1. A. Nursing History
G.T., 64 y/o, male, Roman Catholic, Filipino, born in Antipolo, presently residing in
Western Bicutan Taguig City, was admitted at TPDH on February 27, 2013.
On March 5, 2013 at 1:00pm, the patient was interviewed with 100% reliability.
General Data:
Name: G.T
Age: 64 y/o
Sex: Male
Status: widowed
Religion: Roman Catholic
Race: Filipino
Occupation: none
Date of Birth: 11/18/1948
Place of Birth: Antipolo
Residence: Western Bicutan, Taguig City
Date of Admission: February 27, 2013
Place of Admission: TPDH-ER
Number of Admission: 1
Chief Complaint: Left sided body weakness
History of Present Illness:
Informant/Source of Information: G.T. (patient)
Date of Interview: 03/05/2013
4 days prior to admission, patient had a sudden onset of left side weakness of his body and
no other associated symptoms. 3 days prior to admission, there was progression of his left
side weakness associated with left side body numbness and gradual blurring of vision and
in addition to that, the patient also had nonproductive cough. 1 day prior to admission,
same condition happened and experienced by the patient. 1 hour prior to admission,
patient experienced progression of left side body weakness and suddenly fell out of balance
upon standing. The patient’s significant other was alarmed and decided to rush the patient
to TPDH was admitted around 9:00 in the evening.

2. Past History:
Childhood Illness: The patient had no known childhood illnesses or hospitalization. The
patient reported that he was complete of all vaccination as a child. He has no known
allergies or any foods or certain days of the season. The only medication he took was
Tylenol for fever.
Personal and Social History
The patient is Roman Catholic living with a family of 4 people. They live in a 2 bedroom
single story home. The patient is the only one smoker residing in their residence. The
patient spends most of the time in their house doing nothing but taking a rest due of old
age. The patient is a smoker and alcohol user.
Family History
The patient’s mother has Hypertension. The patient never had the chance to meet his father
since birth. The patient’s mother is still living and the father is unknown. The patient is the
eldest among 3 siblings and the only one living. The cause of death of his sister was Bone
cancer while their youngest died since birth because of Newborn complications. The
patient does not know of smoking/alcohol use of his sister. The patient’s wife died due to a
vehicular accident. She is a non smoker and non alcohol user. The patient has two children,
a daughter the eldest and son. The children do not have any known illnesses or
complications during delivery.

3. Gordon’s Functional Health Patterns
Health pattern Past Condition Present Condition
Analysis and
Interpretation
a. Health
Interpretation
and
Maintenance
Patient is a 64 years
old male. He has
history of high blood
pressure and don’t
take any medications
for his high blood
pressure. He is a
smoker and alcohol
user. He can consume
10-15 sticks of
cigarette a day and
drinks alcohol
occasionally. He
considers himself
very healthy. He does
not like going to
hospitals especially
when he is sick.
The patient is lethargic due to
left body weakness and
numbness. He states that every
time she switches position she
feel dizzy and sleepy. The
patient is afebrile with 35-36
degree temp on the right outer
surface axilla arm.Patient
continues to experiences blurry
vision, headache, oriented to
time, place and person. He
perceived his health is not that
well and is aware of his
condition. His long stay at the
hospital made him realize the
importance of eating healthy by
consuming low salt low fat diet.
His eldest daughter is more
supportive of his health than
before. The patient is in
complete bed rest.
I: Client’s health
perception is not
altered.
A: Because of his
condition, the
patient feels that
his illness is not
severe. He
assumes total
responsibility for
decision-making
and self-care.
Reference:
Kozier and Erb’s
Fundamentals of
Nursing 8th
edition, vol.1,
page 295-307.

4. b. Nutrition and
Metabolic
pattern
Patient eats on time
since 3-5 meals a day.
He loves to eatfish
and chicken which his
daughter prepares.
During times when
his daughter is at
work he enjoys eating
fried foods three
times a week and eats
salty foods three
times a week. The
patient’s favorite dish
is adobo. His
daughter states that
he has a stronger
taste than her because
he puts too many salt.
He also eats heavy
meals and sleeps an
hour after.
He drinks
(250cc/8oz/glass)
more than 3-4 glasses
every day. He also
enjoys drinking soda
with his meals and
consumes 1,000 to
2,000cc per day.
When the patient is
sick he usually gets
better the next day.
Patient is currently on a low salt
and low fat diet. He needs
assistance in eating every time.
He cannot hold his spoon and
fork and his daughter is the one
who feeds him. He eats small
meals a day at different times
and drinks 2,500ccsof water
every day as ordered by the
doctor. He is not allowed to
drink soda. Most of his diet
consists of noodles, fish,
vegetables, crackers and rice.
The patient displays no appetite
to eat. The patient switches
position in bed every hour
because he feels warm all the
time. His skin is moist but cool
to touch.
I: Client’s
nutrition is
hindered because
he needs help in
eating every time.
He cannot do
activities of daily
living as
important as
eating.
A: The
nutritional–
metabolic pattern
focuses on food
and fluid intake,
however the
client has
problems in
eating and that
might influence
intake.
Reference:
Cox’s Clinical
Applications of
Nursing
Diagnosis 5th
edition, page 120
c. Elimination
pattern
Patient has no
problem in defecating
and urinating. He
usually defecates once
The patient has not defecated
since he was admitted.He
urinates in approximately 500-
800cc in 24 hours with small
I: Client’s
elimination
pattern is not
altered however

5. a day at night time
and urinates 5-8
times a day with
yellow colored urine.
Hedrinks
approximately 3-4 of
250 cc each glass of
water and 1,000-
2,000cc of soda per
day. Client’s stool is
brown and loose in
consistency.
amounts of light yellow urine.
The patient does not have any
pain or difficulty urinating.
client needs
assistance in
doing so.
A: Medications
like Methyldopa
affects the central
nervous system
that interferes
with the normal
urination and
elimination
process and may
cause retention.
In addition, her
water intake is
regulated at
2,500cc/day.
Reference:
Kozier and Erb’s
Fundamentals of
Nursing 8th
edition, vol.2,
page 1288-1289.
d. Activity and
Exercise
pattern
Patient does not
require any help and
is completely
independent in
performing activities
such as feeding,
bathing, dressing,
toileting and
ambulation. He
usually walks around
outside the house in
the morning as a form
of his daily exercise.
During spare time he
Patient is unable to perform
activities of daily living due to
left side body weakness. When
the patient moves around he
feels very dizzy which makes
him feels sleepy. He also has
difficulty sleeping because his
blood pressure is checked every
hour. The patient is in complete
bad rest.
Patient is a level 2: Requires
assistance or supervision from
another person, his daughter
I: The client
needs assistance
when performing
all daily living
activities. His
daughter is his
primary care
taker.
A: Because of her
condition, the
client is unable to
do her tasks

6. walks around the
basketball court
outside his house. He
states that he has
enough energy
throughout the day.
He has not
experienced any
musculoskeletal
impairment.
Patient is Level 0: Full
self-care.
alone such as
eating. A problem
in the activity–
exercise pattern
may be the
primary reason
for the patient
entering the
health-care
system or may
arise secondary
to problems in
another
functional
pattern.
Reference:
Cox’s Clinical
Applications of
Nursing
Diagnosis 5th
edition, page 270
e. Sleep and Rest
pattern
Patient usually sleeps
5-8 hours.
During rest time, he
usually walks outside
at the basketball
court. Although most
of the time he is at
home doing house
work.
Patient has no difficulty in
sleeping and usually sleeps 8-12
hours at night. Throughout the
day the patient also takes naps
because of the left side body
weakness. His rest is disturbed
because his vital signs are
checked every hour.
The patient appears weak
because of his slow movements,
drowsiness and restlessness
from his medications.
I: The client is
having prolonged
sleep at night and
daytime
sleepiness due to
her dizziness and
blurry vision
Reference:
Kozier and Erb’s
Fundamentals of
Nursing 8th
edition, vol.2,
page 1171-1172.

7. f. Cognitive and
Perceptual
pattern
The patient has no
problem with his
hearing and in the
past. He use to wear
glasses but they were
5 years ago and never
worn corrective
lenses since.
His memory from his
past and condition is
still accurate. He can
remember names of
most of the drugs he
took, and his regiment
before hospitalization.
.
When he feels sick he
usually uses natural
methods such as
herbs. He rarely takes
medication because of
their financial
situation.
There are no
problems in her
senses.
He is lethargicdue to his
condition yet responds to
questions and has no signs of
looseness of association or any
flights of ideas.
He does not experience any
chills.
I: The client is
coherent,
cooperative, and
alert with no
problems with
his sensors.
A: Client
manifests intact
sensory
mechanisms and
perception.
Reference:
Kozier and Erb’s
Fundamentals of
Nursing 8th
edition, vol.2,
page 981.
g. Self Perception
and Self
Control
pattern
The client would then
view himself as
someone who regards
life to the fullest. He
rarely worries about
his problems.
The patient feels that
he has enough energy
throughout the day
and rarely rests.
During the assessment the
patient was responsive yet
answered every question with
ease and depth. He defined that
his hospitalization caused a big
impact on his life that changed
the way he viewed life. He is
more focused on eating less fat
and salty foods. He Also realizes
that eating late at night and
sleeping immediately is should
I: The client has
positive views on
his condition. He
thinks that his
hospitalization
only affected his
body and
lifestyle. He is
still calm and
positive about

8. He does not believe
that he unhealthy
since he eat
frequently and
abundantly since he
incorporates
vegetable and fruits in
his diet.
be avoided. things.
A: The patient’s
behavior is
affected not only
by experiences
prior to
interactions with
the health-care
system, but also
by interactions
with the health-
care system.
Reference:
Cox’s Clinical
Applications of
Nursing
Diagnosis 5th
edition, page 520
h. Role and
Relationship
pattern
The patient lives with
his two children
together with his
mother.
Most of their
problems are financial
reasons. They
manage by saving
money and eating
what they could
afford.
The patient would
view himself as a
kind, and responsible
father to his children
The relationship of his family
remains strong. They remain
firm and gather strength from
each other. They support each
other and exude strength to the
patient.
His children is his main source
of support. His daughter said
that it is her turn to take care of
him.
I: The client’s
relationship with
his family
remains strong.
A: The client’s
hospitalization
made their family
become stronger.
They used each
as a source of
energy and hope.
Reference:

9. and a loving son to his
mother. When they
have problems in the
family they solve it by
talking between the
members.
He has no problems
raising his children
since they help
around the house.
She involves himself
in decision-making
for the household and
major decisions. .
Cox’s Clinical
Applications of
Nursing
Diagnosis 5th
edition, page 606
i. Sexual and
Reproductive
pattern
The patient ‘s wife
died a long ago.
A: Sexuality
patterns involve
sex role behavior,
gender
identification,
physiologic and
biologic
functioning and
the ability to
express sexual
feelings. Client is
able to fulfill
sexual needs.
Reference:
Cox’s Clinical
Applications of
Nursing
Diagnosis 5th
edition, page 715

10. j. Copping-Stress
Tolerance
Pattern
He is not the type of
father that gives up
easily. He views
stresses as challenges
to keep him firm and
grounded.
According to the
patient, he faces
stressors of life such
as financial crisis, and
emotional conflicts by
talking with
hischildren at all
times.
He deals with his
problems as a family
and it makes him feel
better..
Patient tackles stress by resting.
The patient’s short-term and
Long-term coping strategies is
supported by his conversing
with his children.
I: The client’s
coping
mechanism is not
hindered because
of the continued
support of
hisdaqughter.
Whenever he
experiences
stress, the client
would take time
to rest.
A: His ability to
respond to stress
is affected by a
complex
interaction of
supportive social
and emotional
reactions.
Reference:
Kozier and Erb’s
Fundamentals of
Nursing 8th
edition, vol.2,
page 1068.