GORDON’S FUNCTIONAL HEALTH PATTERN

PATTERNS ASSESSMENT ANALYSIS

Patient G.A.D, 44 y/o post-op BP ranges from 130/60 to

CS last January 19, 2019 with 160/100 mmHg. Patient’s BP
OB history of G4P4 (4004) was above normal level.
was admitted in Capitol Patient was given Catapress
HEALTH PERCEPTION & Medical Center with a 75 mg sublingual during
HEALTH MANAGEMENT principal diagnosis of Pre- admission.
eclampsia and Gestational
Diabetes Mellitus. The patient
verbalized her overall health
as “Maayos naman pero yung
BP ko mataas pa din.” When it
comes to serious health
matters, she readily seeks
help of medical care. She
verbalized that she completed
her prenatal check-ups and
was able to maintain healthy
lifestyle by eating balanced
diet, good hygiene, enough
sleep and taking her
prescribed medications for
elevated BP and blood sugar.
She took Methyldopa 500mg
3 x a day and Metformin
500mg 3 x a day.
Patient G.A.D had
experienced colds, fever,
measles and flu from her
childhood until adulthood. The
patient stated also the she
completed her immunizations
and had no known allergies.
Patient eats balanced diet for Normal.
breakfast, lunch and dinner.
NUTRITION AND She drinks water a lot, 6-8
METABOLISM glasses per day. She drinks
coffee 1-2 glasses a day but
stopped drinking when she is
pregnant. She doesn’t have
problem associated with her
appetite. She takes her iron
supplements regularly and
doesn’t have food allergies.
 Patient urinates frequently. Normal.
ELIMINATION Her urine color is mostly
yellow and doesn’t have
problems with urination. She
had Foley catheter when she
was admitted at Maychilds for
Cesarean Section. Patient’s
bowel movements happen
once a day and her stool
varies from formed yellow
brown to dark brown due to
iron supplements. She doesn’t
have any problem with
defecating.
Prior to delivery, the patient Episode of palpitations were
ACTIVITY AND EXERCISE exercises frequently by present.
walking around their
neighborhood. Her leisure
activities are listening to
relaxing music sang going out
with her family and friends.
She had experienced
shortness of breath,
palpitations, colds, and
doesn’t experience any
weakness, chest pain, and
muscle joints. She could do
full self-care.
Patient has now 4 children Normal.
SEXUALITY AND and no history of abortion.
REPRODUCTION She doesn’t have any sexual
problems in her relationship.
She said that she is
comfortable with her sexual
functioning and doesn’t have
any difficulties. She had her
menarche at 13 years old.
Patient said that her sleeping Normal.
SLEEP AND REST pattern is usually 6 hours
because of frequent urination.
She goes to bed around 10 in
the evening and wakes up
around 8 to 10 in the morning
if her sleep is not disrupted.
Her usual sleep ritual before
sleeping is praying and she
never experienced difficulty
staying asleep.
COGNITION AND Patient is able to speak and Normal.
PERCEPTION write. She speaks tagalog,
 English and ilokano and
learns best when someone is
teaching her. She never
experienced problem with
hearing and doesn’t have poor
eyesight.
Patient lives with her family. Patient has good roles and
ROLES AND RELATION She said that her significant relation with her family.
others and their relationship
are healthy and satisfying.
She described her family as
“close”. They openly talk to
each other in order to solve
and make decisions in their
family matters. She said that
they don’t have any problems
right now and described that
their family income is enough
for their daily needs. There
are 5 members of their family.
When someone is sick in their
family, they feel uneasy and
seek medical attention.
The patient described herself Strong self-perception and
SELF-PERCEPTION AND as strong but easily gets upset self-concepts
SELF-CONCEPTS and tensed. She hasn’t
experienced anything yet that
could make her so different.
She is now currently happy
because she is still alive
despite of what complication
she has had during her
pregnancy.
The patient verbalized that Stress can easily tolerated by
COPING AND STRESS she doesn’t have any changes the patient.
TOLERANCE in her life these past few
years. She talks to her
husband whenever she was
stressed and had problems.
The patient is Roman Catholic Normal.
VALUES AND BELIEFS and mentioned that God and
her family is her source of
strength and meaning. Patient
said that relationship with God
is very essential. She prays
every night and attends mass
with her family every Sunday.
 PHYSICAL ASSESSMENT

BODY PART TO BE ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS

EXAMINED

Vital signs:

TEMPERATURE 37 36.5-37.5 - No abnormal

findings.

PULSE RATE 76 bpm 70-80 bpm - No abnormal

findings.

RESPIRATORY 19 cpm 12-20 cpm - No abnormal

RATE findings.

BLOOD PRESSURE 180/100 mmHg 120/80 mmHg Elevated BP.

Diagnosed Pre-
eclampsia.
Hair -Hair is evenly -Evenly distributed No abnormal findings
distributed hair
-Black color -The scalp should be
free from dandruff and
lesion

Head and face Symmetrical facial -Rounded and No abnormal findings

movement symmetrical
-Absence of mass or
lesions
-No edema noted
-With symmetrical
facial movement

External Eyes -Eye brows -Eye brows No abnormal findings

symmetrically symmetrically align,
-In equal movement equal movement
-Pupils round -Pupil round
-No discharge -Skin intact, no
-Skin intact discharge or
discoloration
-No edema or
tenderness over
lacrimal gland

Ears -Proportionate to -Color same as No abnormal findings

head facial skin
 -No drainage -Proportionate to the
-Symmetrical head
-Should be no foreign
bodies, redness,
drainage or pain

Nose -Symmetric -Symmetric and No abnormal findings

-No discharge pointed nose
-No discharge or
flaring
-Uniform in color
-Not tender, no
lesions

Lip -Uniform pink color -Uniform pink color Patient has a slightly
-Slightly dry lips -Soft moist, smooth dry lips
texture
-Symmetry of contour

Teeth, Gums and -Moist -Pink gums No abnormal findings

throat -With pink colored -Moist, firm texture to
gums gums
-No retraction of gums

Tongue -Pink in color -Central position No abnormal findings

-No tenderness and -Pink color
move freely -Move freely
-No tenderness

Skin -Medium brown skin -Varies from light to No abnormal findings

-Uniform deep brown
-No edema -Uniform except in
-No lesion areas exposed to the
-Good skin tugor sun
-Dry, with moisture in
skin folds and axilla
-When pinched, skin
springs back to
previous state, with
good skin tugor

Nails -Smooth texture -Smooth texture, No abnormal findings

-Capillary refill color slightly round or flat
should return to -Capillary refill color
normal in less than 4 should return to
seconds normal in less than 4
seconds

Abdomen -With linea nigra -Unblemished skin, -impaired skin

-Rounded in shape uniformed in color. integrity related to
 -Patient has classical post-surgical trauma
incision, post secondary to
Cesarean section. cesarean section.
Upper extremities -With edema -Both extremities are No abnormal findings
-Uniform in color equal in size
-Can perform -No edema
complete range of -Can perform
motion complete range of
-Both extremities are motion
equal in size -Uniform in color

Lower extremities -No deformities -No deformities No abnormal findings

-Properly aligned and -Properly aligned and
symmetrical symmetrical