Gordon'S Functional Health Pattern

Nursing Related Learning Experience Manual
Name of Student Aira Shane C. Marges Yr & Sec BSN 4B

Clinical Instructor Eva B. Jugador, RN, MAN Area
Date of Exposure October 19, 2023 Hospital Socsargen County Hospital
GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Cue Cluster Inference Diagnostic Statement Priority Rationale
Pattern
1. Health Perception & S – Patient denies Not a problem Not a problem Not a problem This is not
Management history of recent considered a
trauma or similar nursing problem
problems in other because the
joints. Patient reports patient shows
receiving tetanus compliance with
vaccine five years ago. medication
“Gina inom man nako taga regimen and also
adlaw ang akoa uses health
maintenance kay lisod promotion
magka sakit.” as activities such as
verbalized by the annual check-ups
patient. The patient
has labs drawn yearly
for cholesterol and to
check for diabetes.
O – Patient has no
previous
hospitalizations or
surgeries.
2. Nutrition / S – Patient admits to Overweight Overweight r/t High 2 This is given a
Metabolism drinking 3-4 beers per excessive alcohol “High 2” priority
night. Denies the use consumption since nutrition is
of street drugs. Patient a.m.b. BMI of the highest need in
states that he does not 30, average Maslow’s Hierarchy of
exercise regularly due to physical activity less than needs hence, it
his busy schedule. recommended, must be addressed
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
Patient reports eating consumption of immediately since

at least three meals per sugar-sweetened it increases the
day with larger beverages, risk for other
portion sizes and frequent debilitating
frequently eats snacking, and diseases. Also, by
snacks, tries to eat portion sizes addressing this
low-fat, and low larger than problem, the
cholesterol foods. recommended patient will have
Patient stated that he better prognosis
likes to eat and one of for recovery.
his favorite foods is
chicken livers which
he consumes several
times a week. Patient
also likes to drink
carbonated
beverages. Patient
denies skin problems,
rash or unusual
changes, changes in
hair texture or nails,
and hair loss or
thinning of hair on the
body. Denies bleeding
gums, infection, gum
disease, or soreness of
the throat or tongue.
Last dental visit of the
patient was 12 months
ago. Patient reported
brushing and flossing
daily. Denies anorexia,
heartburn, indigestion,
nausea, or vomiting.
O – Weight: 94.6 kg.

Height: 179 cm. BMI

30. Overweight.
Medium frame. No
dryness, cracks,
lesions or swelling in
lips. Buccal mucosa is
pink, smooth, and
moist.
3. Elimination Pattern S - Denies polyuria Not a problem Not a problem. Not a problem. This is not considered a
and polydipsia. Denies problem since the
black or bloody stools, patient shows a
constipation, or normal voiding
diarrhea. Patient stated pattern and reports
that he has not noticed no problems with
any changes in his urination or bowel
normal bowel pattern. movement. Although
Denies difficulty impaired urinary
starting a urine stream elimination is a concern,
or changes in the the respiratory and pain-
strength of the stream. He related issues take priority
also denies dysuria, due to their immediate
flank pain, or nocturia. impact on the patient’s
health. Also, by addressing
O – I & O sheet the problem with the
showed an intake of patient’s renal
1,450 mL and an insufficiency, urinary
output of 1,500 mL. elimination can be
Patient defecated improved.
once within 24 hours.
4. Activity / Exercise S – Patient’s primary Impaired Impaired physical mobility High 3 This is given the third
complaint is pain, physical r/t pain secondary to gout highest priority since
swelling, and redness mobility a.m.b. discomfort, physical mobility is
in the right great toe alteration in gait limited important for the patient to
which started a month range of motion, perform ADLs and to
ago. Patient rated the reluctance to attempt maintain independence.
pain of 8/10. Patient states movement, and difficulty
discomfort to purposely move within

when walking. Patient physical environment.
stated that condition
has interfered with
ambulation and patient .
started to use cane two
weeks ago. Patient denies
smoking. Patient states
that he does not
exercise regularly due
to his busy schedule.
Patient denies fatigue
or weight loss. Denies
frequent colds,
stuffiness, nose bleeds,
and discharge. Patient
denies chest pain or
palpitations but states
history of high blood
pressure for the past
10 years. Denies
history of asthma,
shortness of breath, or
coughing. Denies
spitting up blood,
night sweats, varicose
veins or bruising, and calf
pain with exercise
or activity.
O – Patient walks
with a slight limp.
Hesitates to touch the
floor with the
affected toe. Patient
has difficulty to
purposely move. Has

difficulty going up and
down the examination
table. Tympanic
temperature was 37.0
˚C; pulse was 94
beats/min and had a
regular rhythm;
respiration was 20
cycles/min with even
and unlabored
breathing; blood
pressure was 125/80
mmHg taken on the
patient’s right arm
while sitting. Right
first
metatarsophalangeal
joint has local
tenderness, warmth,
erythema, swelling,
and limited range of
motion. Swelling is noted
on the dorsal
aspect of the foot.
Light touch to left
great toe causes
extreme pain. WBC
count 13.8 X 109
/L.
ESR 30 mm/hr.
Neutrophils 71%. Uric
acid 10.1 mg/dL. AST
59 U/L. ALT 77 U/L.
GGT 56 U/L. X-ray of
the left foot showed
soft tissue swelling

around the first
metatarsophalangeal
joint but no erosion. Fresh
preparation of
synovial fluid showed
needle and rod-shaped
strongly negative
birefringent crystals
under compensated
polarized light
microscopy (400X).
Synovial fluid
examination was
suggestive of
inflammation (WBC –
20,000/μL with 92%
neutrophil).
5. Sleep / Rest S – “Sa akong pagtulog Not a problem Not a problem Not a problem This is not considered a
kay wala man pud problem since the patient
problema, normal lang does not have reports of
man, wala kaayo kalahian problems with sleeping
sa dati naku na pagtulog” pattern.
as verbalized by the
patient.
O – Patient was alert,

cooperative, and
appeared well-rested.
6. Cognitive / S – Patient’s primary Acute pain Acute pain r/t High 1 This is given the highest
Perceptual complaint is pain, priority since the patient
inflammatory process
swelling, and redness will not be able to
in the right great toe secondary to gout a.m.b. participate well in the
which started a month treatment and perform
pain level of 8/10,
ago. Patient rated the needed ADLs when in
pain of 8/10. Patient states discomfort, facial pain.

discomfort
expression of pain,
when walking. Patient
denies headaches and diaphoresis, and protective
dizziness. Reported
behavior.
that he has never lost
consciousness in the
past. Stated that he
does not wear
corrective lenses.
Denies double vision
or photophobia.
Denies hearing
difficulties, ringing in
the ears, discharge,
and pain. Denies any
loss of coordination,
paralysis, weakness,
numbness, or tingling
in extremities.
O – Patient appeared
his stated age, alert,
cooperative, pleasant,
well-groomed,
communicates
appropriately, makes
eye contact, and
expresses appropriate
concern throughout
history. Oriented to
person, place, and
time; short- and long-term
memory was
intact; comprehends
and follows directions
easily; speech was

clear and appropriate;
the mood was
appropriate for the
setting. Left first
metatarsophalangeal
joint has local
tenderness, warmth,
erythema, swelling,
and limited range of
motion. Swelling is
noted on the dorsal
aspect of the foot. Light
touch to right
great toe causes
extreme pain. Patient
had a grimacing
expression. Patient
tried to pull back
foot. Patient was
diaphoretic.
7. Self – Perception / S – “Panan-aw nako sa Not a problem Not a problem Not a problem There were no problems
Self - Concept found with the patient’s
akong sarili kay buotan ko
self-concept since the
ug maalaga ko sa akong patient was able to
verbalize positive self-
pamilya”, as verbalized by
image despite his
the patient. condition.
O – Patient was
pleasant, well groomed,
communicates
properly, makes eye
contact, and expresses
appropriate concern
throughout history. Patient

responded appropriately
and had a calm tone of
voice.
8. Role / Relationship S – The patient is married Not a problem Not a problem Not a problem There were no problems
for 25 years and have 2 found since the patient
grown children. Patient verbalized satisfaction with
reports going to the familial relationship.
Catholic church every
Sunday with his family.
“Palangga jud nako akong
pamilya ug daghan man
sad ko mga barkada.” the
patient verbalized.
O – Patient was
accompanied by
daughter in his hospital
room.
9. Sexuality / S – Patient reported having Not a problem Not a problem Not a problem No problems were found
Reproductive since the patient did not
2 children.
provide much information
about his sexual
relationship and did not
O – Reproductive
consent to a reproductive
assessment was not
assessment.
performed.
10. Coping – Stress S – Patient reported her Not a problem Not a problem Not a problem Although the patient stated
Tolerance current condition as her concern over his current
stress factor. “Kapoy situation, this is not
kaayo kung daghan sakit. considered as a problem
Unta maulian na ko”, as since the patient has a
verbalized by the patient. positive attitude that he
will be able to overcome
O – Patient is cooperative this problem.
and communicates
properly.
11. Value Belief S – “Naga simba ko Not a problem Not a problem Not a problem There were no problems
kauban akong pamilya”, as found because the patient
stated by the patient. showed strong religious
Patient reported being a and spiritual belief through
Roman Catholic. active religious
participation.
PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Acute pain r/t inflammatory process October 19, 2023 4:30 PM The date of resolution of all of the
secondary to gout a.m.b. pain level problems cannot be provided due to the
of 8/10, discomfort, facial fact that the nurse-patient interaction only
expression of pain, diaphoresis, and happened within one shift due to certain
protective behavior circumstances.
Impaired physical mobility r/t pain October 19, 2023 4:30 PM The date of resolution of all of the
secondary to gout a.m.b. discomfort, problems cannot be provided due to the
alteration in gait, limited range of fact that the nurse-patient interaction only
motion, reluctance to attempt happened within one shift due to certain
movement, and difficulty to circumstances.
purposely move within physical
environment.
Overweight r/t excessive alcohol October 19, 2023 4:30 PM The date of resolution of all of the
consumption a.m.b. BMI of 30, problems cannot be provided due to the
average physical activity less than fact that the nurse-patient interaction only
recommended, consumption of happened within one shift due to certain
sugar-sweetened beverages, frequent circumstances.
snacking, and portion sizes larger
than recommended.

PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Prioritization Rationale

Acute pain r/t inflammatory process High Priority 1 This is given the highest priority since the patient will
secondary to gout a.m.b. pain level of
not be able to participate well in the treatment and
8/10, discomfort, facial expression of
pain, diaphoresis, and protective perform needed ADLs when in pain.
behavior.
Overweight r/t excessive alcohol consumption a.m.b. High Priority 2 This is given a “High 2” priority since nutrition is the
BMI of 30, average physical activity less than highest need in Maslow’s Hierarchy of needs hence, it
recommended, consumption of sugar sweetened must be addressed immediately since it increases the risk
beverages, frequent snacking, and portion sizes larger for other debilitating diseases. Also, by addressing this
than recommended. problem, the patient will have better prognosis for
recovery.
Impaired physical mobility r/t pain secondary to gout High Priority 3 This is given the third highest priority since physical
a.m.b. discomfort, alteration in gait, limited range of
mobility is important for the patient to perform ADLs
motion, reluctance to attempt movement, and difficulty
to purposely move within physical environment. and to maintain independence.
NURSING CARE PLAN

Name of Rm/Bed No. Age Chief

Patient Complaints
Address Admission Sex Diagnosis
Date
ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN DIAGNOSIS
Subjective Cues: Cognitive/Perceptual Note: Use P-E-S General: Independent  Before discharge, The nursing
Patient’s primary format Before discharge, the  Establish rapport with the patient reported interventions
complaint is pain, patient will report that pain patient. a pain level of 3/10. were carried
swelling, and redness Acute pain r/t is relieved with a rating of R: To gain  Before discharge, out
in the left great toe inflammatory 3/10. cooperation. the patient has successfully;
which started a process  Explain any followed prescribed the patient was
month ago. Patient secondary to gout Specific: procedure. pharmacological able to
rated the pain of a.m.b. pain level  Before discharge, R: To ease patient’s treatment. participate, the
8/10. Patient states of 8/10, the patient will anxiety.  Before discharge, actions were
discomfort when discomfort, facial follow prescribed  Assess vital signs, as the patient has acceptable to
walking. Patient expression of pharmacological needed. followed him, and this
denies headaches and pain, diaphoresis, regimen. R: To monitor nonpharmacological helped to
dizziness. Reported and protective  Before discharge, patient’s condition. methods to relief achieve the
that he has never lost behavior. the patient will  Elevate linens with pain. desired results.
consciousness in the Background follow bed cradle as needed.  Before discharge,
past. Stated that he Knowledge nonpharmacological R: Elevation of bed the patient was able
does not wear Knowledge methods that linens reduces to demonstrate use
corrective lenses. Sudden onset of provide relief. pressure on inflamed of relaxation skills
Denies double vision an unpleasant  Before discharge, or painful joints. and diversional
or photophobia. sensory and the patient will  Suggest patient activities to relieve
Denies hearing emotional demonstrate use of assume a position of pain.
difficulties, ringing experience relaxation skills and comfort while in bed
in the ears, associated with diversional or sitting in a chair.
discharge, and pain. an inflammation activities, as Promote bedrest as
Denies any loss of of a joint caused indicated, to relieve indicated.
coordination, by gout. pain. R: In acute
paralysis, weakness, exacerbation, total
numbness, or

tingling in bedrest may be

extremities. necessary (until
objective and
Objective Cues subjective
Patient appeared his improvements are
stated age, alert, noted) to limit pain or
cooperative, injury to joint.
pleasant, well  Place and monitor use
groomed, of pillows.
communicates R: Rests painful joints
appropriately, and maintains a
makes eye contact, neutral position.
and expresses  Encourage frequent
appropriate concern changes of position.
throughout history. Assist the patient to
Oriented to person, move in bed,
place, and time; supporting affected
short and long-term joints above and
memory was intact; below, avoiding jerky
comprehends and movements.
follows directions R: Prevents general
easily; speech was fatigue and joint
clear and stiffness. Stabilizes
appropriate; the joint, decreasing joint
mood was movement and
appropriate for the associated pain.
setting. Right first  Recommend that
metatarsophalangea patient take a warm
l joint has local bath or shower upon
tenderness, warmth, arising or at bedtime.
erythema, swelling, Apply warm, moist
and limited range of compresses to affected
motion. Swelling is joints several times a
noted on the dorsal day. Monitor water
aspect of the foot. temperature of
Light touch to right
great toe causes compress, baths, and

extreme pain. so on.
Patient had a R: Heat promotes
grimacing muscle relaxation and
expression. Patient mobility, decreases
tried to pull back pain, and relieves
foot. Patient was morning stiffness.
diaphoretic. Sensitivity to heat may
be diminished and
dermal injury may
occur.
Dependent:
 Administer NSAIDs
(ibuprofen, naproxen,
celecoxib), as
indicated.
R: These drugs control
mild to moderate pain
and inflammation by
inhibition of
prostaglandin
synthesis.
 Administer
corticosteroids
(prednisone), as
indicated.
R: These drugs modify
immune response and
suppress inflammation
caused by gout.
Collaborative
 Consult with a
dietician.

R: If patients cannot
maintain proper diets
or restrictions they
may require further
teaching and
interventions from a
registered dietician.
DIAGNOSTIC EXAMINATIONS
Name of Rm/Bed No. Age Chief

Patient Complaints
Address Admission Sex Diagnosis
Date
Diagnostic Normal
Date Ordered Result Significance
Examination Values
Complete Blood Hemoglobin: Hemoglobin: Hemoglobin (Hb) measures the amount of oxygen-carrying protein in the red blood cells.
Count 120-150 g/L 66 g/L The patient had a low hemoglobin count which may indicate anemia. This can be most
Hematocrit: Hematocrit: likely attributed to the patient’s chronic kidney disease which can interfere with the
0.35-0.49 0.20 production or lifespan of red blood cells, leading to anemia.
RBC: 3.80- RBC: 2.2 cells/mcL Next, hematocrit (Hct) represents the percentage of the blood volume occupied by red
5.20 cells/mcL MCV: blood cells. The patient had a low hematocrit level which can also indicate anemia.
MCV: 80-100 90.9 fL As for the red blood cell (RBC) count, this determines the total number of RBCs which
fL MCH: carry oxygen throughout the body. This can be caused by anemia and CKD which can
MCH: 26-34 30 picograms/cell interfere with RBC production and cause a decrease in the RBC count. Since the patient
picograms/cell MCHC: had a low hemoglobin, hematocrit and RBC count, this manifested as fatigue, shortness of
MCHC: 320- 330 g/L breath, pallor, and cold hands and feet. This finding also warranted the blood transfusion
360 g/L RDW: --- of packed RBCs that the patient received.
RDW: --- WBC: Next, the mean corpuscular volume (MCV) determines the average size of red blood cells
WBC: 4.0-10 x 3.6 x 109/L and helps classify different types of anemia. The patient had a normal MCV level which
109/L Neutrophil: suggested that the size of the RBCs of the patient was within the normal range.
Neutrophil: 0.77 Moreover, the mean corpuscular hemoglobin (MCH) measures the average amount of
0.50-0.70 Lymphocyte: hemoglobin within red blood cells. The patient had a normal MCH level which indicated
Lymphocyte: 0.20 that the amount of hemoglobin in each red blood cell is within the normal range.
0.18-0.42 Monocyte: Furthermore, the mean corpuscular hemoglobin concentration (MCHC) measures the
Monocyte: 0.2- 0.02 average concentration of hemoglobin within red blood cells. Since the patient had normal
0.11 Eosinophil: MCHC level, this indicates that the hemoglobin concentration in the RBCs is normal.
Eosinophil: 0.01 The white blood cell (WBC) count measures the total number of WBCs, which are crucial
0.1-0.3 Basophil: for immune function. The patient experienced leukopenia, which is a decrease in the
Basophil: 0-0.2 0 number of WBCs in the bloodstream. This can be attributed to the patient’s current
Platelet: 150- Platelet: 106 x 109/L respiratory infection which was CAP as manifested by a nonproductive cough and fatigue.
450 x 109/L This was also supported by a low neutrophil count which can also be caused by a viral
infection.

Next, the patient had a normal lymphocyte count which meant that the immune system of
the patient is responding normally to the infection. The patient also had a normal basophil
count because the patient was not experiencing any allergic attack.
Furthermore, the patient had a low monocyte count which was also due to the patient’s
respiratory infection. This was also supported by a low eosinophil and a low platelet
count, all of which can be attributed to an infection.
Clinical Chemistry Creatinine: Creatinine: The patient had an elevated creatinine level in the blood which is an indication of
0.7-1.2 mg/dL 8.4 mg/dL impaired kidney function. Creatinine is a waste product produced by the muscles during
Uric Acid: 3.5- Uric Acid: their normal metabolism, and it is filtered out of the bloodstream by the kidneys. An
8.5 mg/dL 9.9 mg/dL elevated creatinine level suggests that the kidneys are not effectively clearing creatinine
SGOT/AST: 0- SGOT/AST: from the body. This condition can be caused by CKD where the kidneys are damaged and
40 U/L 33 U/L lose their ability to function properly over time. As CKD progresses, creatinine levels in
SGPT/ALT: 0- SGPT/ALT: the blood tend to increase.
35 U/L 29 U/L Next, a high uric acid level can be associated with kidney dysfunction. Uric acid is a waste
product that is produced when the body breaks down purines, which are found in certain
foods and also occur naturally in the body. The kidneys play a crucial role in filtering uric
acid from the bloodstream and excreting it in the urine. If the kidneys are not functioning
properly, uric acid can build up in the blood, causing hyperuricemia. This can occur as a
result of CKD.
Aside from these, liver function tests (LFTs) are a group of blood tests that provide
information about the health and function of the liver. These tests assess various markers
and enzymes in the blood that indication liver health and potential liver damage. This
includes SGOT/AST and SGPT/ALT.
Alanine aminotransferase (ALT) is an enzyme primarily found in liver cells. A normal
ALT level suggests that the patient did not have conditions such as hepatitis, fatty liver
disease, or alcohol-related liver disease. Next. Aspartate aminotransferase (AST) is an
enzyme found in the liver, heart, muscles, and other organs. A normal AST level indicates
that the patient did not have liver damage, muscle injury, or a heart disease..
Lipid Profile Cholesterol: Cholesterol: Total cholesterol is the sum of all types of cholesterol in the blood. A normal cholesterol
0-210 mg/dL 175 mg/dL level indicates that the patient did not have an increased risk of developing cardiovascular
Triglycerides: Triglycerides: diseases like heart disease and stroke.
0-150 mg/dL 121 mg/dL Furthermore, triglycerides are a type of fat found in the blood. An elevated triglyceride
HDL: HDL: level is associated with an increased risk of heart disease. However, since the patient had a
40-60 mg/dL 24 mg/dL normal triglycerides level, this does not put the patient at such risk.
LDL: 0-100 LDL: Moreover, the patient had a low HDL level. HDL cholesterol is known as “good”
mg/dL 126 mg/dL cholesterol. HDL cholesterol helps remove excess cholesterol from the bloodstream and
VLDL: 2-30 VLDL: 24 mg/dL carries it back to the liver for processing. Higher levels of HDL cholesterol are generally
mg/dL associated with a lower risk of heart disease. This signifies that since the patient had a low
HDL cholesterol, the patient is more predisposed to developing cardiovascular diseases.
Next, the patient had a high LDL cholesterol. LDL cholesterol is often referred to as “bad”
cholesterol and is responsible for transporting cholesterol from the liver to the body’s
cells. High levels of cholesterol can contribute to the formation of plaque in the arteries,
increasing the risk of heart disease.
Lastly, VLDL transports triglycerides from the liver where they are synthesized or
obtained from dietary sources to other tissues in the body. A high VLDL cholesterol levels
are considered a risk factor for cardiovascular diseases. Since the patient had a normal
VLDL, this lessens the risk of the patient for cardiovascular diseases.
In summary, the results of the patient’s lipid profile signifies that the patient needs
medical intervention to increase HDL and lessen LDL and it also signifies that the patient
needs lifestyle changes to manage cholesterol levels effectively and reduce the risk of
heart disease most especially that the patient’s attending physician was considering a
diagnosis of Congestive Heart Failure.
Electrolytes Sodium: Sodium: A low sodium level in the blood, known as hyponatremia, occurs when the concentration
135-148 116.3 mg/dL of sodium in the blood is lower than normal. Sodium is an essential electrolyte that helps
mg/dL Potassium: regulate fluid balance in the body. A low sodium level can be caused by kidney failure
Potassium: 4.93 mEq/L and manifested in the patient as fatigue and muscle weakness. Next, a normal potassium
3.50-5.30 level indicates that the patient did not experience a potassium imbalance which meant that
mEq/L the patient’s body was able to maintain proper cell functioning.
HbA1c HbA1c: 3.8- HbA1c: 6.2% HbA1c, also known as glycated hemoglobin, is a blood test that provides an indication of
5.8% a patient’s average blood glucose levels over the past two or three months. This measures
the percentage of hemoglobin that has glucose attached to it. This is also used to monitor
and diagnose diabetes, as well as to assess long-term glucose control in individuals with
diabetes. The patient had a high HbA1c level which indicates a poor control of blood
glucose levels over time.
Ionized Calcium Ionized Ionized Calcium: 1.07 Ionized calcium represents the biologically active form of calcium that is readily available
Calcium: 1.13- mmol/L for physiological processes in the body. The patient had a low ionized calcium in the body
1.32 mmol/L which can be attributed to the patient’s kidney dysfunction. The kidneys play a vital role
in maintaining calcium balance by filtering and reabsorbing calcium. If the kidneys are not
functioning properly, such as in CKD, it can lead to impaired calcium reabsorption and
subsequent hypocalcemia.
Phosphorus Phosphorus: Phosphorus: 6.6 mg/dL Phosphorus is an essential mineral involved in various biological processes, including

2.5-4.5 mg/dL bone formation, energy metabolism, and cellular function. The patient had a high
phosphorus level which can be caused by kidney dysfunction. The kidneys play a crucial
role in maintaining phosphorus balance in the body by filtering and excreting excess
phosphorus through the urine.
BUN BUN: 7-17 BUN: 48 mg/dL A high blood urea nitrogen (BUN) level, known as hyperuremia or azotemia, indicates an
mg/dL elevated concentration of urea nitrogen in the blood. BUN is a waste product that results
from the breakdown of proteins in the body. The most common cause of elevated BUN
levels is decreased kidney function or kidney disease. The kidneys play a vital role in
filtering and excreting waste products, including urea nitrogen. When the kidneys are not
functioning properly, they may have difficulty removing urea nitrogen from the blood,
leading to an increase in BUN levels.
ABG Analysis pH: 7.35-7.45 pH: 7.331 The pH value indicates the acidity or alkalinity of the blood. The patient had a low pH
PaCO2: 35-45 PaCO2: value but only by a few. Values below 7.35 indicates acidosis due to inadequate
mmHg 30.8 mmHg ventilation secondary to the patient’s Community Acquired Pneumonia (CAP). This was
PaO2: 80-105 PaO2: evidenced by symptoms of fatigue and shortness of breath.
mmHg 79.5 mmHg Next, PaCO2 reflects the amount of carbon dioxide dissolved in arterial blood. The patient
HCO3: 22-26 HCO3: had a low level of PaCO2 which indicate that the patient was hyperventilating. This can be
mEq/L 15.9 mEq/L attributed to the patient’s compensatory response to difficulty of breathing as a result of
TCO2: 23-27 TCO2: the patient’s respiratory disorder.
mEq/L 16.9 mEq/L Furthermore, PaO2 measures the amount of oxygen dissolved in arterial blood. The
patient had a low PaO2 but not by a significant amount. A low PaO2 level can indicate
low blood oxygen levels or hypoxemia and respiratory problems which the patient was
experiencing due to CAP. This was evidenced by the patient’s symptoms of shortness of
breath, fatigue and weakness, and chest pain.
Moreover, HCO3 is an important buffer in the blood that helps maintain the acid-base
balance. The patient had a low bicarbonate level which indicate metabolic acidosis.
Metabolic acidosis can be caused by impaired excretion of acids. Kidney diseases can
reduce the kidneys’ ability to excrete acids, leading to their accumulation in the
bloodstream. This may be due to the patient’s chronic kidney disease. This was
manifested by the patient’s fatigue and generalized weakness.
Lastly, the patient had a low TCO2 which may indicate diabetic ketoacidosis or renal
failure. It can be noted that the patient had preexisting Diabetes Mellitus Type II and
CKD.
ECG Normal ECG Sinus tachycardia The result of the patient showed that she had sinus tachycardia. This condition is
findings. characterized by a fast heart that originates from the sinoatrial (SA) node, the natural
Otherwise normal ECG pacemaker of the heart. In sinus tachycardia, the SA nodes fires electrical signals at a
faster rate than normal, causing an increased heart rate. However, upon assessment, the
patient did not exhibit tachycardia but showed other associated symptoms like shortness of
breath, chest pain, and fatigue. This can be contributed to several factors such as the
patient’s preexisting medical condition.
Chest PA Xray Normal chest - The heart is markedly Interstitial infiltrates refer to abnormal accumulations of fluid or cells in the interstitial
x-ray. enlarged with lateral and spaces of the lungs. Infiltrates in the hilar areas suggest involvement near the lung hilum,
downward displacement which can be seen in conditions like pneumonia or congestive heart failure.
of the cardiac apex. Normal pulmonary vascular markings suggest that the blood vessels supplying the lungs
- There are interstitial are not excessively dilated or constricted. This finding is generally associated with normal
infiltrates in both hilar blood flow and can be a reassuring sign in the evaluation of pulmonary conditions.
areas. Trachea is midline. Diaphragm and sinuses are intact. Bony thorax is unremarkable. These
- Pulmonary vascular findings refer to the normal position and appearance of the trachea, diaphragm, sinuses,
markings are within and bony structures of the chest. No significant abnormalities are noted in these areas.
normal.
- Trachea is midline.
Diaphragm and sinuses
are intact.
- Bony thorax is
unremarkable.
- No significant findings
of note.
Impression
- Cardiomegaly with
probable left ventricular
hypertrophy.
- Concomitant
pneumonia versus
beginning pulmonary
congestion.
2D Normal - Concentric left Normal right ventricular dimension with good systolic function indicates that the right
findings ventricular hypertrophy ventricle is within normal size limits and is contracting effectively. Normal right
Echocardiography with good systolic ventricular function suggests that the heart’s ability to pump blood to the lungs is
function and mild maintained’
diastolic function. Aortic sclerosis refers to the thickening and stiffening of the aortic valve leaflets, which
- Normal right can impede blood flow from the left ventricle to the aorta. While it is not as severe as
ventricular dimension aortic, aortic sclerosis can still cause turbulence and strain on the heart.
with good systolic Mitral sclerosis refers to thickening and stiffening of the mitral valve leaflets, which can
function. affect the flow of blood from the left atrium to the left ventricle. Trivial mitral
- Aortic sclerosis. regurgitation means there is a small amount of backflow of blood from the left ventricle to
- Mitral sclerosis. With the left atrium due to incomplete closure of the mitral valve. Mitral sclerosis and trivial
trivial mitral regurgitation can indicate degenerative changes in the mitral valve, although they may not
regurgitation. cause significant clinical symptoms.
- Normal pulmonary Normal pulmonary artery pressure suggests that there is no excessive pressure in the blood
artery pressure. vessels leading from the heart to the lungs. Elevated pulmonary artery pressure can
- Minimal pericardial indicate pulmonary hypertension, a condition that puts strain on the right side of the heart.
effusion. Pericardial effusion refers to the accumulation of fluid in the pericardial sac surrounding
- Left-sided pleural the heart. Minimal pericardial effusion indicates a small amount of fluid, which may or
effusion. may not have clinical significance depending on the cause and associated symptoms.
Pleural effusion refers to the buildup of fluid between the layers of the pleura. Left-sided
pleural effusion suggests that fluid has accumulated specifically on the left side of the
chest. The presence of pleural effusion can have various causes, including heart failure,
infection, or inflammation.

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Nursing Related Learning Experience Manual

Name of Student Aira Shane C. Marges Yr & Sec BSN 4B

GORDON’S FUNCTIONAL HEALTH PATTERN

Patient reports eating consumption of immediately since

O – Weight: 94.6 kg.

Height: 179 cm. BMI

discomfort to purposely move within

purposely move. Has

soft tissue swelling

O – Patient was alert,

pain of 8/10. Patient states discomfort, facial pain.

easily; speech was

throughout history. Patient

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

Problem (PES) Date Identified Time Date Resolved

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

Nursing Diagnosis Prioritization Rationale

NURSING CARE PLAN

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

Name of Rm/Bed No. Age Chief

ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

tingling in bedrest may be

great toe causes compress, baths, and

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

Name of Rm/Bed No. Age Chief

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

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