University of Cebu Lapu-Lapu and Mandaue

A. C. Cortes Ave. Looc, Mandaue City

COLLEGE OF NURSING

GORDON’S FUNCTIONAL HEALTH

PATTERN

Submitted by:

Darnley Lovielyn C. Latoja

BSN-IV

Submitted to:

Arlene L. Galon, RN, MAN

Clinical Instructor
A case of Patient L.S.N., 72 years old, Single, Female, Roman Catholic, currently residing at 80
Osmeña St. Purok Tugas, Gun-ob, Lapu-Lapu City, with a diagnosis of Hypertensive Urgency
under the service of Dr. Michael Jeremy Tabaloc, M.D.

History of Present Illness

Patient have been long diagnosed with Hypertension for more than 10 years now. She has been
compliant with her maintenance medications just recently. She sought consult here at University
of Cebu Medical Center - Emergency Room for further work-up and medication of her elevated
blood pressure and possible change of medication since it has been causing her some anxiety
attacks.

Past Health History

Patient is hypertensive for more than 10 years now with a highest blood pressure rate of
200/130mmHg. Her maintenance medications are Losartan 100mg and Amlodipine 5mg. Her
Amlodipine was increased to 10mg after she had experience stroke last September 2018. Patient
is non-smoker, non-diabetic, non-alcoholic, but is allergic to seafoods. No significant feredo-
familial disease.

On the year 1998, patient had Dilatation and Curettage; TAHBSO on May 2001. Last September
12, 2018, patient had stroke. She had medications but cannot recall.

Environmental History
Patient is residing in a two-storey house at Gun-ob, Lapu-Lapu City since she was born. Three
people lived in her house. The health center, Barangay Hall, and Church are of walking distance
from her house. Her house and lot are owned by herself. She has three dogs. Patient described
their neighbourhood as “fine”.

Their water is supplied by Metropolitan Cebu Water District (MCWD) and their electricity by
Mactan Electric Company (MECO).

GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception - Health Management

She looks at her health as not so good since she often experiences anxiety attacks and describes
it as “Mangulba kog kalit ba nya di nako ma control akong kawgalingon.” She rates her health
as 6 out of 10 wherein 0 is the lowest and 10 as the highest. She sees the doctor whenever she
feels like she needs to. She does not practice self-medication but she takes vitamins namely,
Vitamin C, Omega-3, Centrum and Caltrate Plus. Patient is aware that her high blood pressure is
high and often says that she is anxious. Her hospitalization did not change her health perception.

Nutritional Metabolic Pattern

Patient stands 5’0” and weighs 45.7kg. Her diet upon admission is DAT Hypoallergenic diet.
She eats thrice a day. Her usual breakfast is Ensure Milk with herbal coffee and bread; lunch is
rice with vegetables and the same with dinner. She usually eats with her sister’s grandson. She
loves to eat fruits especially banana. She has no problems with eating. Patient has dentures. Her
diet did not change upon hospitalization. No weight loss was noted.

Elimination Pattern
Patient eliminates her bowel once or twice daily and urinates multiple times per day. She
describes her stool as light brown and well-formed. She does not use any laxative and does not
experience any difficulties in eliminating her bowel. Whenever, she experience constipation,
patient would just drinks lots of water and eat fruits.

She described her urine as clear. No difficulty in urination was experienced. No pain and blood
noted upon urination. Patient’s elimination pattern did not change upon hospitalization.

Activity Exercise Pattern

Patient was a retired teacher. Upon describing her work, she verbalized, “Kapoy kay dugay
matog pero fulfilling kay makatudlo ko sa akong mga students and my lessons are always
advanced since I am teaching in the fast-learners (FL) section.” After she had retired, at the time
she wakes up she waters her plants and roam around their house. At lunch time, she does her
siesta and bonds with her family. Before going to bed, patient prays. She does not exercise and
spends her recreational time with her sister’s grandson.

Upon admission, she often feels that she is not cared for since no one is with her in her ward.

Sleep and Rest Pattern

Patient usually sleeps at 9 in the evening and wakes up at 4 in the morning. She does not take
any sleeping aids and has no problem in sleeping. She describes her sleep as restful. Her
hospitalization, did not change her sleeping pattern.

Cognitive Perceptual Pattern

Patient is oriented to time, place, and people. She is able to recall past events as evidenced by
her recollection of her past hospitalizations. Her condition did not change her cognition and
perception.

Self Perception and Self Concept Pattern

She sees herself in a neutral manner. She describes her life as fine but she often feels uncared
for. Patient is happy with her accomplishments. Her only concern is that she feels that her family
does not care for her. Her current condition did not affect her self-concept.

Role Relationship Pattern

Patient has five siblings and she is the third child among them. She is single. She verbalized that
“Wa ko nag minyo kay mahadlok man ko magminyo.” She often says that her family does not
seem to care for her. Her condition did not change her role relationship pattern.

Sexuality Reproductive Pattern

Patient had her menstruation at the age of 15 years old and her menopause at 51 years old. She
did not further elaborate any other information.
Coping Stress Tolerance Pattern
She defines stress as “kapoy sa paminaw.” Patient believes that she is stressed during the
interview because she does not have any significant other to accompany her. She makes most of
the decisions in her family. She, together with her sister’s grandson, does the chores in the
house. Presently, she is in conflict with her family members because of her disease condition.

Value Belief Pattern

Patient is a Roman Catholic and verbalized, “I am a devoted Catholic.” She offers her devotion
to the Sacred Heart and the Virgin Mary. She prays the rosary often and goes to church every
Sunday. Her hospitalization did not falter her faith in God, in fact, it even strengthen her faith.
University of Cebu Lapu-Lapu and Mandaue
B. C. Cortes Ave. Looc, Mandaue City

COLLEGE OF NURSING

PHYSICAL ASSESSMENT

Submitted by:

Darnley Lovielyn C. Latoja

BSN-IV

Submitted to:

Arlene L. Galon, RN, MAN

Clinical Instructor
A case of Patient L.S.N., 72 years old, Single, Female, Roman Catholic, currently residing at 80
Osmeña St. Purok Tugas, Gun-ob, Lapu-Lapu City, with a diagnosis of Hypertensive Urgency
under the service of Dr. Michael Jeremy Tabaloc, M.D.

AREA TECHNIQUES
ACTUAL FINDINGS ANALYSIS
ASSESSED USED
Hair Patient’s hair is black in color,
evenly distributed. No
Inspection Normal
infestations and infection were
noted.
Skin Patient has a senile, warm skin A senile skin turgor
Inspection turgor. No edema were noted. is normally seen in
adult patients
Head and Face Patient is normocephalic,
Inspection and smooth skull contour, uniform
Normal
Palpation in consistency. No tenderness
were noted upon palpation.
Eyes A whitish color is noted.
Eyebrows are evenly
distributed. Eyelids skin are
Inspection Normal
intact; it closes symmetrically.
Bilateral blinking. Sclera is
white.
Ears Ears are symmetrical. Auricles
are aligned with the outer
Inspection canthus of the eye. Patient’s Normal
ears are mobile, firm and not
tender upon palpation.
Nose Patient’s nose is at midline. The
nasal septum are intact. No
Inspection and
inflammation in the sinus are Normal
Palpation
noted. Patient has no problem in
smelling.
Mouth Gums and tongue are pink. No
Inspection lesions were noted. Tonsils are Normal
not inflamed.
Neck Neck is at midline. No lesion
and deformities were noted.
Inspection Normal
Patient can freely move her
neck.
Arms and Hands Patient can freely move her
arms and hands. She can shrug
Inspection her shoulders and freely move Normal
her writs and fingers in both
hands.
Heart and Lungs Auscultation Patient’s pulse are palpated. No Normal
 AREA TECHNIQUES
ACTUAL FINDINGS ANALYSIS
ASSESSED USED
abnormal pulsation were noted.
Abdomen No scars were noted. Bowel
Inspection and
sounds were heard upon Normal
Palpation
auscultation.
Legs, Feet, and Patient can freely move her feet.
Inspection Normal
Toes She can ambulate well.
Genital Area Patient refuses to be assessed in
Inspection Normal
the genital area.
Reflection Paper

Hypertensive urgency is different from Hypertensive emergency in a way that the in HPN
urgency, an organ/organs were already affected due to elevated blood pressure while HPN
emergency organs are not affected. With this description, as a nurse, it is our responsibility to
immediately assess and treat patients with hypertensive urgency.

I chose this topic as the subject for my reflection paper since my patient was diagnosed with
hypertensive urgency. During our rotation, I monitored her vital signs and managed her anxiety
which is associated with her hypertension by encouraging her to verbalize her feelings.
Reflection Paper

Patients with cancer often undergo chemotherapy to eliminate the cancer cells in the body. In
regards to this, patients who undergo chemotherapy often experience side effects and it is our
duty as a nurse to manage these side effects.

I chose this topic to be the subject of my related reading since my patient was diagnosed with
Papillary Thyroid Carcinoma. Instead of chemotherapy, she had undergone Total
Thyroidectomy. During our rotation, I monitored her vital signs and attended to her needs.