D.S.E.

B
Patient’s Initials

Submitted by:
Josiah David P. Maraat
Kyrah Mae Nerez

Submitted to:
Asst. Prof. Zorrina Luague

Date:
10/24/2022
 ASSESSMENT OF MARJORY GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Student’s Name: Josiah David P. Maraat, Kyra Mae Nerez Level: III - A2

Biographical Information

● Patient’s Name : Delos Santos, Edilberto Bandiala

● Age : 55 Years Old Gender: Male Insurance: PhilHealth
● Marital Status : Married Birthdate: Dec. 16, 1966
● Address : Dampalad, Dapitan City Occupation: Farmer

● Race : Filipino Religion: Filipiniana

● Educational Level : Primary Language Spoken: Bisaya

● Date of Admission : October 17, 2022 at 8:18 AM Ward/ Bed: NEM 3

● Mode of Admission : Elective Medical Dx. On Admission: Sacral Decubitus Ulcer Stage 4

Reason for Seeking Care: CC: Bed Sores, sacral area

History of Present Illness: 8 weeks PTa, patient had incomplete Spinal Cord Compression sec to Burst Fracture, S/P posterior decompression T12, instrumental spinal
fusion T10 - L2 (8/18/22). G weeks PTA, onset of blisters on sacral region 5 weeks PTA, follow up check up at SUMC, advised Flammazine on
blisters BIDA BIO on blisters. 4 weeks PTA, blisters progressed to ulceration ~2 cm deep. Worsening of symptoms prompted consult &
subsequent admission at a local hospital in Dapitan. Transferred with 7 units PRBC, confined for 3 weeks. In the interim, symptoms now with
urinary & bowel incontinence & numbness on R leg. On the day of admission, worsening of symptoms prompted consul in this institution &
subsequently admitted.

General Impression: Pt lying in bed, on his side. Pt is non-ambulatory and is with the company of his wife and niece who take care of the pt while admitted. Pt
responded well and clearly to all questions
 Nursing Diagnosis

● Priority
○ Electrolyte imbalance related to excessive loss of potassium
○ Impaired Skin Integrity related to immobility as evidenced by stage 4 sacral ulcer
○ Risk for infection due to presence of stage 4 sacral ulcer
● Other
○ Disturbed sleep pattern
○ Self care deficit
○ Altered comfort
○ Impaired physical mobility
 USUAL FUNCTIONAL PATTERNS INITIAL APPRAISAL ONGOING APPRAISAL
10/ /2022 10/ /2022
1. Health-perception – Health –management pattern

● No food or drug allergies

● No comorbidities, no maintenance medication
● Doesn’t use any herbal/traditional remedies
● No COVID vaccines given. Stated “mahadlok man
gud kog dagom.”
● verbalized “naa man ko gina tumar nga vitamins
man siguro to pero di ko ka hinumdom sa ngalan”
● does not smoke or do drugs, occasionally drinks
when invited
● stated “na ingani ko kay wa ko ga pangingkamot
maayo mao na aksidente ko.”
● Niece verbalized “ nagka sugod na siyag ka ulcer
sukad atong gi operahan na siya unya wala na siyay
lihok lihok sa iya higdaanan kay sakit man kung mo
lihok siya.”
● verbalized “wala man ko tagda sa mga doctor
didtos amo kay murag ma hadlok sila mo tandog
nako mao sige ra ko higda sa ako likod sukad na
operahan ko.”
● experienced fever last October 17, 2022

Examination

● Vital Signs (10/24/2022 - 6:15 PM)

○ T: 36.5 ºC, RR: 16 cpm, BP: 125/70 mmHg;
PR: 81 bpm; SaO2: 99%
● Urinalysis (10/17/2022)
○ few dysmorphic RBC’s seen
● CBC (10/21/2022)
○ Hgb: 9.60 g/dL
○ Hct: 29.80%
○ Mean Corpuscular Hgb: 26.20pg
○ Mean Corpuscular Concentration: 32.2%
○ creatinine serum: 1.50 mg/dL
○ potassium: 2.30 mEq?L
● 10/23/2022
○ potassium: 2.90 mEq/L

2. Nutritional-metabolic pattern

● Eats three meals a day

● Each meal consisting of vegetables, fish, and rice
● Has no problem with appetite
● Has no eating disorder
● Drings 2 L of water everyday
● Has multiple missing teeth but does not affect his
ability to eat
 3. Elimination pattern

● Defecates 1-2x a day

● Stool is of normal characteristic but has difficulty
passing due to the bed sores in the sacral area
● Use of condom catheter
● Urine is light yellow, slightly hazy

Examination

● 10/17/2022
○ Chemical Examination
■ Blood: Trace
○ Urine Flow Cytometry
■ RBC: 40 /uL
○ Other
■ Few Dysmorphic RBCs seen. Please
correlate clinically.

4. Activity-exercise pattern

● wakes up at 5:00am in the morning and prepares to

feed his carabao’s
● tends to his farm by 6:00am
● goes home by 3:00pm after tending to his carabaos
and making “sug-angan” and clay pots with his son
● generally active and enjoys doing work verbalizing
“ganahan ko magpa singot.”
● talks to neighbors and friends during leisure time
● has not reported any dizziness or fainting spells
prior to accident
 ● Perceived ability according to functional levels
code below:
○ feeding: 2
○ grooming:2
○ bathing:2
○ general mobility:4
○ toileting:4
○ bed mobility:4
○ home maintenance:4
○ dressing:4

grade description

0 Independent

1 Requires use of equipment or device

2 Requires assistance or supervision of another

person

3 Requires assistance or supervision of another

person and equipment or device

4 A dependent and … participate

Examination

● Pulse: 81bpm, regular, 2+ normal

● BP: 125/70 mmHg
● SaO2: 99%
● motor function impaired on both lower legs
● unable to move independently on bed
● to be turned every 2 hours with a flat, left, flat, right
pattern
5. Sleep-rest pattern

● Sleep is inconsistent every night

● Every 2 hrs PT has to move from side to side
● Wakes up throughout the night, “Kay init ako
lawas” on the side lying upon
● Snores occasionally but not loud as to disturb
others

6. Cognitive-perceptual pattern

● Patient main complaint is that his body gets warm

● Does not experience much pain and rarely asks for
pain medication
● Responded well to all answers and is oriented to
location, time, and date
7. Self-perception-self-concept pattern

● Patient main worry is his inability to walk and use

his legs verbalizing “ang ako ra jud maam ug sir
maka lakaw ra ko balik ug maka trabaho kay ako
ang breadwinner sa among pamilya.”
● Is hopeful to get well and regain ability to walk
after a successful spinal surgery
● Niece said that before the fall, patient was very
active and healthy

8. Role-relationship pattern

● Has a wife and one son

● Arguments are resolved by talking and
communication
● Wife verbalized, “talagsa mi mag away”
● 22 year old son is typically the mediator of
arguments between parents

9. Sexuality-reproductive pattern

● Wife verbalized that their son is a miracle child as

they tried five times before had to have a child
before their son was born
● After the birth of their son, they continued to try to
have a second child, but at the 3 month mark wife
had a miscarriage.
10. Coping stress tolerance pattern

● Talks to his “kompare” when feeling stressed and

feels that he cannot tell his feelings to his wife

11. Value-belief pattern

● Wife is Roman Catholic

● Patient practices Filipiniana with his son
 Nursing Care Plan
Nursing Diagnosis #1: Deficient knowledge related to infection and inflammation in the urinary tract as evidenced by multiple questions and verbalization of inaccurate information
causes and treatment regimen

CUES / EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: At the end of our 8 hour nursing Independent

● niece verbalized “mo ● low fluid intake may
care, the patient as well as his
inom man nuon na siya ● assess hydration status result in a more
tubig pero kalabanan juice attending loved ones will: concentrated urine that
iya gina inom. basig can promote bacterial
● verbalize in their own
nagka kidney stones na na growth inside the urinary
siya karon ma’am mao words the importance of tract.
gipa ultrasound.” ● monitor urine output ● provides baseline data on
increasing fluid intake to
● niece verbalized “ gi noting its color, the condition of the urine
kidney stones jud ni siya at least 2-3L per day transparency, tubidity and helps to assess any
kay wala man ni siya abnormalities that may be
● differentiate cystitis from
kalibutan unsa ang para present in the urine such
magka kidney stones ang kidney stone formation as blood
usa ka tawo. pero ngano
● verbalize proper care of
man nga sakit pag ● there may be an elevation
pangihi? tungod ba na kay condom catheter ● monitor laboratory and on the white blood cells
mo tubo siya sa kidney?” diagnostic results due to inflammation and
infection
Objective:
● dilated ureters bilateral, ● evaluate learning barriers ● learning barriers such as
cystitis with bladder cultural differences,
obstruction, slight religious beliefs, financial
nephromegaly on right status, etc. may affect
kidney (12.2cm) their perception on
appropriate interventions

● provide health teaching on ● condom catheters

the difference between although convenient, is
kidney stones and cystitis more prone for bacterial
and ways in order to growth and may cause the
 prevent further
complications from
infection such as routinely
cleaning condom catheter
using proper aseptic
technique
● encourage increase fluid
intake
● encourage the patient and
loved ones to ask
questions
● have
Collaborative
● collaboration with the
radiology department for
monitoring and evaluating
of urinary tract
Dependent
● administer sultamicillin
PO, 750mg, 1 tab BID
development of already
existing infection
● practicing proper aseptic
technique when cleaning
or changing condom
catheter minimizes risk
for infection
● increasing fluid intake to
at least 2-3 liters per day
helps dilute urine,
reducing irritation of to
the bladder and helps
flush away bacteria when
urinating
● helps addresses any
misconceptions the patient
and his loved ones may
● KUB ultrasound will help
examine and evaluate the
urinary tract for any
progression of the
infection
● sultamicillin helps prevent
bacterial infection
Nursing Diagnosis #2: Risk for further impaired Skin Integrity related to immobility as evidenced by stage 4 sacral ulcer

CUES / EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: At the end of our 8 hour nursing Independent

● Niece verbalized care, the patient will:
“kalabanan karon kay iya
position kay mag takilid
siya kay ang gi ingon sa
doctor di man kuno pwede
nga mag higda siya sa iya
likod kay naay ulcer.”
● Patient verbalized “wala
man ko tagda sa mga
doctor didtos amo kay
murag ma hadlok sila mo
tandog nako mao sige ra
ko higda sa ako likod
sukad na operahan ko.”
● patient verbalized “di
kaayo ko ganahan nga ga
takilid ko kay dali ra ko
laayan sa akong kamot.”
● Have reduced risk of
additional skin integrity
degradation
● enumerate and locate the
different sites pressure
ulcer can develop in the
body
● verbalize in his own
words the importance of
proper wound care
● verbalize the importance
of keeping the bed free
from objects that might
put pressure to the body,
proper positioning and
keeping linens dry and
free from wrinkles
● continue to determine,
document and assess
dimension and depth of
pressure ulcer, exudates
noting its color, odor and
amount, evidence of
necrosis (color gray or
black) or healing (pink or
red granulation tissue)
● Maintain head of bed at
the lowest elevation
● follow proper aseptic
technique when cleaning
and dressing wound
● keep bed linens dry and
● establish comparative
baseline data and early
detection of possible skin
deterioration or healing
● elevating head of bed can
distribute weight to the
lower region of the body
causing more pressure to
the ulcer
● to reduce risk for infection
● wrinkles and wet bed
Objective: wrinkle free and use
● presence of stage 4 sacral appropriate padding or
ulcer on left and right pressure reducing devices
butocks
● develop regularly timed
repositioning schedule
linens can cause put
pressure to the already
existing ulcer
● paddings or pressure
reducing devices such as
egg crate foam can reduce
pressure on sensitive areas
and enhance circulation to
compromised tissue
● to reduce stress on
pressure points and
promote proper
circulation to tissues

● monitor other pressure ● other pressure ulcers may

sites on the body that can develop in the body as a
develop ulcers such as the result of pressure exerted
shoulder, back of the by the body in specific
head, thigh, elbow and positions
legs
Dependent
● administer sultamicillin ● suppresses bacterial
PO 750mg 1 tab BID growth that can cause
infection
Nursing Diagnosis #3: Risk for falls related to immobility and lack of side rails

CUES / EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: After 5 hours of nursing Independent

● patient verbalized “unsa
diay nang side rails
maam? ganahan man gud
kong naa kos pinaka
kilid”
● niece verbalized “ ako pa
pangitaan pamaagi kung
unsaon nako pag suhid
ang higdaanan diris
hospital kay mahal man
diay kaayo ning stretcher
nya lahi man amo
higdaanan sa balay.”
intervention, the client with the
help of the significant others will
be able to:
● verbalize in their own
words the importance of
side rails in relation to the
condition of the patient
● identify and enumerate
innovative ways to
provide protection of the
client from falls in the
absence of side rails
● Provide health teaching
on reducing risk for falls
on bed such as utilizing
pillows to act as a barrier,
removing excess
equipment or furniture at
the patient’s bedside,
keeping the floor free
from clutter, keeping the
bed at the lowest position
with side rails up and
wheels on lock (in
hospital)
● proper health teaching
will ensure continuation
of patient safety and care
after discharge
● providing pillows to both
of the patient’s side will
help secure and prevent
risk for falling
● side rails act as a barrier
to prevent the patient from
rolling off the bed

Objective:

● presence of stage 4 sacral

ulcer on left and right
butocks on a side lying
positioned, periodically
turned to the opposite side
every 2 hours.
● side rails always kept
down with patient at the
edge of the bed