Psychosocial Profile (Gordons Functional Pattern)
Description Assessment
Health Perceived level on health
Perception and and well-being and
Health practices for maintaining
Management health. Habits that may be
detrimental to health are
also evaluated, including
smoking, and use of
alcohol or other drugs.
Nutrition and Pattern of food and fluid
Metabolism intake relative to metabolic
needs. The adequacy of
local nutrients supplies is
evaluated.
Initial
(Sept. 22, 2017)
Patient has no recent surgery.
Patient doesnt have any vices.
He doesnt use cigarettes and
doesnt drink alcohol. During
our first visit, Gikan sa pag-
anak sa akoa, naa nakoy sakit
sa heart as verbalized by the
patient. He was admitted last
April 2017 at St. Joseph
Southern Hospital with his
chief complaint of dizziness
and fainting. His usual blood
pressure is 140/100 if
antihypertensive medication is
not taken.
Reco Ibarra
Verbalized that he has good
eating appetite. He usually
consumes vegetables, fish,
rice and fruits and he limits to
consume foods like chocolates
and coffee. And he also
verbalized that he eats
everything what is served on
the table. He is underweight as
Ongoing
(October 21, 2017)
Patient still has no recent
surgery. Reco Ibarra
Verbalized that his major
illness is rheumatic heart
disease. During assessment,
we asked Reco Ibarra what
are his usual health
management and he verbalized
that he monthly visits his
doctor, Dr. Abrena, a
cardiologist at Don Carlos,
Maramag, Bukidnon. Still his
usual blood pressure is
140/100 if antihypertensive
medication is not taken.
Patient is still underweight
with the BMI of 17.3604. No
food allergies but restricted to
eat chocolates and drinking
coffee. He only drinks water
not more than 6 glasses per
day as ordered by his Doctor
Ongoing Appraisal
(November 08, 2017)
Patient still has Rheumatic
heart disease without any
surgery. Patient is exposed to
his uncle who uses cigarettes,
dust from the surroundings and
smoke from their dirty kitchen,
he does not perceive it as a
high risk for developing
another cause of diseases. Still
his usual blood pressure is
140/100 if antihypertensive
medication is not taken.
No appetite changes. Able to
eat average daily food but
restricted to eat chocolates,
green leafy vegetables,
drinking coffee, and advised to
drink only 6 glasses of water
per day.

Elimination Excretory pattern (GI, GU,
Pattern and skin). Incontinence,
constipation, diarrhea and
urinary retention.
Activity- Activities of daily living
Exercise Pattern requiring energy
expenditure including self-
care activities. Assess
major body system
involved with the activity
and exercise including
respiratory, cardiovascular
and musculoskeletal
systems.
Sleep-Rest Sleep, rest and relaxation
Pattern practices. Dysfunctional
sleep pattern and fatigue
may be identified.
evidence by his body mass
index is 17.3604.
Reco Ibarra verbalized that
he has no any family history of
kidney diseases/failure. He
stated that he usually defecates
once a day with a brownish-
yellow coloured and formed
stool. In terms of voiding,
Reco Ibarra usually urinates
3-4 times a day, with a
yellowish coloured urine.
Nara man ko sa balay sa
akong uncle permi maam,
usahay maglakaw-lakaw uban
sa barkada ug gabantay pud ko
diri sa baligya namo nga
saging as Reco verbalized.
Reco verbalized that he
usually sleeps at 10:00 pm and
wakes up by 7:00 in the
morning. He also stated that he
gets 30 minutes to 1 hour of
nap on the afternoon. Sleep
disturbance rarely occurs for
Reco and this was
associated to urination at
night.
Patient urinates 3-4 times a
day with yellowish in color
with no presence of blood.
Early in the morning, he
usually defecates once a day
with no presence of blood.
Sometimes, he experienced
constipation or diarrhea.
Patient used to stay in the
waiting shed near the highway
to sell some bananas and is
exposed to dust and smoke
from the cars passing by.
Patient has limited daily joint pain during some of his
activities such as walking,
Sometimes Reco felt joint
pain during some of his
activities.
The patient sleep routine is
7:00 pm to 5:00 am. No
symptoms of sleep apnea.
Sometimes, his sleep is
disturbed due to urination at
night.
Patient feels no discomfort in
his elimination pattern.
Urgency to defecate usually
early in the morning. No used
of laxatives. Patient able to
urinate 6 times a day without
any discomfort feels. No
problem with bladder control.
Sometimes, he experienced
diarrhea and constipation.
Patient is still exposed to dust
and smokes. The patient is
advised to avoid heavy
workloads and extraneous
activities. Reco still felt
activities.
Patient sleeps 7-9 hours
soundly. Still with episodes of
waking up because of
disturbance due to urination at
night.
Cognitive- Ability to comprehend and
Perceptual use information. Assess
Pattern sensory function. Sensory
experience such as pain
and altered and altered
sensory input may be
identified and evaluated.
Self-Perception Ability to perceive concept
and Health of self and perception
Concept Pattern towards current situation
and scale of perception.
Role- Roles in the world and
Relationship other relationships.
Pattern Satisfaction with roles,
role strain or dysfunctional
relationship may be further
evaluated.
Sexuality- Satisfaction/dissatisfaction
Reproductive with sexual partners and
Pattern production functions.
Concerns with sexuality
may be identified.
Reco is a high school Patient was able to understand Patient still has no problems on
graduate. Able to hear, see, the questions being asked to his sensory functions, and is
speak without difficulties. him but sometimes there are able to comprehend. Already
some deviations on his able to answer questions
answers. No problems on his without deviations.
sensory function.
Kulbaan ko usahay sa akong Still fears about his current Patient is conscious and
condition, labi na katong nag- health conditions. Patient is coherent, even he fears about
ingon ang doctor nga calm and able to answer his condition, he still shows
kinahanglan ko operahan he questions being asked to him. being happy to live his life.
verbalized as we asked him
about his condition.
Reco is currently living with Patient still lived with his Still separated with his mother
his uncle since the day that his uncle while his mother is and lived with his uncle and
father died due to an accident. separated from them having a grandmother. Patient still
He was separated to his mother new family. He helped with assumes the responsibilities of
since that day, as his mother his uncle and grandmother. He taking care of their pigpens
found a new partner in life. is the one who takes care for and stall helping his uncle and
Wala namay pakialam ang their pigpen and their stall. grandmother especially in
iyang inahan ni Reco sa doing household chores.
iyaha bisan naa siyay sakit, dili
na daw siya magpasilabot sa
iyaha as verbalized by Recos
uncle.
Reco is single and not Patient still is single and not Still with no sexual activities
sexually active. sexually active. done
Coping Stress General coping pattern and Patient sometimes has Patient still keep his personal Patient is already able to share
Tolerance effectiveness in terms of problems in coping skills problems inside of him, and some of his problems with his
Pattern handling stress. because he will just keep it sometimes he listens music as friends, and still listens to
inside in him, there is no one a way of coping his stress. some music for coping stress.
he can tell his problem on even
his friends.
Value-Belief Values, belief and goals Family belongs to a Cebuano Patient is a Roman Catholic in There are no significant effects
Pattern that may guide choices or ethnicity and a Roman religion of religious beliefs to the
decision. Catholic. patients current situation.
Patient is a Roman Catholic in
religion.
GENERAL HEALTH SURVEY
AREA/SYSTEM PHYSICAL ASSESSMENT
INSPECTION PALPATION PERCUSSION AUSCULTATIO NURSING
N DIAGNOSIS &
PROBLEMS
1. INTEGUMENTARY Skin was brown Cold humid Impaired Skin
and even skin Integrity
Cold humid skin Poor skin
Nails were turgor Hypothermia
untrimmed and
appear pale
Lesion was seen in
lower extremities ------------------------ ----------------------
No redness noted
Body temperature
of 35.3 degree
Celsius
2. HEAD and NECK Skull is No Fluid Volume
normocephalic tenderness Deficit
Hair is black and upon
evenly distributed palpation
Pupils equally
round and reactive
to light and
accommodation
from 4 mm to 2 -------------------------- ----------------------
mm.
Yellowish sclera
observed on both
eye
 Lips appeared dry
and pale
3. RESPIRATORY Thorax is Respiratory Lungs/Thorax Crackles Ineffective
symmetric depths are are resonant sound Breathing
Respiratory rate is irregular during heard upon Pattern
25 cycle per minute percussion auscultatio
n
4. CARDIOVASULAR Jugular distention Radial pulse Murmurs Decrease
noted was strong, heard upon Cardiac Output
Extremities were bounding auscultatio
mostly cold to and irregular n Ineffective
touch, pale and in terms of Irregulariti Tissue
humid pattern es in apical Perfusion
140/100 blood Pulse rate of pulse in
pressure 62 beats per terms of
minute rate
Brachial ------------------------- Heart rate
pulse of 65 of 53 beats
beats per per minute
minute
Capillary
refill time is
4 seconds
indicating
delay
5. GASTROINTESTINAL Lesions are noted Firm Dullness on Heartbeat Impaired Skin
The client had a abdominal four quadrants was heard Integrity
history of muscles heard on the
constipation and No upper left Risk for
diarrhea tenderness quadrant Constipation
Eliminates waste felt upon Bowel and Diarrhea
twice a day; palpation sound
heard with
17 clicks
per 5
minutes
6. MUSCULOSKELETAL Symmetrical No nodules Altered ability
bodily structures or any mass to continue
and is able to palpated on previous
mobilize any joint of activities
Normal gait muscle site
No muscle wasting -------------------------- ----------------------
No inflammation,
swelling or wound
noted
Sometimes he felt
joint pain
7. NEUROLOGIC Responsive and Risk for
able to answer Trauma
questions
Oriented to time,
place and event ------------------------ --------------------------- ----------------------
He has history of
fainting and
dizziness.

8. GENITOURINARY Voids 3-4 times a No bladder

day with a distention
yellowish coloured
urine
No pain felt upon
urination -------------------------- ---------------------- -------------------
REVIEW OF SYSTEMS
General: The patient 20 years old. The patient is calm, responsive, cooperative, clean, no foul odor. Body proportions are normal. He has a traumatic
life event when his father died five years ago and when he was separated to his mother. The patient has rheumatic heart disease since birth. He
was recently admitted last April 2017 at St. Joseph Southern Hospital with his chief complaint of dizziness and fainting. The patient is single. He
is satisfied with the way his life has been developing despite of his illness and no religious restriction to care.
HEENT: The patient experiences no visual changes but the sclera is yellowish in colour, no hearing loss, and no impaired sense of taste and smell.
With history of headache, fever, cough, dizziness and faint.
Respiratory: The patient had experience dyspnea and does use accessory muscle to assist breathing. Has symmetric chest expansion. The patient
do not smoke.
Cardiovascular and Hematologic: The patient had family history of heart disease and hypertension. The patient experiences chest pain and have
visible pulsations at the neck.
Gastrointestinal: The client had a history of constipation and diarrhea. The client usually eliminates his waste twice a day. Lesions are noted on
the abdomen. Heartbeat was heard on the upper left quadrant. Bowel sound heard with 17 clicks per 5 minutes.
Genitourinary: The patient didnt experience painful urination. He usually urinates 3 to 4 times a day and in a total amount of 800 cc. he usually
voids with yellowish colour.
Reproductive: The patient is not sexually active and no history of sexually transmitted disease.
Musculoskeletal: Symmetrical bodily structures and is able to mobilize with normal gait. No muscle inflammation, swelling or wound noted. No
nodules or any mass palpated on any joint of muscle site. But sometimes he feels joint pain.
Neurological: The client doesnt have any problems in smelling, vision, taste, touch and hearing. The patient has coordinated movement, proper
orientation of date and place. The client has no history of loss of consciousness convulsions, trauma and loss of memory. He has history of fainting
and dizziness.
Endocrine: No unexplained weight loss. No polyphagia, no polyuria and no polydipsia.