Part for OLPH Case Study

8/13/2019 Part for OLPH Case Study

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Gordons Functional Health Pattern

Before Hospitalization During Hospitalization Interpretation

Health Perception and Management

Patient This is her 2ndconfinement in the

hospital. According to her daughter she

is having a hard time dealing with her

illness. The patient feels very week.

There is a big transition from

the patients health

perception now that she has

an illness.

Nutrition And Metabolism

Patient loves to eat pork, fish and often

eats vegetables. According to patients

daughter, patient is not fond of eating

chocolates and drinking carbonated drinks

but during the time of stay in here their

province the patient loves to eat rice with

sugar.

Patients daughter prefers less rice, soup

and fish for her daily meal.

Patients diet should be

followed as ordered by the

attending physician.

Elimination

Patient moves her bowel regularly and

urinates frequently.

In patients five days of hospitalization,

during the first 3 days she moved her

bowels regularly but for the next dayshe havent. Patient also find it painful

when she urinates.

For the bowel movement of

the patient, there was a bit

changes but for theurination, there was a

difference because now

theres pain every time she

urinates.

Activity and Exercise

As a barangay tanod, patient loves to walk

as part of her job and also participates in

some barangayactivities.

During hospitalization, according to her

daughter, she just walks a little.

The patient cant do more of

her activities aside from

walking because she now

also gets tired easily and

experience difficulty of

breathing.

Sleep and Rest


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According to patients daughter, patient

gets enough sleep but by the time she had

a skin allergy the patient find it hard to get

into sleep.

Patient cant totally sleep due to

hospital environment and her skin

allergy.

Patient cant get enough

sleep.

COGNITIVE AND PERCEPTUAL PATTERN

Patient went only in to elementary. Patient is oriented. Patient is oriented.

SELF-PERCEPTION AND SELF CONCEPT PATTERN

Patient feels good about herself but their

life situation makes feel sad.

Now, she feels no good about her

condition.

Patient feels not good about

her condition.

ROLE AND RELATIONSHIP PATTERNAccording to patients daughter, they have

a good relationship with their mother.

During hospitalization, only 3 of her

children was able to visit her.

Patient still have a good

relationship to her children.

SEXUALITY AND REPRODUCTIVE

Patient was married and had 11 children. Patients husband has passed on.

according to patients daughter, patient

did not have any relationship thereafter.

Patient just gave focus to her

11 children.


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COPING AND STRESS TOLERANCE PATTERN

Patient doesnt have vices but her way to

relieve stress is to eat nga-nga.

Now, the only form of relieving stress is

to chat to her daughter.

Patient just verbalizes

VALUE-BELIEF PATTERN

Patient is a Catholic. She often go to

Sunday mass but they practice praying

before meals.

There were no changes when it comes

to their spiritual activities.

The patient just continuous

what she does when it comes

to spirituality.


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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATIOSUBJECTIVE:

madalassyangnakahiga, pagnaglakadsya,

magsasabisyananahihirapansyanghuminga

s verbalized by the patients daughter.

OBJECTIVE:

Bodyweakness

Restlessness

Poor appetite

With limitedROM

V/S

aken asfollows:

T 36.4

PR 83

RR 23

BP 140/90

ActivityIntolerance:Level

related

todifficultywalkingsecondary

tobody weakness.

After 4

hours

of nursing

intervention

thepatient

willimprove

mobility

participation

inthe

activities

of dailyliving.

.

Note presenceof

medicalconditions

orsituations

thatpotentiate

fluidexcess.

Auscultated

breath sounds

Advice to restrictsodium and

fluidintake, as

Indicated.

Recorded I and O

After 4 hou

of nursingi

thepatient

toimprove

mobilitypa

in theactivi

dailyliving


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DISCHARGE PLAN

MEDICATION - explain all the medication that was prescribed by the physician and

emphasize its importance, advice the client not to miss any of her medication and instruct the

client to continue with follow up medical.

ENVIRONMENT AND EXERCISE- maintains a quiet, pleasant environment to promoterelaxation. Provide clean and comfortable environment. Encourage the patient to do someexercise that she can tolerate. Activities that require exertion of too much energy should beavoided.

TREATMENT all medication should be taken regularly. Safety precaution should always done.

HEALTH TEACHING explain the underlying disorder and treatment plan,lifestyle change (proper foodpreference), general health measures (adequate sleep, proper diet, and maintaining acleansurrounding.)

OUT-PATIENT - will be advised to go back in the hospital in a specific date to have a follow-upcheck -up after discharge. Consult doctor for are any problems or complications encountered.

DIET diet as prescribed by the doctor should be followed.

SPIRITUAL encourage the patient to pray for the good prognosis of her illness.


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Part for OLPH Case Study