I.

PHYSICAL EXAM ASSESSMENT FINDINGS BEFORE (SEPT 12, 13)

ASSESSMENT DATA SKIN Color Temperature Turgor Texture Lesion Integrity Others NAILS Color Texture Shape Others HAIR Color Texture Distribution Quantity Others

Fair 36.8 C Poor skin turgor dry skin (+) Lesions/Rash Intact

Pinkish Smooth Concave capillary refill = 1-2sec

White Coarsely dry Evenly distributed Moderate

HEAD Shape Size Configuration Headache Round Normocephalic Symmetrical None

ASSESSMENT DATA EARS Hearing Tinnitus Vertigo Earaches Infection Discharges Poor None No vertigo No earaches No infection No discharges

NOSE AND SINUSES Frequent colds Nasal stiffness Nose bleed Sinus trouble MOUTH & THROAT Condition of teeth Lips Bleeding gums Tongue Throat Hoarseness Mucous membrane Incomplete teeth (+) crack lips No bleeding Tongue is at midline, Throat Non-tender None Pinkish None None None Sinuses are non-tender

ASSESSMENT DATA NECK Symmetry Condition of trachea Thyroid Lymph nodes

ASSESSMENT FINDING

Symmetrical in the midline (-) nonpalpable (-) nonpalpable

LUNG Symmetry Shape Respiratory movements # of breath Symmetrical A:P diameter 1:2 Asymmetrical, use of accessory muscles 28cpm

AUSCULTATION: Character of respiration (+) crackles on upper lung fields diminish breath sounds

HEART AND NECK VESSELS: Apical Pulse Cardiac Sounds Apical/Radial pulse data Blood pressure Pulse pressure Any special procedure Done 120/80mmhg 110bpm 110 bpm (-) murmurs

ASSESSMENT DATA ABDOMEN: Symmetry Contour Skin Lesion Masses Bowel Sounds Tenderness

ASSESSMENT FINDING

Symmetrical Globular none (-) Masses Normoactive bowelsounds None

MUSCULOSKELETAL SYSTEM: Posture abnormal postures arent present

ROM

passive

Muscle Strength

3/5

HEAD AND NECK: Facial muscle symmetry Swelling Scars Discoloration Weakness ROM Posterior neck cervical spine Muscle spasm Crepitus Symmetrical None (+) scars None (+) Weakness

can turn head from side to side

Non-tender (-) Spasm (-) Crepitus heard

MOTOR SYSTEM: Muscle tone Without hypertrophy or atrophy Muscle strength is 3/5 Ability to move extremities against gravity Spasticity, flaccidity or rigidity, tremors, lies None

MENTAL STATUS: LOC Long term memory Short Term Memory Semi-Conscious Not assessed

II.

GORDONS FUNCTION HEALTH PATTERN:

Clients Profile: Name: o. N. Date of Birth: June 24, 1929 Age: 84 years old Sex: Male Address: Block 1 Lot 5 Asttoville, Pajac, Lapu-Lapu City, Cebu Occupation: Retired Military Religion: Roman Catholic Ethnicity: Filipino Marital Status: Married

1. Developmental History During the younger years of the patient, he didnt experience any physical handicaps and even hospitalizations. sukad pagcollege ani niya nagsugod nani siyag sigarilyo ug inom as verbalize by the significant others. When he was still young, he was influenced by his friends to smoke and drink alcohol for at least once a week until he got married at age of 25 he still used to it, will in fact he can take 1 case of alcohol and consume more than 1 pack of cigarette per day. 2. Health Perception- Health Management Pattern Kana si papa gud kay maghilom-hilom lang ba kung naay bation, mao nang amo rasad gipasagdaan as verbalized by the significant others. My patient doesnt like to be hospitalized. There is less medical intervention from my patient and he doesnt like to be cared by anyone and unfortunately he cant manage himself. After my patient

experienced vehicular accident, he manifested disorientation to place, time and person around him.

3. Nutritional-Metabolic Pattern

Before when hes not yet admitted, she eat three times a day breakfast, lunch and dinner, and loves to eat on the restaurant but doesnt like to eat fish and vegetables. He likes to eat anything that is sweet. He usually take 2-3 liters of water per day. When hes already admitted, she eats three times a day but through NGT feeding. He usually takes 200cc of blenderized feeding every feeding. 4. Elimination Pattern Before, the patient urinate everyday especially every morning on his underwear and defecate regularly once a day. The colour of her stool is brownish and her urine is yellowish. After, he can defecate everyday specially when hes still at the ICU, but after he transferred to 3A hes not yet able to defecate. He urinated freely because a catheter was attached on him and his urine output was monitored and recorded every day. 5. ACTIVITIES-EXERCISE PATTERN Before, my patient loves to clean on their backyard and take a walk as early as 6am around their home. Gahan kay na siya magsige mi pang lakaw sa mga mall mangaon as verbalized by the significant others.

 When hes admitted and attached with him his FBC and mechanical vent, he can no longer able to ambulate but still on passive exercise. 6. SLEEP AND REST PATTERN According to the significant others my patients sleeping time is at 910pm and he usually watch movies or tv until he get sleep. Dili man na siya ganahan matulog sa iya kwarto, ambot ngano, mas ganahan nuon siya sa sofa matubig pero mao lge magsige ug mata-mata as verbalized by the significant others.

Karon na naa na siya sa hospital magsige ra jud na cyag katulog, naa gani usahay na bisan unsaon nimog pukaw dli jud mo mata as verbalized by the significant others.

7. COGNITIVE-SENSORY-PERCEPTUAL PATTERN According to the significant others his father was diagnosed of Alzheimers disease after he was experience vehicular accident he is disoriented to time, place, and even with his own daughter. His action is not appropriate to his physical stimuli.

8. SELF-PERCEPTION or SELF-CONCEPT PATTERN

Sa balay kung ilisan gani namo na siyag underwear dili jud na siya mo sugot kay ganahan siyag siya ra, pero kung tagaan namog underwear dli mi makabalo na gisapao sa d I niya as verbalized by the the significant other.Before when he still at their home he cant managed himself for personal hygienge that why he develops rashes on his inguinal area.

9. ROLE-RELATIONSHIP PATTERN He is very strict personality and believes on his own principle in life. He has one biological daughter and one adopted son. His wife is 87 years old and disable and they have two adopted girl but not legally adopted. He was finished his college degree and served on military field but was on early retirement and worked at PAL as repairman of damaged airplane. They are currently living at Lapu-Lapu City, Cebu.

10.

COPING STRESS PATTERN Kung naa siyay problema before kay magsige ra jud na siyag inom ug sigarelyo pero after niyang na aksidente wala na, ang nakaapan aning papa dili siya mo sulti kung naa siyay problema as verbalized by the significant other. He is not expressive father in terms on his problem, he usually leave it on his own.

11.

VALUES BELIEFS PATTERN Hes a roman catholic and believes in God. They often go to church with her daughter and grandson. He doesnt blame the almighty God for having that condition, and hes still thankful because he knows that God has plan for him.