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8/8/2019 Gordons Pa.payward

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GORDONS PATTERNS OF FUNCTIONING

A. Psychological Health

The Psychological health of the child falls on Erik

Eriksons first stage of development, the Trust vs. Mistrust

where the virtue is Hope. A per observation, the child puts

everything in her mouth and if referred as the Oral

Sensory stage. The major emphasis is on the mother'spositive and loving care for the child, with a big emphasis

on visual contact and touch. Since the child is on his

infancy stage, she depends most of her needs to his

mother or to his parents, from his food (milk) to self-care

(changing diaper). It is believed that if we pass

successfully through this period of life, we will learn to

trust that life is basically okay and have basic confidence

in the future. If we fail to experience trust and are

constantly frustrated because our needs are not met, we

may end up with a deep-seated feeling of worthlessness

and a mistrust of the world in general

B. Sociocultural Health

The infant is receiving breast milk from her mother

which is obviously free and very helpful for the childs

health. The mother also uses Bona, infant milk which she

gives as substitute formula milk for her son whenever they


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go out or if she has some chores to do like going to the

market that requires her to be gone for a while.

C. Spiritual Health

The child is not yet baptized according to her

mother. The parents are both Roman Catholic. They have

belief like, whenever their son has hiccups, they applied a

small of paper on the childs forehead; they believe that

upon doing so will make the hiccups go away. They also

believe on usog which they believe will cause their sonto become irritable and uncomfortable or sometimes will

have fever whenever someone praise their son as a

precautionary measure they will make that person put a

cross on the childs feet or forehead with a little saliva on it

that will prevent him from being irritable or be normal

again.

ACTIVITIES OF DAILY LIVING

A. Nutrition

The child receives human breast milk from her

mother and a Milk Formula Milk (Bona) which can be

bought over the counter from any stores. The child has a

good sucking reflex. According to the mother, her son

consumes a maximum of 3-4 bottle of a 4 ml bottled milk

of the formula milk whenever she has something to do +

her breast milk every 4 hours. She uses boiled water or


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commercial mineral water to prepare the infants formula

milk.

B. Elimination

According to the mother, the child consumes 3-4

diapers a day. Defecates 1-2 times a day usually early in

the morning or late in the evening. As described by the

mother, the child has soft yellow colored stool.

C. Exercise

An infants exercise is merely his play ( Solitary

Play). Her mother said that she is able to massage the

childs body at times.

D. Hygiene

The mother has her son take his bath at 8:00 in the

morning after having him exposed to sunlight. She uses

warmed water with calamansi in bathing her son. In the

days of Tuesday and Friday, she prefers not taking her son

to bathe because of certain belief which she doesnt know

but she exercised because her mother told her so.


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COMPREHENSIVE PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENT 1 (HEAD TO NECK)

BODY PARTS NORMAL FINDINGS ACTUAL

FINDINGS

ANALYSIS

GENERAL

APPEARANCE

Relaxed, coordinated

movement, clean,neat, no body odor,

healthy appearance;

cooperative, has

sense of reality

Fatigue

appearance,uneasiness,

coherent;

conscious;

labored

breathing

Abnormal

due toundergoing

disease

condition.

Pneumonia

which

compromises

that

respiratory

system of

the child.SKULL Rounded and

symmetrical, with

frontal, parietal, and

occipital

prominences;

Smooth skull contour

Rounded;

smooth skull

contour

Normal

SCALP Smooth, uniform

consistence; absence

of nodules or masses

Has no

tenderness; no

masses or

nodules

Normal


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HAIR Evenly distributed

and covers the whole

scalp; Maybe thick or

thin, No infection and

no lice.

Evenly

distributed with

no patches of

hair loss; thick

hair; Silky and

no lice.

Normal

FACE Symmetric or slightly

asymmetric facial

features

Symmetrical

facial features

while talking or

elevating the

eyebrow.

Normal

EYES Shape depends on

the race

Mild sunken

eyes

Might be a

manifestatio

n of sleep

disturbance.EYEBROWS Symmetrical and in

line with each other;

maybe black, brown

Symmetrical

and aligned

with eachother; black;

evenly

distributed.

Movements are

symmetrical.

Normal

EYELASHES Evenly distributed;

turned outward

Turned outward

eyelashes; hair

equally

distributed

Normal

EYELIDS Upper eyelids cover

the small portion of

the iris, cornea, and

Able to close

the eyes and

has the ability

Normal


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sclera when eyes are

open; eyelids meet

completely when the

eyes are closed;

symmetrical

to blink.

LOWER

PALPEBRAL

CONJUNCTIVA

Pinkish or red in

color; with presence

of small capillaries;

moist; no foreign

bodies; no ulcers

Red in color;

smooth in

texture

Normal

SCLERA &

CORNEA

White in color; clear;

no yellowish

discoloration; some

capillaries maybe

visible

Pale white

sclera with

some visible

capillaries.

IRIS Anterior chamber is

transparent; no

noted visiblematerials; color

depends on the

persons race

Dark brown in

color;

transparentanterior

chamber

Normal

PUPILS Color depends on the

persons race; size

ranges from 3-7 mm,

and are equal in size;

equally round

Pupil color is

dark brown;

3mm in size.

Normal

EYE

MOVEMENT

Constrict

briskly/sluggishly

when light is directed

to the eye, both

Dilates when

looking at far

objects and

constricts when

Normal


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directly and

consensual

looking at near

objects.

Constricts when

there is light.PERIPHERAL

FIELD VISION

When looking

straight ahead, client

can see objects in

the periphery

N/A

VISUAL

ACUITY

Able to read

newsprint or small

details

N/A Normal

AURICLES Color same as facial

skin; symmetrical;

auricle aligned with

outer canthus of eye;

no tenderness

Same color as

the facial skin;

tip of auricle

aligned at the

outer canthus

of the eye; not

tender

Normal

EAR CANAL Contains hair follicles

and glands. Dry

cerumen, grayish-tan

color, sticky wet

cerumen with

various shades of

brown

Contains hair

follicles and

glands. With

sticky wet

cerumen with

various shades

of brown

Normal

HEARINGACUITY

Normal voice tonesaudible

N/A.

NOSE Air moves freely as

the client breathes

through the nares;

no tenderness

Both nares are

patent; intact;

no secretions:

no painful

Normal


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sensation when

palpated

INTERNALNARES

Air moves freely asthe client breathes

through the nares

Both nares arepatent..

Normal

NASAL

SEPTUM

Nasal septum intact

and in midline

Nasal septum

intact and in

midline

Normal

LIPS Uniform pink color;

soft, moist, smooth

texture; symmetry of

contour; ability to

purse lips

With ulceration

on the upper

lips

Lack of Vit. C

and proper

mouth

hygiene.

GUMS Pink gums; no

retraction

With some

sores

Due to non-

cleaning of

tongue after

breastfeedin

g and bottle

feeding. TEETH 32 adult teeth;

smooth, white, shiny

tooth enamel;

smooth, intact

dentures

N/A ( no teeth)

TONGUE Central position; pink

color; smooth tongue

base with prominent

veins

Located and

positioned in

the center. With

white spots due

to milk residue.

Normal

FRENELUM pink color; moist;

slightly rough; thin

Pink and moist.

Tongue moves

Normal


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whitish coating;

moves freely; no

tenderness

freely and no

pain felt.

BUCCAL

MUCOSA

Uniform pink color;

moist, smooth, soft,

glistening, and

elastic texture

Pink color and

moisten.

Normal.

SOFT PALATE Light pink, smooth,

soft palate

Light pink Normal

HARD PALATE Lighter pink hard

palate , more

irregular texture

Has lighter pink

than the

sof t palate

Normal

UVULA Positioned in midline

of soft palate

Positioned at

the center of

the oropharynx

Normal

TONSILS Pink and smooth; no

discharge; of normal

size

Has no

discharge;

pinkish

Normal

NECK

(gag feflux)

Present Present Normal

PHYSICAL ASSESSMENT 2 (THORAX & ABDOMEN)

BODY

PARTS

NORMAL

FINDINGS

ACTUAL FINDINGS ANALYSIS

POSTERIOR Anteroposterior to Has a anteroposterior Normal


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THORAX transverse

diameter in ratio

1:2; Chest

symmetric

to transverse

diameter ratio of 1:2,

elliptical in shape and

symmetrical chestANTERIOR

THORAX

Skin intact;

uniform

temperature;

chest wall intact;

no tenderness; no

masses; Quiet,

rhythmic, and

effortless

respirations

Has an intact skin;

has equal warmth on

both sides. With

wheezes and effort

respirations

Because

pneumonia is

a general

term that

refers to an

infection in

the lungs,

the person

tend to have

tachycardia

because of

the effort of

the lungs to

compensate

to the

infection.

Wheezing is

an indication

of viral

invasion.

HEART With palpations With palpable

pulsations on the

apical area.

Normal

BREAST Females: round

shape, slightly

Impact skin of breast,

round shape and

Normal


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unequal shape in

size, generally

symmetric

somewhat unequal in

shape but generally

proportion.

AREOLA Round or oval and

bilaterally the

same, colors

varies from light

pink to dark

brown

Dark brown in color

and round in shape

Normal

NIPPLES No tenderness,

masses, nodules

or nipple

discharge

Have no masses and

nodules.

Normal

ABDOMEN Pigmentation and

skin color should

be uniform; no

presence of scaror rashes; bowel

sounds: shape flat

or rounded

Even skin color and

pigmentation; free of

scar/rashes; bowel

sounds at RLQ: roundin shape; 41cm in

size.

Normal

PHYSICAL ASSESSMENT 3

(EXTREMITIES & NEUROLOGICAL ASSESSTMENT)

BODY PARTS NORMAL ACTUAL ANALYSIS


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FINDINGS FINDINGSUPPER & LOWER

EXTREMITIES

Able to

move, followROM

N/A

FINGERS & NAILS Clean,

pinkish

Long nails with

dirt at the tip

and some in

sides of the

nails.

Abnormal

Proper

hygiene is

recommend

ed

RANGE OF MOTION OF

UPPER & LOWER

EXTREMITIES

Able to

move

without

assistance

N/A

NEUROLOGICAL

ASSESSTMENT

*MENTAL &

EMOTIONAL STATUS

LEVEL OF

CONCIOUSNESS

Apply the

Glasgow

Coma Scale:

eye

response,

motor

response

and verbal

response.

An

assessment

totaling 15

pts indicates

the client is

alert and

completely

Eye opening


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oriented.

Comatose

client scores

7 or less.INTELLECTUAL

FUNCTION

Able to

repeat

series of

three digits

spoken

slowly and

gradually

increases

N/A

*SENSORY FUNCTION

PAIN

Able to

discriminate

sharp and

dull

sensation

N/A

LIGHT TOUCH Light

tickling or

touch

sensation

N/A

* MOTOR FUNCTION

A. COORDINATION

FINGER -TO-NOSE TEST

Repeatedly N/A


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and

rhythmically

touches the

nose.ALTERNATING

SUPINATION &

PRONATION OF HANDS

ON KNESS

Can

alternately

supine and

pronate

hands at

rapid pace

N/A .

FINGERS TO THUMB Rapidly

touches

each finger

to thumb

with each

hand

N/A

B. BALANCE

WALKING GAIT Has upright

posture and

steady gait

with

opposing

arm swing

N/A

ROMBERG TEST Negative

Romberg:

may sway

slightly but

is able to

N/A


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maintain

upright

posture and

foot stance.HEEL TOE WALKING Maintains

heel-toe

walking

along a

straight line

N/A

CRANIAL NERVES

CN 1 (OLFACTORY)

Able to

smell and

recognize

stimuli

N/A

CN2 (OPTIC) 20x20

vision, able

to read, 3-5

mm [pupil

size]

N/A

CN3 (OCCULOMOTOR)

CN4 (TROCHLEAR)

CN6 (ABDUCENS)

(+)

Extraoccular

Movement

(EOM);

Lateral

Upward and

downward;

pupils

reactive to

light.

Pupils react to

light. There is

constriction and

consensual

accommodation

. Able to move

the eyes in any

direction in

unison.

Normal

CN5 (Trigeminal) Able to feel

and clearly

N/A.


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identify

stimulus,

with

bilateral

facial

sensation.

With active

corneal

reflex.CN7 (FACIAL) (+) Corneal

reflex ,

Facial

asymmetry

N/A

CN8 (AUDITORY) Able to hear

clearly, can

maintain

balance

N/A

CN9(GLOSSOPHARYNGEAL)

CN10 (VAGUS)

(+) gag

reflex, uvula

at the

center, soft

palate rises

Present gagreflex, able to

swallow.

Normal

CN11 (ACCESORY) Able to

shrug

shoulders

against

resistance

and able to

N/A


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turn the

head side

and against

resistance.CN12 (HYPOGLOSSAL) Able to

move

tongue from

side to side

Able to extend

beyond the

tongue and

move it side to

side.

Normal

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