Age:67 years old
Address:Annafunan, Tuguegarao City
Date of Admission:Nov. 01, 07
Time of Admission:9:45 pm
Chief Complaint:Irritability and DOB
Final diagnosis:CVA infarct pneumonia
Attending Physician:Dr. Marlene Cinco
Past Health History:
Patient D.E. had completed his immunization when he was a child. He experiences cough and cold in the past. According to the SO, the patient had a Hypertension.
History of Present Illness:
Five days prior to admission, the patient had a stroke and was confined at CVMC and few hours prior to admission the patient was irritable and had a difficulty of breathing.
Family Health History:
Patient D.E. has family history of hypertension and heart disease but not on respiratory problems such as bronchitis, asthma or pneumonia.
Gordon’s 11 Functional Pattern
1. Health Perception – Health Management Pattern
According to the S.O, the patient views health as very important to human. One cannot function that well with the absence of it. Once health is absent, other aspects such as emotional, spiritual and social are affected. They always consult a doctor for any health problems. The S.O. also reports that he also takes over-the-counter drugs for simple illnesses such as fever
The S.O. said that patient D.E perceived his self as weak and wasn’t able to do his daily activities. He manages his condition by complying with the entire doctor’s order and taking adequate rest. He reported no allergies to any foods and medications. At present, he manages his condition by complying with the entire doctor’s order and taking adequate rest.
2. Nutritional – Metabolic Pattern
According to the S.O., the patient eats 3 times a day with snacks in between. He prefers to eat more on meat than vegetables. He drinks at least 7-9 glasses of water approximately 220/glass throughout the day. He usually eats crackers, biscuits and bread for his snacks with coffee. He had no difficulty in swallowing. Five days prior to admission, the patient was under OF feeding.
Patient D.E’s diet was OF at 1600kcal every four hours. He drinks about 220/glass throughout the day via NGT.
3. Elimination Pattern
According to the S.O., patient D.E. had no problem with urination and defecation. Patient D.E urinates at least 3-5 times a day depending on the urge he feels. The S.O describes the patient urine as light yellow in color. He defecates 1-2 times a day before starting his day in the morning and sometimes in the evening before going to bed. He describes his stool with brown color.
According to the S.O., the patient urinates smoothly without difficulty. The S.O. describes patient D.E.’s urine as light yellow. Due to the presence of catheter she cannot estimate the amount. He defecates once a day with brown in color.
4. Activity – Exercise Pattern
According to the S.O., patient D.E., has no difficulty doing his ADLs such as gardening, fixing their house and watching his grandchildren. Five days prior to admission, he can no longer do his activities of daily living because of his condition even with assistance.
“Hindi niya maigalaw ang kanang bahagi ng kanyang katawan,” as verbalized by the S.O. The S.O. reports that he needs assistance in every movement he does.
5. Sleep – Rest Pattern
He sleeps about 6-7 hours at night and sometimes 5-6 hours....