GORDONS FUNCTIONAL ASSESSMENT HISTORY PATIENTS PROFILE Clients Name or Initial: R.T.B.

Age: 57 Sex: Male Civil Status: Married Religion: Roman Catholic Address: Zapote, Bacoor, Cavite Birth date and place: October 17, 1955 at Cavite city Race/Nationality: Filipino Usual source of medical care: St. Dominic Hospital Source of information: TV, Internet, and Doctors Educational Attainment: College Occupation: Barangay Captain Admitting date and time: August 2, 2013 at 2:51PM Admitting Medical diagnosis: CAP MR ongoing treatment Bronchogenic Carcinoma St. IV SVC syndrome S/P RT 2008 R Mid Lobe X28 sessions, for RT RUL.

1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN A. HISTORY OF PRESENT ILLNESS Past Patients relative stated that the overall health of the patient is not okay because the patient has been diagnosed with cancer since 2008. He experiences persistent coughing. He thinks that reason for his illness is his smoking history and his previous work as a welder. The patient has been going back and forth to the hospital for radiation therapy and follows the prescribed treatments given to him. He takes influenza vaccine yearly. He is an occasional drinker. He is a smoker (1 stick per day) since he is 40 years old. He described that his familys health is okay. He is aware that because of his smoking history, he is at risk of having a disease. Present Patients relative stated that the overall health of the patient is getting better because of the therapy. He still experiences cough but not persistent. He thinks that reason for his illness is his smoking history and his previous work as a welder. The patient has been going back and forth to the hospital for radiation therapy and follows the prescribed treatments given to him. He takes influenza vaccine yearly. He is no longer a smoker or a drinker. He described that his familys health is okay. He is aware that because of his smoking history, he is at risk of having a disease.

B. MEDICAL HISTORY OF PAST HEALTH The patient doesnt have any history of pediatric illness or history of injuries or accidents. His only history of hospitalization was about his

treatment or radiation therapy for cancer. The patient only had the BCG immunization in which he received during adulthood and currently takes influenza vaccine yearly. The patient doesnt have any known allergies of any kind.

C. FAMILY HISTORY (GENOGRAM)

Father (Emphysema)

Mother

Aunt Breast cancer

Patient

Legend: - Male - Female

NOTE: ETO LANG TALAGA ANG SINABI NG PATIENT.

2. NUTRITIONAL/METABOLIC PATTERN Past Present The patient usually eats egg for He eats more vegetables and fish breakfast, vegetables or meat for during his stay. He eats fruits for lunch and dinner. He eats fruits or snacks. He drinks about 3 bottles of biscuits for snacks. He usually water a day. He still doesnt any drinks plenty of water. He doesnt appetite problems. He is not in a any appetite problems. He has no specially prescribed diet. He history of specially prescribed diet. described that he eats more He described that hes a rice lover vegetables to help cure his illness. and likes to eat meat (specifically He doesnt have any prescribed pork). He doesnt take vitamins or vitamins or food supplements. No food supplements. No food food allergies, no experience in

allergies, no experience in difficulty in chewing or swallowing. He thinks that he weighs around 195 lbs. before hospitalization. When he has a wound it heals quickly. He thinks that he doesnt have risk factors susceptible to skin ulcers. 3. ELIMINATION PATTERN Past He usually urinates about 5 times a day. The appearance of his urine is from clear to yellowish. He has no urination problems nor uses any assistive devices to urinate. He experiences 5 times bowel movements a day. The appearance of his stool is ranging from watery to form. He doesnt use any assistive devices to bowel movement. 4. ACTIVITY/EXERCISE PATTERN Past He described that he is active prior to hospitalization. He takes walking as exercise. For his leisure activity, he buries himself at the barangay and doing his work. He experience chest pains. He doesnt require assistance in doing daily activities. 5. SLEEP/REST PATTERN Past He usually sleeps about 6-8 hours. He sleeps at around 10pm and wakes up at 6am. He feels rested after sleeping. His sleep ritual is counting money to help him sleep. He doesnt have any sleeping problems.

difficulty in chewing or swallowing. He lost 20 lbs in weight and he weighs 175 lbs. now. When he has a wound it heals quickly. He experiences skin around his chest area and dry skin due to radiation side effects.

Present He urinates about 8 times a day. The appearance of his urine is from clear to yellowish. He wakes up at night to urinate. He doesnt use any assistive devices to urinate. He experiences 1 or 2 times bowel movement a day, skipping 1-2 days since the last movement. The appearance of his stool is formed. He uses laxatives to assistive his bowel movement.

Present He described that he is less active. For his leisure activity, he watches television and talking to his relatives. He experience shortness of breath and coughing. He only requires assistance when using the toilet.

Present He sleeps about less than 5-6 hours. He doesnt have a definite sleeping and waking hour, Paputol-putol lang as stated by patient He doesnt feel rested after sleeping. His sleep ritual is still counting money to help him sleep. He has a difficulty falling asleep problem.

6. COGNITIVE/PERCEPTUAL PATTERN Past Present The patient is able to read and The patient is able to read and write. He speaks Tagalog and write. He speaks Tagalog and English language. He learns best English language. He learns best when by himself or when someone when by himself or when someone

taught him. He doesnt have any hearing problems. He wore glasses since he is 40 years old and the grade of his glasses is 250 both. His last visual examination is in 2012. He doesnt experience dizziness. He doesnt have any insensitivity to cold, heat or pain. He experiences chest pain.

taught him. He doesnt have any hearing problems. He wore glasses since he is 40 years old and the grade of his glasses is 250 both. His last visual examination is in 2012. He doesnt experience dizziness. He doesnt have any insensitivity to cold, heat or pain. He experiences no pain.

7. SELF-PERCEPTION/SELF-CONCEPT PATTERN Past Present He described himself as being okay He described himself as sad. He and normal. He was diagnosed with was diagnosed with cancer since cancer since 2008 thats why he 2008 and has been in undergoing feels different about himself. He is treatment thats why he still feels most concerned about his work. He different about himself. He is most has feelings of anxiety about his concerned about his illness. He has illness, family and work. feelings of anxiety about his illness and his family. 8. ROLE RELATIONSHIP PATTERN Past He lives with his wife and two sons and has satisfying and close relationship with each one. He is the breadwinner of the family. He and his wife make family decisions. Family conflicts are resolved by talking. He said that finances are inadequate to meet family needs. Outside the family, he is close friends with his fellow barangay officials and is friends with his neighbors. They are 4 members in the family. The family feels sad about illness.

Present He lives with his wife and two sons and has satisfying and close relationship with each one. He is no longer the breadwinner of the family. He and his wife still make family decisions. Family conflicts are resolved by talking. He said that finances are inadequate to meet family needs. Outside the family, he is still close friends with his fellow barangay officials and is friends with his neighbors. They are 4 members in the family. The family still feels sad about illness.

9. SEXUALITY/REPRODUCTIVE PATTERN Past Present The patient has 2 sons. He is no The patient has 2 sons. He is no longer active in sexual activity with longer active in sexual activity with his wife due to his age and because his wife due to his age and because of his illness. of his illness. 10. COPING/STRESS TOLERANCE PATTERN Past Present A major change happened in his life It still a major change that happened was when he was diagnosed with in his life was when he was

cancer and he felt sad about it. His family copes by praying and talking with each other during crisis. When he has a problem, he talks about it to his family. He described himself as relaxed and doesnt use any medications to help him relax.

diagnosed with cancer and he felt sad about it. His family copes by praying and talking with each other during crisis. When he has a problem, he talks about it to his family. He described himself as a little tensed and relaxes by doing divertional activities like watching t.v. or by talking to his family.

11. VALUE/BELIEF PATTERN Past The patient stated that he doesnt generally get what he wants out of life. He has plans for his family, especially his sons and for his barangay. There are no personal values and beliefs he feels may be compromised. Religion is very important to his life, his family prays for him to get better. Being hospitalized does not interfere with his religious practices. He makes decision often with himself but will ask help from his family. There are no changes in the last year or two. He said that what he likes about himself is that hes relaxed. He would like to change his familys life. When he is stressed, he tries to calm down and talk to his family. Present The patient stated that he doesnt generally get what he wants out of life. He has plans for his family, especially his sons and for his barangay. There are no personal values and beliefs he feels may be compromised. Religion is very important to his life, his family prays for him to get better. Being hospitalized does not interfere with his religious practices. He makes decision often with himself but will ask help from his family. There are no changes in the last year or two. He said that what he likes about himself is that hes obedient in his prescribed treatment. He would like to change his familys life. When he is stressed, he tries to calm down and talk to his family. He said that the nurse could provide more comfort and security by being more remindful of the medications he is taking.