Keizel H.

Cruz N3B B5 Patient: Jesther Mae Joy Buenafe ISO FD: Malignant Lymph nodes, schedule for surgery

Gordon's Functional Assessment

Health perception and Health management pattern S> The Client is not a smoker nor a Alcohol drinker - Sakitin talaga yan kahit nung baby pa sya isang anak lang namin sya kaya lang sakitin nga as verbalized by the mother of patient. Nag e exercise naman sya eh kaya lang mga once a month lang pag umuwi mga pinsan nya. As verbalized by the mother of patient. The mother also state that the client does not have any absences from school before she was in grade school though she was prone to colds and other sickness. Ang sabi lang nya sakin natatakot daw sya kasi nga ooperahan na bukas eh first time nya As verbalized by the mother of patient. O> The client is oriented to person, She smiles when she see her mother, relatives and the nurse. Shes not lethargic. She does not use hearing aids but uses eye glasses for reading. Has fine, black, white and evenly distributed hair which is free from lice. She has fair, free from lesion skin. The client was diagnosed with Malignant Lymph nodes and was scheduled for a surgery on Aug 2,201. D> Fear related to separation from support system in potential stressful situation secondary to operation. Nutrition Metabolic Pattern S> According to the Father of patient Malakas kumain yan wala ng ginawa kundi kumain lagi pang may meryenda pa paminsan kaya tignan mo naman ang katawan. She usually eats 3 4 times a day and a snack at the afternoon. She prefers to eat rice, fried foods and vegetables. She also loves to drink friut juice and water. The client drinks at least 6-10 glasses of water a day. O> The client has warm and moist skin. She has a pink, moist and free from lesions mucous membrane. The client does not have dentures. Has poor gag reflex and has limited range of motion. The client is on a DAT diet. D> Readiness for enhanced nutrition. Elimination Pattern

S> The client usually have a bowel movement daily and it was usually formed before the admission. The relative claimed that it the frequency was the same but it's consistency was change from formed to semi formed upon admission. The relative stated - Hirap sya dumumi minsan kahit na araw araw sya dumudumi . O> The client has no history of hemmorhoids. During the shift she has an output of 420cc and no stool recorded. A>Risk for constipation related to ineffective physical immobility

Activity - Exercise Pattern S> Pag ba badminton pa minsan minsan lang yung pinaka exercise nya eh, kaya lang isang beses lang sa isang buwan sila nag kikita kita ng mga pinsan nya kaya dun lang yan nakakapag badminton. Sa bahay naka higa lang yan kung di naman naka upo lang nanonood ng tv at nag tetext palagi as verbalized by the mother of patient O> The client does not manifest cyanosis. She has easily palpable radial, brachial, carotid and temporal pulses. She has warm extremities. She has whitish nail beds and trimmed finger nails. Her hair is evenly distributed. The client h. Crackles were heard on left lower lungs upon auscultation. D> Activity Intolerance related to sedentary lifestyle.

Sleep Rest Pattern S>The client usually sleeps late and wakes up early. There is a change in her sleeping pattern upon admission as verbalized by the mother of patient - Sya kadalsan hanngang bukas yung tv gising pa din yan, mga 10pm o kaya 11pm yan nakakatuolg para makatulog pinapatay ko na yung tv. Sa umaga naman maaga gumising. Mga 8am o kaya 9am gising na yan. Kaso simula ng nahospital sya hirap na siya makatulog, madalas nga syang gising eh iidlip lang ng mga 30 minutes tapos gising na naman hirap siya makatulog madami kasing tao sa labas at maingay. The mother said that the client usually sleep during afternoon for 2 hours before admission. O>The client sleep using 4 pillows, one on the head, two on sides and the other one under the feet. She is in supine position. She has an eyebags and drowsy. D>Sleep deprivation r/t sustained environmental stimulation as manifested by drowsiness and presence of eye bags. Cognitive perceptual pattern S> Hindi naman hirap yan magdesisyon eh, madalas nga lang tatanungin nya muna kami bago sya mag desisyon minsan naman sya nalang mag isa nag dedesisyon as verbalized by the mother of patient.

O> The client is oriented to person. She is not lethargic. Has a normal pupil size. She does not use hearing aide. He has an eye glasses which she use when reading. D> Readiness for enhanced decision making.

Self- perception and Self concept Pattern S> Kinakabahan na sya hindi lang nya pinapahalata pag may ibang tao. Kasi ooperahan na bukas pero pinapalakas naming loob nya kesa naman mahirapan pa sya as verbalized by the mother of patient. O> The client is anxious due to upcoming operation, She looks fear but diverting her attention by doing other things while on a interview. D> Anxiety related to upcoming surgery. Role Relationship Pattern S> The client is living with her parents at Cavite. The patient is single. The mother of patient describe her daughter as - Si Jesther sobrang bait na nanay nyan. Alam nya pag mali yung ginawa nya. Nag sosorry agad yan inuunahan na kami. Hindi man sya nakapag highschool pero sobrang bait nya hndi mo sya makikitaan ng hinanakit sa magulang nya. Masipag din sa bahay, kung pa minsan tinotopak pero dala lang ng panahon nya yan teen ager kasi. O> The client smiles to her parents during the interview upon hearing things about their family. D>Readiness for enhanced family process

Sexuality and Reproductive Pattern S/O> cannot be assessed

Coping stress tolerance S> The mother verbalized - Sa nakikita ko si nastrestressed lang talaga siya pag nagkakasakit siya buti nga ngayon sa nakikita ko nakakapagadjust na siya eh. pag naiistress siya madalas nanonood lang kami ng tv o di kaya minsan panay text nya at panay ang kain The client does not use counselling groups in solving problems due to adequate and effective communication with the family member. O> The client is sleepy. She wears casual clothing. He has warm skin and nails are trimmed. Client is oriented to person and smile after addressing name. D>Readiness for enhanced coping

Value Belief Pattern S> The mother verbalized - Catholic kami, sama- sama kami tuwing linggo sa pagsisimba sabay sabay na nananalangin n asana mawala na lahat ng nararamdaman at sakit nya. pero kahit may sakit sya alam kong hindi nawala yung relasyon nya sa Panginoon. The client believes on the different healing through prayers and medicinal plants. O> The client is a Roman Catholic; The client smiles when addressed by name. D>Readiness for enhanced spiritual being