FAMILY MEMBER: Triseta Rovilla

DATE OF BIRTH: October 10,1964

AGE: 60
GENDER: Female

HISTORY

Mrs. Triseta is a 60 year old who has hypertension and diabetes. She has a history of
Tuberculosis(TB) and sometimes experiences muscle pain at hands and feets, but no history of
accidents. She has a daughter, son, grandsons and granddaughters living with her.

11 GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception and Health She seeks medical attention when experiencing serious
Management Pattern illness or pain. She has no allergies. Taking
Multivitamins, Neurobion everytime the pain appears,
Losartan, and Amlodipine

Nutrition and Metabolism Eat vegetables thrice a week, have a snack every
afternoon, and drink 1 liter or 4 glasses of water daily.

Activity and Exercise The client verbalized “maglimpyo, baklay og sewing ra

jud ma’am ang matawag nako na exercise tungod
sakong ka busy og bation rakog kakapoy og kagutom
mahuman

Cognition and Perception Communicates well, oriented to time, date, place and
people, attentive and actively participates, and
expression coincides with the topic being asked

Sleep and Rest Sleeps early at 8pm to 4am but 3 hours interval due to
constant peeing

Roles and Relationships Has a good relationship with her daughter and son after
fighting they talk about it

Sexuality and Reproduction Doesn’t care about it after husband died 3 years ago
due to high blood

Coping and Stress Tolerance Watches facebook reels, talking with helpers, sleeps
and sewing with all the problem just to rid, forget about
it and talks everything about the problem with daughter
in law

Values and Beliefs She goes to church every Sunday and participates in
meetings, and activities. Pray all the time about the
health and protection. Devout Roman Catholic.
 DATABASE PHYSICAL EXAMINATION

Vital Sign:
● Temperature: 36.5°C
● Pulse Rate: 83 bpm
● Respiratory Rate: 18 cpm
● Blood Pressure: 140/80

PHYSICAL ASSESSMENT

AREA METHOD FINDINGS INTERPRETATION

SKIN Inspection and Client skin is normally ABNORMAL

palpation brown; presence of scar
on both left and right
patella about 2cm on the
right side and 1cm on the
left side

HAIR AND NAILS Inspection Presence of dandruff, oily, ABNORMAL

and not evenly
distributed; hair is black,
light brown and white; nail
is not clean, and not well
manicured

HEAD AND FACE Inspection and The head of the client is NORMAL/
palpation symmetrical; no evidence ABNORMAL
of any lesion or
irregularities; no sign of
tenderness; presence of
warts on the left cheek

EYES AND VISION Inspection Pupils are equal and NORMAL/

round, visible engorged ABNORMAL
on the sclera, reactive or
constrict to 3mm using
pen light to light up

EARS AND Inspection Absence of pain, no ABNORMAL

HEARINGS presence of drainage can
hear to both sides of the
ear but unable to identify
the words; light brown
discharge

NOSE AND SINUSES Inspection and The nose appeared NORMAL

palpation symmetrical no presence
 of discharge and foreign
body; identifies the smells
during smell test

MOUTH AND THROAT Inspection Lips are cracked and dry, NORMAL/
no sore throat, lesions, ABNORMAL
hoarseness, nasal
obstruction, sneezing,
and coughing; snores in
every sleeps; 18 tooth's
left; presence of cavity to
the wisdom tooth

NECK Inspection and Neck muscle are equal in NORMAL

palpation size; the lymph nodes of
the client are not visible
and palpable: no limited
range of motion

MUSCULOSKELETAL- Inspection Identifies pen when NORMAL

UPPER EXTREMITIES holding while closing the
eyes; no limited range of
motion

THORAX AND LUNGS Inspectio, Chest rise and fall are NORMAL
palpation, equal bilaterally; absence
percussion, and of masses or tenderness
auscultation upon palpation; lung
sounds are clear in all
lobes and no reported
pain; easily get choke
upon eating sometimes

BREAST Inspection Breast is sagging; no NORMAL

lumps, dimpling or
redness

HEART Inspection, No chest pain or ABNORMAL

palpation, and pressure, no edema;
auscultation blood pressure is 140/80;
last ECG is 3 or 4 years
ago

ABDOMEN Inspection, Presence of pain at the ABNORMAL

auscultation, umbilical region and left
percussion and iliac; no swelling and
palpation discoloration

MUSCULOSKELETAL- Inspection Can raise feet's without NORMAL

LOWER pain; no presence of
EXTREMITIES redness, stiff joints
 SPINE Inspection Absence of pain and has NORMAL
a proper sit position: no
sign of scoliosis

GENITALIA (FEMALE) Inspection and Absence of pain, voiding NORMAL

palpation problems, swelling,
tenderness, masses and
the color of the discharge
are yellow white

ANUS AND RECTUM Inspection and Absence of pain in NORMAL

palpation defecation, hemorrhoids
and no presence of
constipation

REVIEW OF SYSTEMS
SKIN, HAIR, AND NAILS

Client describes skin color as normally brown and scalp is oily and lots of dandruff. Skin
temperature is 36.5°C and warm to touch. Reports hair loss sometimes and excessive sweating.
Client reports about no presence of rashes and lesions. Describes capillary refill within 2
seconds and hasn’t done any manicure for 3 weeks.

HEAD AND NECK

The client reports not having headache, neck stiffness, and sore throat or enlarged lymph
nodes, but having difficulty swallowing.

EARS

Reports of unclearly hearing. Denies hearing ringing or buzzing, earaches, drainage from ears,
dizziness, and exposure to loud noise.

EYE

Client denies pain, infections, tearing, discharge, itching, and trauma to eyes. Reports of
needing eyeglasses when reading

MOUTH, THROAT, NOSE, AND SINUSES

Clients report having problems with eating, and swallowing and that leads to choking
sometimes. Denies having sore throat, problem with smell, sneezing, coughing. Patient denies
difficulty of tasting food

THORAX AND LUNGS

Client reports of using 2 pillows when sleeping. Denies having difficulties breathing, and chest
pain. The client's respiratory rate is 18 cycles per minute.
BREAST AND REGIONAL LYMPH NODES

The client reports of not having discharges since she’s pregnant with her last born daughter.
Denies having tenderness, pain, and swelling.

HEART AND NECK VESSELS

The client reports of having the last blood pressure 140/80mm Hg and the last ECG is 3 or 4
years ago at Dr. Cruz. Denise having pain and palpation.

PERIPHERAL VASCULAR

The client reports of not having sores on feet, swelling, color is normally brown and does not
feel any pain this month. Client states that her legs has a presesnce of scars of her pass
experience.

ABDOMEN

The client states of having pain in the stomach

Character: as client verbalized “murag gi tusok-tusok”
Onset: client stated “nagsugod sya karon rajung 11 oktobre sa hapon”
Location: “sa tunga og kilid sa ubos aring wala” as verbalized by the client
Duration: “ karon ra nagsugod wapa nawala sukad ganiha ala una” verbalized by the client
Severity: “ang kasakit niya naa sa 6 maagwantahan ra gamay” stated by the client
Pattern: as the client verbalized “dirakaau sakin pag makipagtabi ko mosakit sya kanang diko
ma distract”
Associating fators: as the client stated “dili ko ka focus og tahi ani”

FEMALE GENITALIA

Client denies of having problems in voiding. Reports of her menarche started at the age of 15
years old and forget about when menopause happen. Client also stated “atong nag buros pod
ko suka-suka Raman akong problema”.

ANUS AND RECTUM

The client reports of having no problems, no pain, and hemorrhoids. As the client stated
“malibang ko sa isa ka adlaw og ika duha”

MUSCULOSKELETAL

The client denies of not having pain, swelling, redness, stiff joints, strength of extremities are
good, and could take care of herself and could still do her job.

NEUROLOGIC

Denies of difficulty of speech, formulating ideas or expressing feelings, and anger occurs when
her granddaughter is not sleeping. States that “dinako ka hinomdom kaau sauna”
FAMILY MEMBER: Jhane Vhinzynth Rovilla
DATE OF BIRTH: January 15, 2010
AGE: 14
GENDER: Male

HISTORY

Mr. Vhinzynth a 14 year old male who is in excellent health and a resident of Sindangan
Zamboanga Del Norte where they lived with her parents in his grandmother’s house. He has no
history of illness, hospitalization, or accident. He enjoys an active lifestyle and participates in
regular physical activity and experiencing muscle pain after exercise.

11 GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception and Health His a proactive about his health, has no allergies. He
Management Pattern maintains a healthy lifestyle and follows medical advice
diligently.

Nutrition and Metabolism Eat vegetables from their garden, fruits, and meats and
drinks 6-8 glasses of water daily.

Activity and Exercise Engages in regular exercise, including weight training

to maintain his physical fitness. Plays basketball every
weekend.

Cognition and Perception Mentally sharp, and has no cognitive impairments

oriented to time, date, place and people, attentive and
actively participates, and expression coincides with the
topic being asked

Sleep and Rest Sleeps 7-8 hours each night and wakse up feeling
refreshed and energized.

Roles and Relationships Has a strong and loving relationship with his parents
and lola, after every fight they make sure everything
works out well

Sexuality and Reproduction Underage and young for this.

Coping and Stress Tolerance Effectively manage stress through exercise, relaxation
techniques, and spending time with her family and
phone.

Values and Beliefs Devoured Roman Catholic and sometimes can’t attend
to church due to school works.
 DATABASE PHYSICAL EXAMINATION

Vital Sign:
● Temperature: 36.6°C
● Pulse Rate: 95 bpm
● Respiratory Rate: 18 cpm
● Blood Pressure: 120/80 mm Hg

PHYSICAL ASSESSMENT

AREA METHOD FINDINGS INTERPRETATION

SKIN Inspection and Client skin is normally NORMAL/

palpation brown; presence of scar ABNORMAL
on left ankle about 2cm
and right patella about
1cm. Skin turgor intact
with immediate recoil of
skin over 2 seconds, no
presence of lesions and
masses.

HAIR AND NAILS Inspection Hair is normally black NORMAL

and silky, straight, no
scalp lesions or flaking
and no dandruff.
Fingernails are long and
dirty. Capillary refill
within 2 seconds and no
clubbing

HEAD AND FACE Inspection and The head of the client is NORMAL
palpation symmetrical round,hard,
and smooth; without
lesions or bumps. Face
is oval and symmetric,
no tenderness.

EYES AND VISION Inspection Pupils are equal and NORMAL

round, sclera is white,
20/20 vision reactive or
constrict to 3mm using
pen light.

EARS AND Inspection Absence of pain, no ABNORMAL

HEARINGS presence of drainage,
has a weak hearing to
 both sides of the ear and
has a light brown
discharged

NOSE AND SINUSES Inspection and The nose appeared NORMAL

palpation symmetrical no
presence of discharge
and foreign body;
identifies the smells
during smell test

MOUTH AND THROAT Inspection Lips is normally pink, NORMAL

smooth, gums are pink
and moist without
inflammation, bleeding,
or discoloration. No
presence of sore throat,
lesions, hoarseness,
nasal obstruction,
sneezing, and coughing

NECK Inspection and Neck muscle are equal NORMAL

palpation in size; the lymph nodes
of the client are not
visible and palpable: no
limited range of motion

MUSCULOSKELETAL- Inspection Identifies paper when NORMAL

UPPER EXTREMITIES holding while closing the
eyes; no limited range of
motion

THORAX AND LUNGS Inspection, Chest rise and fall are NORMAL
palpation, equal bilaterally;
percussion, and absence of masses or
auscultation tenderness upon
palpation; lung sounds
are clear in all lobes and
no reported pain; easily
get choke upon eating
sometimes

BREAST Inspection Breast is symmetric, NORMAL

skin is dark brown with
black brown areola.
Absence of masses,
tenderness and no
reports about any
discomfort
 HEART Inspection, No chest pain or NORMAL
palpation, and pressure, no edema;
auscultation blood pressure is 120/80
mm Hg and heart rate is
18cpm

ABDOMEN Inspection, The client’s abdomen NORMAL

auscultation, are symmetric without
percussion and presence of lesions,
palpation absence of pain,
masses. Umbilicus in
midline without swelling
and discoloration.

MUSCULOSKELETAL- Inspection Can raise feet's without NORMAL

LOWER pain; no presence of
EXTREMITIES redness, stiff joints

SPINE Inspection Absence of pain and has NORMAL

a proper sit position: no
sign of scoliosis

GENITALIA (FEMALE) Inspection and Absence of pain, voiding NORMAL

palpation problems, swelling,
tenderness, and masses

ANUS AND RECTUM Inspection and Absence of pain in NORMAL

palpation defecation, hemorrhoids
and no presence of
constipation

REVIEW OF SYSTEMS

SKIN, HAIR, AND NAILS

Describes skin color as normally brown and no scalp lesions or flaking and no dandruff. Skin
temperature is 36.6°C and warm to touch. Reports no rashes, lesions, hair loss and only get
sweaty after exercise and playing basketball. Describes capillary refill within 2 seconds.

HEAD AND NECK

The client reports not having headache, neck stiffness, sore throat or enlarged lymph nodes and
difficulty swallowing.

EARS

Reports of weak hearing. Denies hearing ringing or buzzing, earaches, drainage from ears,
dizziness, and exposure to loud noise.
EYES

Client denies pain, infections, tearing, discharge, itching, redness and trauma to eyes.

MOUTH, THROAT, NOSE, AND SINUSES

Denies having sore throat, problem with smell, sneezing, coughing. Patient denies difficulty of
tasting food, eating and swallowing

THORAX AND LUNGS

Client verbalized “nag gamit kog duha ka unlan of isa ka teddy bear disad ko katulog of way
unlan”. Denies having difficulties breathing, and chest pain. The client's respiratory rate is 18
cycles per minute.

BREAST AND REGIONAL LYMPH NODES

The client reports of not having any discharges, and tenderness

HEART AND NECK VESSELS

The client reports of having the last blood pressure 120/80 mm Hg. Denise having pain in
palpation, and chest pain when breathing. As client verbalized “ maka feel rakog sakit or pamaol
sa dughan after exercise”.

PERIPHERAL VASCULAR

The client reports of not having sores on feet, swelling, color is normally brown and does not
feel any pain this month. Client states that her legs has a presesnce of scars because of playing
basketball.

ABDOMEN

The client reports of not having pain, nausea, vomiting tenderness, and stomach color as
normally brown.

MALE GENITALIA

Client denies of having problems in voiding, without blood in urine, lesions, and swelling. Client
also verbalized “natuli ko after grade 1 sa bakasyon, ihi sad nako kay yellow white og color
makaabot rapod og tunga sa baso akong maihi”.

ANUS AND RECTUM

The client reports of having no problems, no pain, and hemorrhoids. As the client stated
“malibang ko sa isa ka week ika 3 ra”.

MUSCULOSKELETAL

The client denies without having pain, swelling, redness, stiff joints, strength of extremities are
good, and could take care of herself and could still do exercise, and basketball.
NEUROLOGIC

Reports of being worry and denies having headache, loss of strength or sensation, difficulty of
speech, memory problem, difficulty of reading, and strange thoughts.