C.

PERSONAL PROFILE

a. BIOGRAPHIC DATA

Name: John David Nicanor

Address: Bgy. Kapre , Novaliches Q.City

Age: 9 months

Gender: Male

Place of birth: Clinic (midwife)

Ethnic group: n/a

Primary language spoken: Tagalog

Marital status: single

Educational Attainment: n/a

Occupation: n/a

Religious Orientation: Roman Catholic

Health Care Financing and usaual source of medical care: Parents

Income: 6,000 a month

b. Chief Complaint
– LBM
a. History of Present illness
– AGE with some DHN
a. Past Health History

Childhood diseases

– Fever

Immunizations

– BCG, HEPA B, DPT, OPV except for measles

Allergies (foods, drugs, others)

– n/a
Accidents and Injuries

– n/a

Hospitalizations

– n/a

Medications (prescription/self prescribed)

– Paracetamol Calpol

Foreign Travel

– n/a
a. Personal and Social History
b. Family History of Illness

Presence of any hereditary diseases:

– HPN
– DM
– Asthma
E. GORDON’S FUNCTIONAL HEALTH PATTERNS

a. Health Perception and Health Management Pattern

➢ The client’s general health is currently stable.

➢ The grandmother rated her grandson’s health as 8. ( 10 is the highest)
➢ The grandmother considered his grandson is healthy if he is “active”.
➢ The client’s health goals are: making sure he’s always being clean,
bathing everyday, eating on the right time with the right amount, and
taking vitamin C.
➢ Beliefs and Practices: “Hindi kami pumupunta sa patay”.
➢ The grandmother is making sure that his grandson has always done
his exercise every morning.
➢ Safety practices: taking a bath everyday, eating the right amount of
food, and taking vitamins.
➢ Personal Hygienic process: The grandmother is taking care of his
grandson’s health by means of taking him for a bath, hand washing
before and after eating, trimming of his nails twice a week, and putting
a cologne in him.
➢ Environmental Condition: The client’s home has enough source of light
and has good ventilation.
➢ Environmental Sanitation Process: Their home has a good source of
water supply and good toilet facilities.

b. Nutritional Metabolic Pattern

➢ The client is still breastfeeding but he also eats “taho”, rice, and sopas.
➢ Most likely, the client fluid intake is breastfeed. All in all, the client’s
fluid intake for a day is 5 bottles (6oz).
➢ The grandmother’s knowledge of proper nutrition is based on the food
pyramid guide and “grow, glow, go”.
➢ They usually eat in their home with her parents and other relatives.
➢ They are following a food budget.
➢ According to the grandmother, when the child is having a wound, it
was healing fast.
➢ The client has no eating discomforts.
➢ The client has a weight loss due to DHN. Before: 7.6kg. Now: 7.3kg.
➢ The client’s current skin condition is dry. (due to DHN)
➢ The client has just started having teeth.
c. Elimination Pattern

➢ Bowel Elimination Pattern: The client usually defecates 4 times a day.

Its greenish yellow in color and kind of watery.
➢ According to the grandmother, the client does not experiencing pain or
any discomfort when defecating.
➢ Urinary Elimination Pattern: The client is voiding 8-10 times a day. It
is Light yellow in color and has aromatic odor.
➢ The client is has not experiencing pain or any discomfort when voiding.
➢ According to the grandmother, the client’s perspiration is normal.

d. Activity-Exercise Pattern

➢ The client’s usual activity for a day is playing eating and sleeping.
➢ The client is exercising everyday by means of stretching, playing, and
walking.
➢ As the grandmother said, the client is getting the right amount of
exercise he needs for a day.
➢ The client has sufficient energy for his activities.

e. Sleep-Rest Pattern

➢ The client usually sleeps at the amount of 10 hours.

➢ According to the grandmother, the client is getting the right amount of
sleep. It is continuous and only waking up at midnight when he is
hungry.
➢ The client is sleeping from 7pm and wakes up at 5am.
➢ The client looks refreshed when waking up in the morning.
➢ The client sleeps at the bed, with good ventilation.
➢ Before sleeping, the client usually watches television together with his
parents, and drinks his milk.
➢ As the grandmother said, the client has no problems in falling asleep.
➢ The client takes naps 5 times a day.

g. Value-Belief Pattern

➢ For the grandmother, a person is healthy if he can do his entire task

for a day.
➢ For the grandmother, health is very important especially when it’s the
client’s health we’re talking about.
➢ They usually pray for the goodness of their health.
➢ The grandmother said that their religion is important for them.
➢ When problems are arising they pray for it.
➢ The social values they have are the so called “PAKIKISAMA”. That’s
why they have good neighboring relationships and they are
maintaining it.