Assessment

Date:

Vital Signs Temperature Pulse Rate Respiratory Rate Blood Pressure Weight Height : 37.5C : 98 b.p.m. : 21 c.p.m. : 130/100mmHg : 46.8 kg : feet inches BEFORE HOSPITALIZATION Gordons Functional Health Pattern Subjective She graded her health as 3/10 for difficulty of breathing, shortness of breath, and fatigue. She takes Paracetamol and sleeps whenever she is not feeling well. She consults to a physician only when she can no longer treat herself. She takes multivitamins daily. She had fever and coughs with the past three months. Subjective She graded her health as 8/10 for she felt relieved after taking out the fluid in her right lung (thoracentesis). She also said that she no longer has difficulty of breathing or even shortness of breath. She complies with all her medications prescribed by the physician. Objective General: She has an intravenous fluid of of 0.9% PNSS 1L x KVO at her right arm. The patient is wellgroomed. The patient is calm, assertive, and cooperative. DURING HOSPITALIZATION Route : Axillary Site : Radial

Diaphragmatic Left arm

Health Perception Health Management Pattern

 She had no accidents for the past years. She does not have any vices.

She is somewhat worried about the result of her laboratory because she does not know if she has tuberculosis or pneumonia. When asked what her she thinks that caused her illness; she said that maybe it was brought about by aging. She eats her meal three times a day. She said that her appetite is coming back. She only eats half of the food being rationed to her. She eats more vegetables and fruits. She no longer takes her multivitamins. She drinks more than 8 glasses of water a day. Se has no difficulty in swallowing and already has the energy chewing her foods. She can eat independently. She is still constipated. He defecates once a day. Her stool color is brownish. She urinates 8 times a day. Her urine color is yellowish.

Nutritional Metabolic Pattern

Patient said that she only eats whenever she feels like it. She admitted of losing her appetite for the past three months. She likes to eat fruits and vegetables. She does not eat pork. She takes her multivitamins daily. She drinks 8 glasses of water every day. She drinks milk and coffee every morning. She has no difficulty swallowing but she said that she feels weak chewing her foods.

Integumentary/Oral: She is warm to touch. Her hair color is black and equally distributed. Skin turgor is normal. Skin is not dry. She has dentures. Lips are moist. Oral mucosa is moist and pinkish. Diet as tolerated

Patient is constipated. She defecates 3x a week. Her stool color is black. She urinates 8x a day. Her urine color is yellowish.

Genitourinary: Bladder is not distended. Urine color is yellow. Urine frequency is 8 times a day.

Elimination Pattern

She is not using any laxatives, or diuretics.

She is not using any laxatives She has companion when going to the comfort room.

Genitointestinal: She has constipation. Stool color is normal. She has normoactive bowel movements. Musculoskeletal: Muscle tone is normal. She has slightly kyphotic posture. Gait is normal. Patient has Active Range of Motion. Lovett scale with grade of 4 ; Complete ROM against gravity with full resistance. Respiratory: She has no tachypnea. Normal chest expansion. No chest pain. Cardiovascular: Pulse rate of 98 c.p.m. Nail color is pink. Capillary refill is less than 2 seconds. Negative for Homans sign. No jugular vein

Though she has DOB, she still manage to regularly do some stretching for 15mins and after sometime, clean the house for another 15mins. She does not play any sports. She runs a school supplies store as part of her daily activities.

She ambulates herself every now and then. She tries to sit and only lies to bed when she wants to take a nap/sleep.

Activity Exercise Pattern

Sleep Rest Pattern

Cognitive Perceptual Pattern

Her longest hour of sleep is usually 4 hours and his shortest is usually 1 hour. Patient said that she has insomnia. She feels weak whenever she wakes up in the morning. She usually wakes early. She does not takes a nap in the afternoon. She feels pain at her right back and shortness of breath and difficulty of breathing. She has hearing problems on her right ear. She wears glasses and graded it as 300. She does not have taste problems. She does not have any speech problems. She said that it is better to be taken away than to suffer with her condition. She becomes irritated when there is too much noise. He has a positive outlook in life. She lives alone.

She usually wakes up every now and then. She cannot sleep very well due to hot weather.

distention. No swollen varicose vein. No edema. n/a

She no longer feels pain and she feels relieved from her condition.

GCS of 15. She is oriented with the date, place and people. EENT: Pupils are equally round, reactive to light and accommodation. Pinkish conjuctiva Anicteric sclera

He described her health as satisfactory and relieved

Patient is optimistic.

Self- Perception SelfConcept Pattern

He has a positive outlook in life. Her family is supportive to her She has good interaction

Role Relationship Pattern

She visits her nieces once a week. She helps her family members in terms finances. They help each other to afford what they need. She has good circle of friends in their community. She has good social support system especially in her community. They are always available for her. She said that whenever she feels sad or needed to relax, she goes to her neighbor to have some chit-chat. She feels at ease when she has someone to talk to and when she listens to the radio. She prays to handle her problems. She is a Roman Catholic. Her religion is important to her. She thinks that this helps her whenever she is faced with difficulties in life. She goes to mass every Sunday She prays every morning and at night.

and visits her once in awhile.

with her niece.

Coping Stress Tolerance Pattern

Her niece is the one who Patient smiles and shows accompanies her. a positive outlook. Once in awhile, her neighbors visit her. He feels anxious about her laboratory results.

She always prays. She believes that her prayer gives her strength every day.

n/a

Value Belief Pattern