FUNCTIONAL HEALTH PATTERN ASSESSMENT

Submitted to:
Asst. Prof. Zorinna M. Luague

Submitted by:
Manalo, Ashley Jane
Sibala, Aivy Kaye
 ASSESSMENT OF MARJORY GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Demographic Data

Patient’s Name : Villagracia, John Rey Portes

Age : 25Y9M16D Gender: Male Insurance: PhilHealth
Marital Status : Single Birthdate: 1/6/1997 Birthplace: Maluay, Mag-abo
Address : Maluay, Mag-abo, Zamboanguita, Negros Oriental Occupation: Call Center Agent
Race : Filipino Religion: Roman Catholic
Educational Level : 2nd year College Maritime Primary Language Spoken: Bisaya

Date of Admission : October 22, 2022, 1:45AM Ward/ Bed: NEM 1

Mode of Admission : In-patient Admission Medical Dx. On Admission: Multiple Physical Injuries secondary
to Motor vehicular accident

Doctors: Dr. Carlito P. Go,

Reason for Seeking Care: Multiple physical injury

History of Present Illness: 1hr PTA, patient was driving on a motorcycle in the influence of alcohol with 2 other passengers, no helmet at around 50kph when
suddenly a dog passed by. Patient swerved falling to right side first sustaining multiple physical injuries.

General Impression: Received lying on bed in semi-Fowler’s position with 1L PLR attached on metacarpal vein @ 950ml level at KVO 10gtts/min and O2 therapy
via nasal cannula @ 2L/min, flowing well. Occasional facial grimacing noted. Presence of lacerations and abrasions seen on legs, right buttock, arms, and right
frontal region, are dark brown in color and scabs are noted.
 I. Functional Health Pattern

HEALTH PATTERNS USUAL FUNCTIONAL PATTERNS INITIAL APPRAISAL ONGOING APPRAISAL

10-24-2022 10-24-2022 10-25-2022
Health Perception & ● Health is good for the past 6 months ● Admitted October 22, 2022 @ 1:45 am
Health Management ● No colds and cough due to motor vehicular accident
● No vitamins and medications taken ● Overall health is GOOD
● Drinks alcohol occasionally ● No record of colds, cough
● Used to be a cigarette smoker ● Does not smoke, drink alcohol and does
(2019-2022) not do drugs
● No allergies
● No allergies
● No medications and vitamins were taken
● Does not use any herbal/traditional
● CBC:
remedies
○ Hemoglobin - 14g/dl
○ Hematocrit- 39.70%
○ White Blood Cell- 14580/cumm
■ *Segmenters - 89%
■ *Lymphocyte - 5%
■ Eosinophil - )%
■ Monocyte- 6%
■ Basophil - 0%
○ Platelet Count - 296 T/cumm
○ Red Blood Cell - 4.4 M/cumm
○ Mean Corpuscular Vol- 89 fL
○ *Mean corpuscular Hgb - 31.5
pg
○ Mean Corps Hgb Conc - 35.3%

● Sodium Potassium Level

○ Sodium- 137.8 mEq/L
○ Potassium 3.8 mEq/L

● CT Scan Report:
 - *Subgaleal hematoma in the right
parietotemporal region
- *Skin laceration/ulceration in the
right frontal region
- *Mild ethmoid and sphenoid sinus
disease

● Medications:
○ Cefuroxime (Danoxine) 750mg
○ Tramadol (Analgen) 50g
○ Pantoprazole 40g
○ Skudexa tablet i tab
○ Paracetamol 500mg tab
○ Citicoline 1g tab
○ Ciprofloxacin 500mg/tab
○ Silver sulfadiazine cream

● Vital Signs
○ T: 37.8
○ BP: 120/70mmHg
○ SaO2: 98%
○ PR: 107bpm regular and strong
○ RR: 20cpm

General Appearance: Appears well-groomed and

well-rested.

Level of consciousness:
Conscious and alert, is able to converse well.
Nutrition & Metabolism ● Appetite: GOOD
● Food Restrictions: NONE ● Breakfast:
o ● No difficulties in eating or swallowing ○ Rice with giniling
● No issues with wound healing ○ 1 glass of water
● No record of skin problems ● Lunch
● No dental problems ○ 1 cup rice with 1 piece fried fish
● No food allergies ○ 1 glass of water
Daily food intake ● Snacks
Breakfast: ○ 1 pack graham crackers
● 1 cup rice ● Dinner
● Tortang talong ○ 1 cup rice with kalamunggay soup
Lunch
● 1 cup rice ● No difficulty or discomfort in swallowing
● 1 serve of vegetable viand ● Diet as tolerated
Dinner ● Skin is fair, presence of lacerations and
● 1 cup rice abrasions
● 1 piece chicken/fish/pork ● Oral mucous membrane is moist, pink and
no lesions
Frequently consumes fruits such as banana, ● Has complete set of teeth with no sign of
oranges and apple dental cavities, upper front teeth alignment
is slightly crooked
Daily fluid intake ● Weight: 70kg
Breakfast: ● Height: 172cm
● 1 cup coffee
● 2 glasses of water
Lunch
● 1-2 glasses of water
Dinner
● 1 glass of water
Elimination Pattern Bowel
● Regular, once-twice a day, stool is
consistent; not too soft, not too hard; no
notable problems in defecation, no
laxatives taken
Bladder
● 5-6x a day with less than 1 cup per
voiding, usually depending on water
intake, no discomfort or notable problems
in urinating, urine color is light yellow to
clear
Skin
● No odor problems or excessive
perspiration
Bowel
● Has not defecated since admission
Bladder
● Has urinated twice about 1 cup per voiding
● No pain during urination
● Urine is light yellow in color
● Urinates using urinal
Skin
● No odor problems or excessive
perspiration
● Verbalized, “Gitugnaw ko miss”
● Skin is warm to touch

Activity and Exercise ● He stated that he had sufficient energy ● He stated that his pain limits him from
for work. ambulation
● He describes his activity level for most ● Perceived ability for:
days of the week as moderately active. ➢ Feeding: 0
● He stated that he exercises by walking ➢ Bathing: 4
daily for 1-2 hours. ➢ Toileting: 4
● He stated that his leisure activities ➢ Bed mobility: 1
include playing Mobile Legends. ➢ Dressing: 2
● In the last few months, there were no ➢ Grooming: 0
dizziness and fainting experiences, as ➢ General Mobility: 2
claimed. ➢ Cooking: 4
● Perceived ability for: ➢ Home Maintenance: 4
➢ Feeding: 0 ➢ Shopping: 4
➢ Bathing: 0 Examination:
➢ Toileting: 0 ● PR:107 cpm, strong
➢ Bed mobility: 0 ● RR:20cpm, effortless
➢ Dressing: 0 ● Has limitations for range of motion;
➢ Grooming: 0 impaired on one side
 ➢ General Mobility: 0
➢ Cooking: 0
➢ Home Maintenance: 0
➢ Shopping: 0
Sleep-Rest Pattern ● Stated that he feels rested and ready
for daily activities after sleep
● Does not use sleeping aids
● Sleeps around 8PM-9PM upon arrival
from work
● Usually wakes up at 5AM
● Cannot take afternoon naps because of
work
● Claimed he is a light sleeper
Cognitive & Perception ● Stated that he does not feel any pain in
his body
● He does not have any problems with
his sight, as claimed.
● He does not have any difficulty in
hearing
● Does not have any changes in sense of
taste and smell
● Does not have any difficulty
remembering and recalling
information
● He has graduated 2nd year as a
Maritime student
● He is fluent in vernacular and
understands english well
● Patient is on bed-rest.
● While in bed, the patient can only
tolerate positions such as turning only
on the left side of his body and supine
position.
● Cannot ambulate
● Stated that he usually wakes up during
dawn due to agitating discomfort from
his open wounds.
● Sleeps around 8PM and wakes up at
5AM
● Stated that he wakes up from noises
inside the ward room
Examination:
● Patient is calm and in a relaxed
physical state
● No under eye bags
● Stated that his wounds in the lower
extremities are very painful; He rates
his pain on a pain rating scale of 6 out
of 10 with 0 as the least painful and 10
as the most painful.
● Stated that his wound located in his
right lower buttock is the most painful;
He rates his pain on a pain rating scale
of 7 out of 10 with 0 as the least
painful and 10 as the most painful.
● Patient’s memory is intact
● Able to make decisions for himself
Examination:
● He appears to be aware, alert, and
comfortable in his surroundings.
Self-Perception & ● Stated that he is content with how he
Self-Concept sees himself.
● Does not have any insecurities
● Does not have depression, anxiety, and
fear
● Does not get angry and annoyed easily
● He sometimes loses hope because of
how tiring his work is
Roles & Relationships ● He is the youngest among his 2 other
siblings
● He lives alone in his house; His older
sister lives in Valencia while his other
sister lives in Leyte; His father passed
away; His mother currently lives in
Singapore.
● He stated that his father died two years
ago and it was very difficult for him
since they both lived together.
● He claims that his monthly salary is
not sufficient to provide for his needs
but his older sister and mother provide
financial support
● He claims that he feels safe in his
current relationship
● He claims that if problems occur, they
are usually resolved by talking with
her girlfriend.
● He stated that with his current
condition, he sometimes loses hope
Examination:
● Patient holds eye contact during
conversations
● He appears to be well groomed
● Speaks in a calm and assertive manner
● Patient was seen lying down on the bed
and relaxed during the visit
● Attention span: 10 out of 10
● Mood: 10 out of 10
● Response style: 10 out of 10
● Interacted with his friends that are
accompanying him
● Patient is accompanied in the room by
two of his close friends
● His girlfriend, sisters, mother
occasionally calls him and are
optimistic about his condition
● No signs of relationship distress
 ● He claims that things generally go well
at work
● He claims that he feels lonely since he
lives alone in his family’s house
Sexuality and ● Patient claims that he is satisfied with ● Patient stated that he is still with his
Reproduction his sexual relationship with his girlfriend and they often communicate.
girlfriend and there are no problems ● No examinations were done in regard
● He stated that he does not use any to his condition
medications to influence sexual
performance
● He stated that he does not engage in
safe sex practices; Does not use any
contraceptives

Coping & Stress ● Patient claimed that he plays Mobile
Tolerance Legends to relax and enjoy leisure
time Examination:
o ● Drinks alcohol occasionally to relax
● Stated that when problems occur, it is
handled efficiently and easily.
● Claimed that he has his girlfriend to
talk to when things get difficult
Value-Belief ● Patient is a Roman Catholic
Examination ● He stated that he goes to church for
two Sundays a month.
● He also stated that he has not been
able to go to church due to his busy
schedule in the recent months.
● He stated that his religion does not
interfere with any medical
interventions.
● Patient is optimistic and not stressed
with his condition.
● Anxiety: 1 out of 10 (relaxed)
● Is responsive and alert during the
interview
● No signs of fear or respiratory distress
● No voice quivering
● PR= 107 cpm, strong
BP= 120/70 mmHg
● He stated that he prays that he would
be able to have a fast recovery from his
condition.
● He is faithful and stays optimistic with
his current condition.