A.

Biographic Data
Patient Name: Filomeno Nachor Alejo
Address: 1764 bongavilla st. Cmarin
Age: 55 years old
Gender: male
Place of Birth: nueva ecija
Marital Status: married
Educational Attainment: college Graduate
Occupation: retired navy officer
Religious Orientation: Roman Catholic
Source of financial medical care: pension
HCVD CAD STEMI KILLIP 4
B. Past Health History
Te patient is a known hypertensive since 2009, maintained atenolol 50mg/tab 1 tab once a day. He
is non diabetic, non asthmatic, no history of myocardial infarction, lung diseases and no history of
surgeries or accidents.

C. Family History of Illness

The patient denies any family history of DM, asthma, cancer, kidney, thyroid and lung diseases.
D. Present Health History
The history of present illness started 2 hours prior to admission when the patient suddenly
experienced chest pain and difficulty of breathing, productive, non distressing cough with whitish
sputum and an episode of vomiting. No other associated symptoms noted. The patient sought consult at
a private hospital; however, he was advised to transfer to another institution due to lack of facilities
thus the transfer to seek consultation at our institution

Gordons Pattern of Functioning

PATTERN
HEALTH
PERCEPTION AND
HEALTH
MANAGEMENT

NUTRTIONAL
AND METABOLIC

BEFORE
HOSPITALIZATION
The patient does not go
to the hospital or health
centers for check up
when he feels his illness
is not serious.

DURING
HOSPITALIZATION
The patient is
monitored regularly on
admission to the
hospital.

The patient reports that

he likes to eat meat and

The patient regularly

eats the hospital food

ANALYSIS
An individual should be able to focus
on his/her own perceived level of
health and well-being, and on
practices for maintaining health helps
in improving activities of daily living.
(Health and Illness in the Expanding
Family Jeanette Koshar, RN, MSN, NP,
PhD)
Healthy individuals should normally
take 8- 10 glasses of water a day, eat
fruits and vegetables. Usual pattern

of food, fluid intake and types of food

should be monitored. The adequacy
of local nutrient supplies is essencial
to avoid problems related to fluid
balance, tissue integrity, and host
defenses may be identified as well as
problems with the gastrointestinal
system. ( Health and Illness in the
Expanding Family Jeanette Koshar,
RN, MSN, NP, PhD)
Normally, a person voids 30- 60ml of
fluids via urination. Monitoring the
Bowel and bladder elimination
patterns of patient having problems
with the kidneys specifically on urine
production must be done hourly,
changes will prevent excretory
problems such as incontinence,
constipation, diarrhea, and urinary
retention may be identified. (Health
and Illness in the Expanding Family
Jeanette Koshar, RN, MSN, NP, Ph)

is an occassional drinker
brought to him by the
pressure of his friends.

and takes his medicines

as prescribed by the
doctor.

ELIMINATION

The patient reports that

he voids more than
three times per day. He
has bowel movement
every other day.

The patient voids freely

in the comfort room
during his stay in the
ward. He has bowel
movements every so
often during his stay.

ACTIVITYEXERCISE

The patient does most

of his exercise by his
morning walks.

The patient mostly just

sleeps in his hospital
bed or does newspaper
reading during his stay.

An individual should do regular

exercises in order to maintain proper
functioning. Do jogging or walking at
least twice a week. Activities of daily
living requiring energy expenditure,
including self-care activities, exercise,
and leisure activities. The status of
major body systems involved with
activity and exercise is evaluated
especially for older patients whose
joints becomes stiffer and less mobile
. (Health and Illness in the Expanding
Family Jeanette Koshar, RN, MSN, NP,
PhD)

SLEEP-REST

The patient usually

sleeps moderately when
she has nothing to do
and usually feels
refreshed when he
wakes up. He reports no
sleep disturbances.

The patient on his stay

sleeps more often than
his usual routine
before and reports to
feel refreshed when he
wakes up. He reports
no sleep disturbances.

A person should have a regular

sleeping hours of at least 8 hours to
help and give time for the body to
rest and repair damaged tissues.
Illness that causes pain or physical
distress can result in sleep problems.
People who are ill require more sleep
than normal and the normal rhythm
and wakefulness is disturbed.
th
(Fundamental of Nursing 7 ed by
Barbara Kozier, et al, p 1117)

COGNITIVEPERCEPTIVE

The patient reports no

problem of her other
senses prior to
admission. His memory
is fine as well.
The patient reports that
he is well comfortable
with his own body and
feels contented.

The patient upon initial

examination is
conscious, coherent.
He reports no changes
in her memory
The patient reports
that he is well
comfortable with his
own body and feels
contented.

A person should have no problems on

cognition and perception and have
minimal effort on recalling memory
but as people age their senses go dull
and some requiring assistive devices
to function more productively.
Norms:
Self-concept is ones mental image of
oneself. A positive self-concept is
essential to a persons mental and
physical health. An individual
possessing a strong self-concept
should be better able to accept or
adapt to changes that may occur over
the life span. (Fundamentals of
nursing by Barbara Kozier, Glenora
Erb, Audrey Berman & Shirlee Synder,
th
7 edition, page 957)

SELF-PERCEPTION
AND SELFCONCEPT

ROLERELATIONSHIP

The patient is is living

with his wife

The patient is
frequently with her
wife and has close ties
with his three
offsprings. He is
sometimes visited by
his friends.

A Family should always stay close

together, never leaving anyone
behind. They must be oriented and
well-rounded. How clearly and
openly family members communicate
with each other will be a strong
determinant of how the family
members perform in any of the
family functions. (Fundamentals of
Nursing Phil. Ed by Rick Daniels
p.1582) And the support of the family
will help the client to recover fast.

SEXUALITYREPRODUCTIVE

The patient is a father

and has three offsprings
of a boy whom he
adopted and 2 girls. He
loves his wife who is
currently looking after
him.

The patient is a father

and has three
offsprings of a boy
whom he adopted and
2 girls. He loves his
wife who is currently
looking after him.

Creating and having your own

Offsprings is the foundation of a
family. Individuals, specially couples
should be healthy enough to produce
their own kind. The mother should be
able to ovulate once a month to
maintain an eggcell capable of sperm
cell penetration. On the other hand,
guys should also maintain having a
healthy lifestyle so that they will be
able to produce healthy gonads
capable of reproduction.
Psychosexual integration involves a
dynamic progression of growth along
a wide continuum of behavior and
characteristic also relating to the
mental or emotional attitudes about
sexuality. (Ferder and Heagle, 1997)

COPING-STRESS
TOLERANCE

The patient usually

handles stress by going
out with his friends and
being with his wife.

The patient usually

handles stress by going
out with his friends and
being with his wife.

According to Folkman and Lazaruz,

coping is a behavioral effort to
manage specific external and/or
internal demands that are appraised
as taxing or exceeding the resources
of the person (Fundamentals of
Nursing by Kozier p. 1020)

VALUE BELIEF

The patient is a firm

believer of Christ and is
Roman Catholic by
religion.

The patient is a firm

believer of Christ and is
Roman Catholic by
religion.

Different Religions have different

ways of believing and worshiping
their own Gods and Goddesses.
Respect for particular religious beliefs
and remembering how religious
beliefs may impact a clients choices
and comfort are important.
(Fundamental of Nursing Phil. ed by
Rick Daniels p. 1680)