Chapter VIII Gordons Functional Health Pattern

A. Health Perception and Management Prior to admission: Had immunization on BCG, DPT and OPV Practices healthy habits by eating vegetables and fruits and not by drinking alcoholic beverages nor smoking cigarette Seek health care assistance when unusualities and anomalies are experienced in the body Goes to her obstetrician for yearly pap smear and check-up Attends to check-ups after diagnosed with ovarian cyst Takes medicines only when prescribed but tends to buy OTC drugs for primary treatment of other simple cases such as paracetamol, neozep, decolgen and alaxan. Prepares herself for the surgery regarding the removal of the cyst.

During hospitalization: Oriented Conscious and coherent

Concerns her surgical site after incision and repair after she is aware if acquiring infection

Willing to accept and listen to health teachings Shows interest to recover easily and fast Express desires of self-care and acceptance of her condition.

B. Nutrition/ Metabolism Prior: Eats more of fruits and vegetables Eats 3x a day with snack in between meals Drinks at least 2L of water a day Weight: 58kg Height: 5ft and 1 in BMI 24.16kg/m2 normal Claimed no allergies on food Claimed to have good appetite Takes vitamins

During: Doesnt eat proper diet and drink adequate amount of water Average body temperature is 37.10 C IVF of D5 NSS iL x 100 as main line, infusing well; PNSS iL x KVO with a side drip of PNSS500ML+ narapamin+ morphine+ sulfate x 10mgtts/hour C. Elimination Prior: Voids 4-5 times a day Urine is yellow in color sometimes dark No burning sensation/ pain felt during urination

During: Havent move her bowel yet all throughout the the 8 hour shift Uses underpad with lochia rubra; fully soaked With foley catheter attached to uro bag with bloody urine Slight pain felt during urination

D. Activity intolerance Prior: Ambulates within the house Visits their farm Does simple exercises on the upper and lower extremities Able to bathe herself well-groomed Well-groomed Well coordinated movements

During: Respond to stimuli but with weakness noted Radial pulse rate easily palpable and heard PR: 74bpm RR:23cpm BP: 110/80mmHg Frequent change of resting positions On bed rest with no bathroom privilege Well groomed

Unsteady Frequent sighing

E. Sexuality/ Reproductive Prior: Pap smear yearly checked Diagnosed with ovarian cyst Married, yet dont have a child No history of STD Menarche was the year 1975 @ 9y/o Irregular menstruation

During: undergone ultrasound to confirm cyst post- TAHBSO claimed to be in a depression state aware she cant bear a child ever again

F. Cognitive/Perceptual Prior: no sensory deficits all senses work well oriented to people, time, and place respond to stimuli verbally and physically complains pain on the abdomen specifically @ the left iliac region

During:

Akong samad ang sakit nuon, as verbalized

Felt pain on the left iliac region around the surgical site

Slight facial grimacing

Can still respond to a stimuli verbally and physically with weakness noted

Rated pain as 8, from a pain scale of 1-10, 10 as the highest possible pain perceived

Claimed pain as constant

Believes that cause of pain is due to postoperative experience

G. Roles/Relationship Prior: Native language is Tagalog Close to her parents Married No child Prepares herself for any outcomes Well-supported by her husband

During: Adjusting to the situation No chances of giving birth Dont have plan yet after the discharge (both partners)

H. Self-Perception/Self-Concept Prior: Concerns about own health and manages to practice healthy lifestyle Admission will be helpful as well as surgery according to her to prevent severe complications

Hopeful to have a successful operation

During: Though weak, she still managed to appear calm and relax Major concern is her recovery and how to move on Hopeful and positive in thinking that no complications will arise after the discharge from the hospital I. Value/Belief Prior: A Roman Catholic Have strong faith in God Goes to church with her husband to attend mass

During: No restrictions in the procedure brought by religion The admission and surgery dont interfere with spiritual practices

J. Coping/Stress Prior: Copes up with stress by taking a nap or sleep

No traumatic events experienced before Reason for admission ad surgery is for removal of the ovarian cyst Went to hospital and seek for medical assistance after experiencing pain

During: Takes a nap when lethargic Rests when tired Shows and verbalizes desires to recover and move on Accepts situation

K. Sleep/Rest Prior: Can sleep for 7 hours per night Takes a nap at noon Feels rested No difficulty in going to sleep Awakes early at 5:30 AM Doesnt uses medications to promote sleep

Usually sleeps at 10:30 PM

During: Can sleep for atleast 6 hours per night With rest intervals, usually naps for 2 hours Wakes up at 6:00 AM

L. Medication History Prior: Takes multivitamins Complies to given prescribed medicines

During: NPO IVF of D5NSS 1L x 100 as the main line PNSS 1L x KVO with SD of PNSS 500mL + Narapin + Morphine Sulfate x 10mgtts/hour Administered with cefuroxime IVTT and Ranitidine during pre-op and givenNalbuphine IVTT post-op

Problem List Problem Date Identified 7-27-10 Time Date Resolved 7-27-10

1. Acute Pain r/t surgical incision as manifested by pain rate of 8, from a pain scale of 1-10,10 as the highest possible pain perceived 2. Fatigue r/t postoperative experience as manifested by states of discomfort

8:30 AM

7-27-10

8:35 AM

7-27-10

3. Altered comfort secondary to fatigue as manifested by weakness and frequent change of resting position 4. Impaired urinary elimination r/t surgical trauma as manifested by bloody urine 5. Risk for constipation r/t post-anesthesia effect intake as manifested by not able to defecate within 8 hour 6. Imbalanced nutrition: less than body requirements r/t post-anesthesia effect as manifested by not taking and drinking volumes of water 7. Risk for sexual dysfunction r/t postsurgical procedure as manifested by awareness of not being able to bear child 8. Interrupted family processes r/t postoperative experience as manifested by having no plan after the surgery 9. Ineffective role performance of family building r/t no chances of having a child as manifested by absence of uterus

7-27-10

8:35 AM

7-27-10

7-27-10

8:45 AM

Not yet resolved Not yet resolved

7-27-10

8:45 AM

7-27-10

8:50 AM

Not yet resolved

7-27-10

9:30 AM

Not yet resolved

7-27-10

9:45 AM

Not yet resolved

7-27-10

9:45 AM

Not yet resolved

10. Readiness for enhanced family coping r/t acceptance of the situation as manifested by desires to recover 11. Health-seeking behavior r/t concern of the health status as manifested by expresses desires of recovering and willingness to accept condition

7-27-10

10:00 AM

7-27-10

7-27-10

10:10 AM

7-27-10

Prioritization Health Pattern 1.Health Perception and Management Cue Cluster >willing to accept and listen to health teaching >shows interest to recover easily and fast >expresses desires of selfcare and acceptance of her condition >does not drink and eat any diet >supported by IVF Inference >Healthseeking behavior Diagnostic Statement >Healthseeking behavior r/t concern of the health status as manifested by expresses of desires of recovering and willingness to accept condition >Imbalanced nutrition: less than body requirements r/t postanesthesia effect as manifested by not eating and drinking Priority LOW 5 Rationale >This is a positive response from the patient. Health teachings may be of help

2.Nutrition and Metabolism

>Imbalanced nutrition: less than body requirements

MOD 1

>This is moderately prioritized since even if there is a IVF that gives her nutrition and body fluids, its still different from the nutrition coming from the proper diet but action cannot be done immediately because it needs time for the physician to

3.Elimination

>havent move her bowel yet through-out the shift

>Risk for constipation

> Risk for constipation r/t postanesthesia effect intake as manifested by not able to defecate within 8 hours

MOD 2

change the order from NPO >If the problem in nutrition will be resolved, this will follow

>foley catheter attached to the urobag with bloody urine >slight pain felt during urination 4.Activity/ Exercise >responds to stimuli but with weakness noted >on bedrest with no bathroom privilege

>Impaired urinary elimination

>Fatigue

>Impaired urinary elimination r/t surgical trauma as manifested by bloody urine >Fatigue r/t post-operative experience as manifested by states of discomfort

MOD 3

>The presence of blood in urine is just a result of her surgery

HIGH 2

>This must also be prioritized because lack of energy will make the patient more weak and wont worry be able to do daily activities

>frequent change of resting positions >unsteady >frequent sighing

>Altered comfort

5.Sexuality/ Reproductive

>post- TAHBSO >claimed to be in a depression state >aware that she cannot bear a

>Risk for sexual dysfunction

>Altered comfort r/t fatigue as manifested by weakness and frequent change of resting period >Risk for sexual dysfunction r/t post- surgical procedure as manifested by

HIGH 3

LOW 1

>Discomfort will also lead patient not to do her usual activities thus preventing patient to recover faster >The patient will just need to have the support of her significant others same

child ever again

6.Cognitive/ Perceptual

>felt pain in the left iliac region around the surgical site >slight facial grimacing >can respond to a stimulus but with weakness noted >rated pain as 8, from a pain scale of 1-10, 10 as the highest pain perceived >claimed pain as constant 7.Roles and >dont have a Relationships plan yet after the discharge >no chances of giving birth

>Acute pain

awareness of not being able to bear a child >Acute pain r/t surgical incision as manifested by pain rate of 8, from a pain scale of 1-10, 10 as the highest pain perceives

with the people around her HIGH 1 >Pain must be prioritized first because the patient couldnt focus and will be having the difficulty to deal with all problems if existence of pain will remain

>Interrupted family processes

>Interrupted family processes r/t post- operative experience as manifested by having no plan yet after discharge

LOW 2

>Support may be given and let not the patient feel alone

>Ineffective rate performance of family building

8.Selfperception/ Self- concept

>though weak, she still manages to appear calm and relax

>No Problem

>Ineffective role performance of family building r/t no chances of having a child as manifested by absence of uterus -

LOW 3

>The patient can learn to accept step by step the condition she is experiencing

>The patient has a positive view of her self despite the

9.Value/ Belief

10.Coping Stress

>major concern is her recovery and how to move on >hopeful and positive in thinking that no complications will arise after discharge >no restrictions in the procedure brought by religion >the admission and surgery dont interfere with spiritual practices >no signs of alterations in mood >rests when tired >verbalizes desires to recover and move on >accepts situation >can sleep for atleast 6 hours a day >with rest intervals, usually naps for 2 hours

depression felt of her current condition

No Problem

>Patient still has her faith in God and her religion does not affect strongly the procedure

>Readiness for enhanced family coping

11.Sleep/ Rest

>No Problem

>Readiness for enhanced family coping r/t acceptance of the situation as manifested by desires to recover -

LOW 4

>The family can help her go on with life an accept what had happened

>She can maintain regular hours of sleep