ASSESSMENT

Gordon's Patient Assessment According to Functional Health Pattern

Patient Profile
RMJ is a 4th year (Marketing) undergraduate of New Era University.
He stayed in Tondo, Manila until he was 15 years old. He then moved to
Caloocan and stayed there for 5 years and finally settled in Quezon City. His
reason for seeking medical assistance is his difficulty of breathing and
generalized edema.
Treatment and Medication
Treatment:
Hemodialysis
Medications:
Atorvastatin 20mg 1 tab 1x a day
Allopurinol 300mg 1 tab 1x a day
FeSO4 + FA 1 tab 1x a day
CalciAcid 1tab 3x a day
NaHCO3 650mg 2x a day
Cloxacillin 500mg 1 tab 2x a day
Ciprofloxacin 500mg 1 tab 2x a day
Calctriol 0.25mg 1 capsule 1x a day
IV Iron sucrose 100mg 2x a day

Past Illnesses and Hospitalizations

RMJ is known to have Diabetes for the past ten (10) years. He was
initially diagnosed at their local clinic. This is the first time RMJ is hospitalized.
Allergies
RMJ stated that he is allergic to Penicillin/Amoxicillin. He denies any

food or environmental allergies.

Developmental History
Developmental level: Generativity vs Stagnation
Describes self as the First born of the five siblings. He stated that he
smokes a whole pack of cigarette a day. RMJ states he started smoking when he
was 12 years old.

Health Perception/Health Management Pattern

He rates his present condition as 8 out of 10 and 10 being the worst.
When he was diagnosed with Type II Diabetes Mellitus, he still continued to
drink an average of three (3) bottles of soda, two (2) glasses of juice everyday,
and three (3) 500ml bottles of beer before sleeping. He admits that he did not
understand what Diabetes could do if it is not managed.

Nutrition/Metabolic
RMJ stands 59 tall and weighs 71kg. He usually eats three (3) meals a
day plus snacks twice a day. He drinks soda, juice and beer daily. He states that
he does not drink that much water. Bipedal edema is still present. However
generalized edema gradually decreased after several sessions of hemodialysis
treatment. He wears dentures and states his last dental check-up was 2014. RMJ
has diabetic feet. Skin below both knees is black with a hint of yellow.

Elimination Pattern
RMJ states he defecates on an average of 2-3 times a day. He states
that he does not experience any rectal bleeding or any change in color or
consistency of his stool. He stated that he only urinates 1-2 times a day.

Activity Exercise Pattern

RMJ describes his daily routine as waking up at around 4:00 in the

morning to cook the breakfast meals that he is selling then eats at 7:00 am with
his wife and daughter. After eating he starts selling the food he cooked until
1:00 pm. He then cleans everything up and eats lunch with his wife. After eating
they rest then shop for the ingredients they will use the following day. He does
his usual routine till bedtime.

Sexuality/Reproduction Pattern
RMJ and his wife states that their last intercourse was six (6) years ago
because of erectile impotence and loss of urge for intercourse for RMJ.

Sleep/Rest Pattern
He and his wife usually sleeps at 10:00 in the evening. RMJ also
usually sleeps up to four (4) hours in the afternoon. He stated that he is able to
sleep better after several hemodialysis treatments. He reported no difficulty of
breathing before discharge.

Sensory/Perceptual Pattern
VISION: RMJ only wears glasses for reading. He reports not experiencing any
excessive tearing or discharge or trauma with his eyes.
HEARING: RMJ does not wear hearing aid and reports to not having difficulty
of hearing. He is observed not to ask questions to be repeated again
during the interview.
SMELL: RMJ states he is not experiencing any decrease in his sense of smell
and denies any pain or history of his nose bleeding.
TOUCH: RMJ states he does not feel anything if he or someone or something
touches/brushes anything below both his knees.
PAIN: RMJ denies any painful sensation.

Cognitive Pattern
RMJ speaks clearly without stuttering. He follows verbal cues. He is
able to recall past events without any difficulty. He is oriented with the time,
place and person.

Role Relationship Pattern

RMJ has been married for eighteen (18) years and counting. He
currently lives with his wife and daughter.

Value Belief Pattern

RMJ was a Roman Catholic (1971-1998) and converted to Iglesia ni
Cristo (1998-2000) and then shifted back to being a Roman Catholic.

Coping Stress Tolerance Pattern

RMJ states that his only source of stress is the condition that he is
experiencing right now.