PHYSICAL ASSESSMENT

(Performed August 15, 2018)

General Survey: Conscious, coherent, not in respiratory distress

SKIN -normal color, warm and dry

- Cellulitis (bed sore) on lower back
- no jaundice
HEENT HEAD: Normpocephalic, no lesions with equally distributed tied
up.

EYES: Pupil equally round and reactive to light accommodation.

- Anicteric sclera
- Pale conjuctiva
- No discharges, swelling or redness

EARS: Normal, has no hearing problems

- No discharges, swelling or redness

NOSE: patent nares

- nasal structure alignment is straight

MOUTH, THROAT AND NECK:

- No dental caries
- pink lips
- no palpable nodules
HEART - Distinct heart sounds, normal rate, regular rhythm.
CHEST AND - equal chest expansion
LUNGS - no lagging
- no chest retractions
- no difficulty of breathing noted
ABDOMEN - soft and flabby
- non tender
EXTREMITIES - tattoo on left inner forearm
 GORDON’S FUNCTIONAL HEALTH PATTERN
FUNCTIONAL HEALTH BEFORE
PATTERN HOSPITALIZATION
A. Health Perception and Patient was able to do his
Mgt. daily activities such as
working as a fisherman and
others. Self-medication when
sick and rarely seek
consultation.
B. Nutritional and Metabolic The patient had a good
appetite. He likes to eat pork,
vegetables and fish as their
staple food. He was a habitual
drinker.
C. Elimination Patient has soft, formed stool.
He has a light yellow to amber
color urine. Both excretion
occur daily with no difficulty
D. Activity-Exercise Patient does household chores
and works as a fisherman to
provide for his children’s
needs. He was also able to
bathe himself without help or
supervision.
E. Sleep-Rest Patient has no difficulty
sleeping .He has enough rest
interval with 4-6 hours of
sleep daily.
F. Cognitive-Perception Patient is oriented to time,
place and person. He responds
well to verbal and physical
stimuli. He is functional and
literate.
G. Self-perception/Self- Patient was popular among
concept women he was also friendly
and has a high self-esteem.
DURING
HOSPITALIZATION
Complies with the
medications given and
prescribed by the physician.
His appetite has changed and
began eating less since he was
placed in a nursing home.
Patient uses a diaper. He
urinates and defecates daily
without any pain or
discomfort. Has a brownish
color stool.
Patient is no longer
ambulatory. He is often
observed laid in bed or seated
on a wheelchair. He needs
complete assistance from a
caregiver to bathe himself.
Patient exhibits regular sleep
pattern observed amongst
elderly.
Patient exhibits relatively
good memory recall. However
he was observed with slurred
speech.
Patient has an aversion
towards talking about his wife
and children.It was evident
that the inability of his family
to visit him in the nursing

H. Role-relationship Patient was in a common law
relationship with multiple
women and he had 4 children.
he was the main provider of
their family where he was able
to make ends meet thru his job
as a fisherman.
I. Sexuality-Reproductive Patient was in a multiple
relationships with different
women.
J. Coping/Stress Tolerance Growing up patient had a
strong family support. He had
good relations with his
siblings.
K. Value-Belief Patient is Catholic.
home affects him emotionally.
Patient has been separated
from his family for so many
years even before he was
taken in by the nursing home
after he was found by the
DSWD in Nasugbu, Batangas.
Patient had no recent sexual
activities.
Patient tries to repress his
thoughts and feelings about
his family specifically towards
his wife and children. It was
observed that he refuses to
speak about matters of his
family prior to being found
homeless in Nasugbu,
Batangas.
A mass is held every day at
the nursing home, attended by
the staff and residents.
However, due to patient’s
inability to ambulate he is
unable to attend the said
activity.