain (Monitorinaround the surgical site, and g)slight facial grimacing 22. 7. Altered comfort secondary to 12-14-10 8:35 AM 12-14-10pain as manifested by frequentsighing and complaints of pain8. Fatigue r/t post-operative 12-14-10 9:00 AM 12-14-10 experience as manifested by evidence of weakness and deep sleep9. Impaired Skin Integrity r/t 12-14-10 9:15 AM Not yetsurgery as manifested by resolvedpresence of surgical incisionand colostomy10. 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 23. Prioritization