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GORDON’S FUCNTIONAL HEALTH PATTERN

Health Perception and Health Maintenance


Before pregnancy, patient R.B. admits of smoking and drinking
alcohol occasionally. Before, she used to hang out with friends a lot and
she slept an average of 4-7 hours. She used to defecate twice a week and
did not take any vitamin supplementation. In times of illnesses in the past,
the patient would refuse to take medicines because she finds it hard to
swallow tablets or capsules.
During pregnancy, patient R.B. stopped smoking and drinking
alcohol. She is currently taking ferrous sulphate as her iron
supplementation. She was already given 2 doses of tetanus toxoid. She is
currently exposed to unsanitary environment which could be bad for her
and her baby. Patient R.B. rates her health at no. 6 out of 10 (10 as the
highest and 1 as the lowest).

Nutrition and Metabolism


Patient R.B. eats 3 meals a day with snacks in between. Her current
usual meal is composed of 1 ½ to 2 cups of rice and a serving of either
vegetables, fish or meat, and her snacks would be composed of bread or
cooked banana paired with juice. Her appetite increased since her
pregnancy. She currently weighs 42.5kg. Her weight increases every pre-
natal visit. Patient does not have difficulty swallowing and does not have
any food allergy.

Elimination
Patient’s usual bowel movement is twice a week with a formed,
yellowish to brownish to dark colored stools. She urinates 5-8 times a day
with clear yellow colored urine. She does not experience pain and does
not have difficulty eliminating.

Activity and Exercise


The patient’s usual daily activities would be waking up at around 6, 7
or 8 in the morning, eat her meals, socialize and do basic household
chores such as washing her own clothes. Ms. R.B. does not exercise. Since
her pregnancy, she became easily fatigued.

Cognition and Perception


Ms. R.B. is responsive, alert, coherent and cooperative. Patient’s
educational attainment is up to 3rd year college. She was able to answer
some of the questions without difficulty but some had to be interpreted for
her to understand.

Sleep and Rest


Before pregnancy, patient only gets to sleep an average of 4-7 hours
because she used to hang out a lot with her friends.
During pregnancy, patient now easily gets fatigued and sleeps for an
average of 9 – 12 hours. Sleeping at around 6 – 8pm and waking up at 6, 7
or 8am. She sometimes takes a nap during the afternoon for 1 – 2 hours.
Patient reported a continuous, good quality of sleep.
Sexuality and Reproduction
Patient R.B. is a female, single and living together with her
boyfriend’s family. She is a primigravida teenage mother. She had her
menarche during her 12th year of life. Her menstrual cycle is 28-30 days
which lasts for 4-6 days. She admitted of never being able to use any
form of contraceptive which led to her early pregnancy. Her first sexual
contact when she was 15 y.o. she and her boyfriend have sex once a
week before she got pregnant. But since her pregnancy, she and her
partner ceased having sexual contact. The patient does not have
alternative practices for sexual satisfaction and would not specify their
positions during sexual intercourse.
The patient does not feel pain or any difficulty during elimination.

Self-perception and Self-concept


Ms. R.B. is comfortable with her gender. She hasn’t talked to her
siblings since her belly got bigger because she feels ashamed. She has
accepted her current situation and does not have any regrets.

Roles and Relationship


Patient R.B. is the 2nd of 6th children. Her mother died when she was
13 years old. Her father got upset when he found out about her pregnancy
but still visits her every now and then to check up on her. She hasn’t
talked to her siblings since her belly got bigger.
Currently, she and her boyfriend’s family do not show any obvious
conflicts and they get along well.

Stress Tolerance and Coping


Patient gets fatigued easily, even in doing simple household chores
and walking. She sleeps when she gets tired.

Values and Belief


Patient R.B. is a Roman Catholic and rarely goes to church. She
believes in superstitious beliefs.

PHYSICAL EXAMINATION

Parts Inspection Palpation Percussion Auscultatio


n
Skin - dark skin - moist skin
- rashes - warm to
noted on touch
abdomen - has good
- skin skin turgor
generally - no edema
uniform
- scars noted
on legs and
arms
Hair - long dark - smooth, soft
hair hair
- even on
distribution
of hair
- smooth,
thin hair
- has variable
amount of
body hair
- presence of
lice
Nails - pinkish - pale
- smooth - capillary
- trimmed but refill time is
dirty less than 1
- convex second
- clear
Head - symmetrical - smooth
- rounded - uniform in
consistency
- absence of
nodules and
masses
Face - symmetrical - no presence
facial of masses
features and and edema
movements
- white and
black heads
noted on
the nose
Eyes - equally - no lesions
rounded and edema
brown- around eyes
colored
irises
- no edema
and has
intact skin
around eyes
- has
complete
closure
- chinky
- pink
conjunctiva
- reactive to
light and
accommoda
tion
Ears - color same - mobile, firm
as facial and not
skin tender
- auricle - pinna recoils
aligned with after it is
outer folded
canthus
- symmetrical
- presence of
cerumen
- able to hear
normal
voice
volume
- presence of
ear piercing
Nose and - well aligned - non-tender
sinuses nose bridge - no lesions
- no flaring
- pink
mucosa
- dried
mucous
noted
Mouth - moist lips - smooth
- pale-slightly and soft
pinkish- without
colored lips nodules
- able to
purse lips
- complete,
non-
aligned,
yellowish-
colored
teeth
- pink,
smooth
gums
- pinkish and
moist
mucosa
- tongue on
central
position
- uvula on
midline
- present gag
reflex
Neck/ - muscles - non-palpable
Lymph equal in lymph nodes
nodes size - trachea on
- head on center and
center properly
aligned
Breast - no - absence of
discharges masses or
- elevated swelling

Thorax - chest is - no - resonant - normal


and lungs symmetric tenderness but dull breath
- spine and nodules over bony sounds
vertically - uniform areas
aligned temperature
- skin intact - symmetric
- symmetrical chest
rise and fall expansion
of chest - fremitus is
during heard most
breathing clearly at the
apex of the
lungs
Abdomen ( Inspection ( Auscultatio ( Percussio ( Palpation )
) n) n) -Baby is on
-uniform - audible bowel cephalic
color sounds presentation
- rashes occurring -relaxed
noted every 15-20 abdomen
-rounded secs. with smooth,
abdomen - Absence of consistent
-symmetric friction rubs tension
movements - non-
caused by palpable
respiration bladder

Genito- -no pain


urinary during
urination
-no history of
STD
Musculo- - reported - equal
skeletal easy strength on
fatigability each side of
-muscles the body
equal size - no presence
on both of nodules
sides of
body
- no
contractures
- no tremors
- smooth
coordinated
movements
-no
deformities
- no swelling

3. 12 NEUROLOGIC ASSESSMENT
Patient is conscious, alert and coherent. Oriented to time, place, things
and persons. Does not have difficulty in understanding and can express self.
Patient was able to concentrate and follow instructions.
Patient’s biceps, triceps, brachioradialis, patellar and Achilles reflexes
has normal response. Patient has well-coordinated movements.
Cranial Nerves
• I – Olfactory: Patient was able to identify the different smells given
• II – Optic: Has 20/20 vision; able to read reading material; can see
objects in the periphery
• III – Oculomotor: Able to follow six ocular movements; pupil is
reactive to light and accommodation
• IV – Trochlear: Able to follow six ocular movements
• V – Trigeminal: was able to elicit blink reflex; felt deep and light
sensations; was able to clench teeth
• VI – Abducens: Able to move eyes laterally
• VII – Facial: Patient was able to smile, raise the eyebrows, frown, puff
out cheeks and close his eyes tightly; was able to
identify various tastes such as sour, sweet, bitter and
salt
• VIII – Auditory: Has a sense of equilibrium; is able to hear normal
volume of voice
• IX – Glossopharyngeal: Able to move tongue from side to side and
from up to down; able to swallow
• X – Vagus: Able to swallow; client can speak clearly
• XI – Accessory: can turn head and shrug shoulders against resistance
• XII – Hypoglossal: was able to protrude tongue; able to move tongue
from side to side and from up to down

OBSTETRIC HISTORY
Date Assessed: 5/14/09

I. Demographic Data

Name: R. B. Age: 16 Marital Status: Single


Religion: Roman Catholic Occupation: None

Patient’s name is R.B. She was born on august 25, 1992. Patient is 148
cm in height and 45.2 kg in weight.

II. Characteristics Influencing the Course of Pregnancy

Patient’s menarche was when she was 12 y.o. and has a menstrual
cycle of 28-30 days and lasts for 4-6 days. Patient’s current vital signs are:
BP=80/50 PR=86 RR=21 T=37.5. This is the patient’s first pregnancy and
without a history of abortion. Her last menstrual period was on October 7,
2008 and her expected date of delivery is on July 14, 2009.
The signs and symptoms of pregnancy experienced by the patient are
amenorrhea, enlargement of breasts, nausea and vomiting, fatigue and fetal
movements. She experienced quickening during her 5th month of pregnancy.
Since the start of the patient’s pregnancy, she never experienced
spotting, edema or any type of surgery but already fell twice on a 3-4 step
stair case. The patient has been receiving prenatal care since her 3rd month
of pregnancy and was given ferrous sulfate as her iron supplementation, and
was already given two doses of tetanus toxoid.
The patient had a history of dengue when she was 6 y.o and was
admitted at Cebu City Medical Center. The patient does not take meds for
illnesses because she finds it hard to swallow tablets or capsules.
The patient does not have a regular exercise; instead, she chooses to
socialize with friends during her free time. She only gets to exercise when
doing chores. Patient’s sleep during the night lasts for 9 – 12 hours hours
without disturbance. She also rests during the day for 1-2 hours. Rosella
defecates twice a week with a formed, yellowish to brownish to dark colored
stools.
Patient eats 3 meals and 2 snacks per day. During her meals, she eats
1 ½ -2 cups of rice and a serving of vegetables, pork, chicken, beef or fish.
And for her snacks, she eats bread paired with juice or softdrinks. The patient
does not have difficulty eating and does not have a history of eating
disorders. The patient has gained 3-5 kg since her pregnancy.
According to Patient, she started having sex when she was 15 y.o. She
and her boyfriend have sex once a week before she got pregnant. But since
her pregnancy, she and her partner ceased having sexual contact. The
patient admits of never being able to use any form of contraception and this
led to her early pregnancy. The patient does not have alternative practices
for sexual satisfaction and would not specify their positions during sexual
intercourse.

III. Attitudes towards the Pregnancy

According to Patient, the pregnancy was not planned. When she found
out about her pregnancy she was not worried because this would not serve
as a hindrance for her she already is a ‘tambay.’
According to the patient she is ready to become a mother and is not
worried about finances because her boyfriend has an irregular job of boiling
‘guso’. And her boyfriend’s parents would also finance for her and her child.
Her only concern for now is for a safe delivery.
The patient no longer has her mother and was formerly living with her
father and siblings. According to Patient, her father got upset when he found
out about her pregnancy but still gives her some advices and still visits her
once in a while.

• During the course of the interview the patient was able to


understand some of the questions well; but some had to be
further explained for her to understand. She is financially
unstable and is dependent on her boyfriend and his parent’s
income.
• The patient was advised to exercise, eat nutritious foods and
continue having her pre-natal check-up.

FAMILY ASSESSMENT
INITIAL DATA BASE

A. Family Structure and Characteristics

The family is a nuclear-extended type. Patient, the teenage mother


and her partner, R.P., are living together with Roque’s parents in
__________________. Patient was originally living with her father and siblings in
________________ but transferred to her boyfriend’s house when she found out
about her pregnancy. Patient is the 2nd child of 6 siblings and R.P. is the 7th of
9 siblings. The decision making is usually done by her husband’s mother.
Both Patient and husband are 16 y.o. Patient reached 2nd year high
school while husband reached 3rd year high school. There are no obvious
evidence of conflict in the family and everybody gets along well.

B. Socio-economic and Cultural Characteristics

Both Patient and husband are minors. Husband has an irregular job
boiling ‘guso’ and has an income of P100-150 per day; while Patient stays at
home. Both are trying to save money for their incoming child. Although
Husband has a job, his income is still unstable and they are still dependent on
Husband’s parents.
Husband’s father also works at the fish market and has an income of
P200-300 depending on his share; while his mother also stays at home.
No one in the family was able to finish college. Most of them only
reached high school.

C. Home and Environment

The family resides in a congested area. Their house is made up of


mixed materials and has tight living space. They have 2 bedrooms, one for
Husband and Patient, and another for Husband’s parents. Some of Husband’s
siblings live in different houses but just beside theirs. They all have 1 shared
bathroom w/c drops their feces and urine directly into the seawall. Their
garbage are just also thrown into the sea. Their water supply comes from the
M.C. They have an open drainage system. Their environment is very
conducive as breeding site for mosquitoes, rodents, flies and roaches.
The family life 25-40 meters away from the nearest health center and
the only public transportation available in the area is the ‘tri-sikad’.

D. Health Status of each Family Member

Patient is a primigravida. She cannot remember her immunization


status. She was already given 2 doses of tetanus toxoid. She is still 16 y.o.
and a high-risk mother. She had acquired dengue shen she was 6 y.o and
have had some common childhood illnesses such and cough, colds and fever.
She does not take medicines in times of illnesses because she finds it hard to
swallow tablets and capsules. Patient’s mother dies of Hepatitis B while her
father has a history of TB. Patient smokes and drinks occasionally in the past
but stopped when she got pregnant.
Husband drinks occasionally but smokes an average of 5-8 sticks of
cigarette per day. No one in the family remembers their immunization status.

E. Values, Habits, Practices on Health Promotion, Maintenance and Disease


Prevention

The family sleeps at least 8-10 hours every night. They only exercise
when they work. Patient is currently taking Ferrous Sulfate as her iron
supplementation while the others do not take any vitamin supplementation.
They have poor sanitation practices and does not or rarely goes to the
hospital for a medical check-up for any disease.
FAMILY HEALTH PROBLEMS

• Teenage Pregnancy

CRITERIA COMPUTATION JUSTIFICATION


It is a health deficit
Nature of the problem 3/3x1=1 because it has already
occurred.
Measure could still be
Modifiability of the
2/2 x2=2 taken to decrease the
problem
risks of her pregnancy.
Measure could still be
Preventive Potential 3/3x1=1 taken to decrease the
risks of her pregnancy.
Most of their family
members have already
experienced teenage
pregnancy and has
Salience 1/2x1=1
now become used with
it and does not
consider this as a big
deal.
Total: 5

• Poor Environmental Sanitation

CRITERIA COMPUTATION JUSTIFICATION


It is a health threat
because it could cause
Nature of the problem 2 / 3 x 1 = 0.66
food or water borne
diseases among others.
The problem could still
be modified but the
people living in the
Modifiability of the
1/2x2=1 area have already
problem
become used to it and
they don’t seem to
care about it anymore.
The problem could
easily be prevented,
the only problem is the
Preventive Potential 3/3x1=1
lack of initiative of the
people living in the
area.
Salience 1 / 2 x 1 = 0.5 People in the area
know that heir
sanitation is a problem
but they’ve been living
with it for years and
don’t see it as
important.
Total: 3.16
INTERVENTION PLAN
HEALTH FAMILY NURSING GOAL OF OBJECTIVES Method
Nursing EVALUATION
PROBLEM PROBLEMS CARE OF CARE of Nurse- Resources
Intervention
Family Required
s
Contact

Teenage I. Inability to After 2-3 After a 1. Analyze Home - Bond


Pregnancy recognize the days of series of with the Visit Papers
as a health presence at the nursing nursing couple - Pen
threat problem due to: intervention intervention the issues - Time and
• Attitude/philoso s, the family s, the family related to effort of
phy in life w/c will be able will: pregnanc both the
hinders to accept 1. be able y student
recognition of a the to 2. Discuss and the
problem pregnancy explain with the family
positively what is couple
and reduce pregnanc the
the risks y and its importanc
involved risks per e of safe
especially age motherho
for the group; od
teenage 2. discuss 3. Discuss
primigravida the with the
importan couple
ce of the
prenatal advantag
check-up; es of
3. avail of prenatal
the check-ups
services 4. Provide
in the informatio
health n
center; regarding
4. decide on the risks
a hospital during
delivery pregnanc
for Ms. y at a
R.B.; very
5. show young
whole age
hearted 5. Develop
appreciat the skills
ion on of the
the couple on
importan proper
ce of nutrition
sage and
pregnanc exercises
y and needed
delivery by the
teenage
mother
6. Take vital
Signs
7. Monitor
the FHT
8. Conduct
Leopold’s
maneuver
s
9. Encourag
e to
undergo
basic lab
tests