Gordons Data Health perception

Before

During

Book Based

Evaluation

Hospitalization Hospitalization
According to client Based on his health is something that should be watched out for. Health is one of the most important human needs. condition, he stated that poor knowledge is what led him to his current situation and would like to take his health care more seriously.
Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.

Nutrition

Client stated that he eats 5x a day ( egg, bread and milk ) for breakfast, (rice and meat/vegetables ) for lunch and dinner. And snacks for the in betweens. Client drinks at least 2 liters of water daily

Client stated that his appetite hasnt change but his usual water intake has. He only drinks 3 glasses of water daily because he doesnt feel thirst due to minimal activity in the hospital.

Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

Process of Elimination

Client urinates 4-5 x a day. Patient stated that he has no difficulty in urinating. He defecates once a day and does is not experiencing urinary/ bowel retentions, incontinence or diarrhea.

There has been no change in clients urination or bowel consistency from the time he was admitted to the current day.

Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.

Sleep/Rest Pattern

Client stated that sleeping is his own way of spending his day off due to his work (conductor) he gets at least 4-5 hours of sleep daily

Client has difficulty in sleeping because of unfamiliar setting. Patient is experiencing sleep intervals. Sometimes he sleeps and wakes up in the middle of the night. Client is oriented and conscious. As he knows where he is, what time it is, and why he is in the hospital.

Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.

Cognitive/P Client has finished erceptual Pattern

his secondary level of learning. No problems with hearing and other senses.

Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated.

SelfPerception Pattern

Client stated that he sees himself as an outgoing and fun person.

Client has stated that he feels lazy and weak sometimes but has the senses to pull things together to keep up with his work

Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of selfworth. The person's level of self-esteem and response to threats to his or her self-concept may be identified.

Rolerelationshi p Pattern

Client lives his mother, father and 7 siblings he is the 3 sibling from the eldest and keeps a close bond with his family

Client stated that he is happy with his family but tends to handle problems alone. He is satisfied with the way things are.

Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.
Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified.

Sexuality Pattern

Client has been circumcised at the age of 11 and engaged in sexual activities at the age of 12.

Client has been abstaining from coitus for the past 2 years.

Coping

Client stated that he usually handles his problems alone but when it comes to family problems it was his father that takes control on the situation.

No problem with coping mechanism. He handles stress in a mild and calm manner.

Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated.

Value/belie f

Client belongs to a catholic family. He believes in God Almighty.

According to client he prays daily since he hasnt been to church due to his work.

Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions.