Gordon’s Health Assessment Framework
(Functional Health Patterns)

CLIENT PROFILE:

Client Initials: LT

Date of Birth: 20 September 1975

Marital Status: Married

Gender: Female

Ethnicity: Chinese

Occupation: Full time Registered Nurse working from Monday to Friday in an acute hospital

Religion: Christianity

Education: Bachelor of nursing

Primary Language: English

Usual Health Practitioner(s): 1 General Practitioner / Family doctor
2 Gynaecologist & Breast Surgeon at hospital – yearly check-up
3 Chinese Traditional Medicine Physician – for ………

CHILDHOOD / ADULT ILLNESSES
There were no significant childhood illnesses that LT could recalled.

LT acquired White Coat Hypertension since her 30’s. She does monitor her blood pressure frequently especially she feels fatigue. She manage the symptoms with low salt healthy balance diet, regular non-strenuous exercise, and relaxation techniques.

This year, she had a unplanned pregnancy and was miscarriage due to foetus no heart beat.

IMMUNISATIONS
LT was born in Singapore and has completed all the compulsory/ recommended/neccessary National Childhood and Adolescent Immunisation, ---- Family Health Service, Ministry of Health (MOH), Singapore. (provide website)

She also completed other Optional Vaccinations as follow:
Flu vaccines prior to her year-end overseas vacation trips,
HPV vaccine
Tetanus vaccine
Chicken pox vaccine

HOSPITALISATIONS (List date or age, reason for admission and any sequelae)
At age of 9, 1984
Perforated appendicitis underwent laparotomy appendectomy.
Post-operative complication of complete wound dehiscence down to subcutaneous layer, treated with intravenous antibiotic and wound care in hospital setting.

At age of 27, 2002
Threatening abortion

At age of 38, 2012
Endometrisis underwent
Breast fibrotic cyst underwent removal of

ACCIDENTS / INJURIES (List date or age and any sequelae)
At age of 10, 1985
Fracture of left wrist while practising gymnastic.
M& R and casting done at age of 10.

At age of 18, 1993
Motorbike accident – no serious injury but sustained skin abrasion (about 20 x 10 cm, at lateral aspect of left lower limb)

DRUG REACTIONS (List drug and type of reaction that occurs)
Clarithromycin - Clarithromycin – skin rash, itching & shortness of breath.

ALLERGIES (List substance that prompts allergy, reaction, and treatment if relevant).
Nil

CURRENT MEDICATIONS (Prescription and over the counter (OTC) medication)
(List drug, dose, frequency, duration, and reason for use).
LT is currently taking Traditional Chinese Medication (TCM) from TCM practitioner. It consists of 7 to 10 types of herbs in powder form, to be taken twice a day, for one week before her menstruation cycle up to 3 months. She can choose to stop when her menstruation cycle back to her baseline, when the low is normal with minimal clots. The purpose of the treatment is to recuperate her uterus and general health after miscarriage as her beliefs.

DEVELOPMENTAL DATA 1. http://annals.edu.sg/PDF/36VolNo11Nov2007/V36N11p898.pdf
The Childhood Developmental Screening Programme was started in the Maternal and Child Health Clinics in Singapore in the mid-1980s. The Denver Developmental Screening Test (DDST), Singapore was then developed for the Singapore children.

LT stated she developed normally, not aware of any informed significant delayed milestone.

HEALTH PERCEPTION AND HEALTH MANAGEMENT
LT carries a healthy outlook, good body balance and posture, presented herself tidy and neat in most of the occasion and setting believing this will cheer up herself and people around her. She states that she is generally healthy without any major chronic illnesses, rating her health status eight out of ten (0 = poor & 10 = excellent). She perceives a healthy person must have a healthy mind, body and soul. To achieve this in life, she keeps her house environment clean and tidy to get a condusive, safe and healthy environment and says no to drugs and alcohol. She makes effort to keep herself healthy through exercise, healthy balance diet, health supplement and other health modality (foot reflexology, body massage & acupuncture). The only risk factors that she feels will impact on her will be the white coat hypertension and recurrence of breast fibrocystic tissue…….and endometriosis. Thus she is very persistence / perseverance in keeping herself healthy in the ways mentioned.

GENOGRAM
Please refer to the annex

ROLES AND RELATIONSHIPS
LT thinks she has close contact and good rapport with all family members. Within her own nuclear family, her husband is working out station four to five times annually and up to a week on each trip yet they has intimate relationship. Both children are closer to her, she engage them in things she is doing like house chores, cooking, shopping, attending church and reading. To her both extended family, she often calls both side to find out how are things going on and help them top up their groceries. Family bonding take place during festivals, school holidays and on one’s birthday allowing each of them keep in touch and reach out to their extended family. Most of her family members regard her as their health adviser especially on hospitalisation, medications, wound care and dietary supplement issues
She still keep in touch with her groups of friends (secondary school, diploma and degree classmates through chat group or gathering). She also volunteer herself in a church medical clinic cater to the poor two hours a week.

NUTRITONAL METABOLIC HEALTH PATTERN
LT maintains her body weigh at 53 to 55 kg with the height of 160 cm (BMI – 21.5 normal), no recent weight gain or loss over the past twelve months. She has two dental check-up yearly to ensure healthy teeth and gum, practice good oral hygiene to ensure long lasting teeth to ingest food. She is holding onto the concept of “you are what you eat” especially after plenty of news and report on unethical practices in food industry being released recent years. She drinks about 2L daily. She is particular on reading the food label, expiry date and consider the manufacture countries. She has no food restriction but avoids titbits, preservative meats, gluten, deep-fried food and fasting on meat every Friday and certain occasion for religious purpose. She has normal appetite but high metabolic rate. She takes 2 portion of fruits with light breakfast, full lunch, less portion for dinner, and a cup of cereal or milk two hours before bed. She takes some fruits or wholemeal bread in between if she feels hungry. She is cutting down on red meat intake but more on fishes, organic vegetables, nuts and oats. Her stable income allow her to spend on high quality fresh trustable food source.

SKIN, HAIR, NAILS
Skin is warm most of the time, tone is balance, general pigmentation present (freckles & nevus on face, birthmark on left wrist). No history or present skin disease (lesion, bruising, allergies, hives, psoriasis, eczema, no changes on skin colour, texture moles or birthmarks). She uses sun block and moisturiser before and after long exposure to outdoor.

She likes to comb hair, massage scalp when she washes hair daily. She has healthy scalp, long black straight hair. Hair is no brittle, dry or excessive loss. She is not fancy with perm, dye or blow hair.

Her nail surface is smooth and regular, translucent nail plate with pink nail bed, not brittle or splitting, thickness is uniform, firmly adherent to the nail bed.

GASTROINTESTINAL
History of perforated appendicitis during childhood with laparotomy appendectomy done. No history of intestinal adhesion. (citation on risk of adhesion post laparotomy)
Gastric pain present till early 30’s but hardly has one now. Her yearly medical check-up shows normal scan and blood result for liver, spleen and kidneys.

ELIMINATION HEALTH PATTERN
She passes motion without any laxatives one to two times daily, brown to dark brown colour due to health supplements, formed to soft stools. She experience watery stool during menstruation sometimes and self-resolve. She gets constipation when not drinking enough or taking too much fibres. She resolves this with taking yogurt and concentrated prune juice.
She has good urinary controls, able to hold urine up to 4 hours, and throughout the night. There are absence of frequency and urgency. She pass urine 6 – 8 times daily of light to straw yellow colour. She contacted urinary tract infectin once while holding her bladder up to 6 hours while travelling to places with poor sanitary facilities. Was treated with a course of oral Cephalexin two years ago.

ACTIVITY AND EXERCISE HEALTH PATTERN
Her working environment requires her to stand and walk most of the time. She swims or brisk walks for one hour a week. She takes stairs case of 5 storeys maximum instead of using lift to burn more calories and exercise legs muscle. She has family outing to botanical garden, zoo, beaches, natural reserves parks to breathe the fresh air connect to nature during weekends or public holidays.

PULMONARY FUNCTION
She is a non-smoker. Her yearly chest X-rays done in early March was normal. No history of lung infection, surgery or disease. Two episodes of throat irritation this year with dry itchy cough during the Indonesian Forest Fire since August ( citation….) She takes Manuka honey and Chinese Herbs to reduce the symptoms and it went off.

CARDIOVASCULAR FUNCTION
She has O positive blood group, has no cheat pain, leg cramps, heart disease or surgery before. She did has some episodes of right swollen ankle and lower calf pain due to prolonged standing and walking as reassured by family doctors. No varicose vein on legs. She measure her blood pressure (BP) before going out which is usually normal (110 to 125/ 75 to 90). Sometimes her systolic BP raises to 140 to 160 mmHg at works when she feels tire or has no enough sleep, but she doesn’t experience giddiness or fainting spell. She will take deep breathing exercise and sit down for 10 minutes and remeasure BP one hour later which is normally on downward trend. Her March medical report shows normal Full Blood Count and cholesterol level.

MUSCULOSKELETAL FUNCTION
She had history of right wrist fracture but no side effect to her later days. She had two episodes of ankle sprain this year which leads to muscle and tissue swelling that took 3 weeks to subside with ant inflammatory and compression bandage. She also states that her working environment subjected her to lower back pain and stiff neck once every 3 to 4 months despite trying her best in maintaining good body alignment and posture in daily activities and walking. She resolve this problem by doing stretching exercise, swimming, body massage and acupuncture. Able to move all joints and no deformity.

REPRODUCTIVE HEALTH
She has her first and second children at age of 27 and 29 with normal vaginal delivery with the help of spinal epidural. Followed by one spontaneous abortion at 12 weeks of pregnancy due to no foetus heartbeat when she was 36 year old. She and her husband hope for one more child before she turn into 40’s. She has done the test……Her gynaecologist has advised her to start ……..to increase an…….. which she will consider trying next year as still think natural pregnancy is the best for self and the newborn. Biannual pap smear result is normal for her. She performs breast-self-examination monthly one week after her menstruation. Breast ultrasound two years ago picked up her right breast…….., removal was done by ..... Currently she has yearly follow up with breast surgeon.

SLEEP AND REST
LT has 6 to 7 hours of sleeps during the weekdays but 8 to 9 hours during weekends. She goes to bed not later than 12 midnight and wake up at 6 am. She states that she falls asleep easily and can rest well even when her children are making noises. When she is not able to sleep due to stress, hot shower, hugging onto bolster and prone position helps her sleep better. She never take any sleeping pills before. She feels tire at sometimes after wake up so she takes some health supplement, DOM (Benedictine Liqueur) or chicken essence. She takes opportunity to take short afternoon nap over weekends to recharge herself and boost her immunity. (citation).

SENSORY PERCEPTUAL HEALTH PATTERN

VISION, HEARING, TOUCH AND PAIN
LT is not wearing glasses, she last eye check-up was in March this year. There are no history of eye infection or injuries. She will protect her eyesight with good reading posture, take 5 minutes rest when working on computer, and use sun glasses during outdoor if the sun is very strong.
Her hearing is normal, not exposed to loud noises, no history of discharges and infection. She dry up the water in the external ear canal with cotton bud after swimming.
She is sensitive to touch and pain sensation over whole body & four limbs. No weakness and numbness in limbs. Currently no experience of any pain. She does has numeric pain score of 6 (0 = no pain, 10 = worst pain) for dysmenorrhoea which improve by taking muscle relaxant (Anarex tabled 500 mg twice a day) and bedrest.

TASTE AND SMELL
She can smell and taste normally.

COGNITION AND PERCEPTION
LT is able to mention the correct time, aware of where we are and who I am. Her mood, manner and behaviour are appropriate, speaks clear and fluency English and Mandarin throughout the interview. Her thought processes are logical and relevant as she understand and able to answer my questions. There aren’t any signs of hallucination and memory loss.

SELF CONCEPT
LT states that she is more to Type A personality (citation) as an impact of strict family background. She couldn’t accept failures during her teenager life, but learned that she actually learn a lots from her failure either in academic or career. She does self-reflection to keep improve herself, to post a positive image to the people around her. She has many personal goals (family, career) to achieve from time to time to keep abreast with this fast changing, fast space and competitive society. She is satisfy with what she is and achieves today, she hopes to have one more child but this goal seems to be constrain with her plan to further her master degree in education in the next 2 years. She is contented with her family, career and self-achievement; but doesn’t quite like herself for keep pushing her children in their learning and emphasize them to be success person. She is aware that this will stress up herself and her children and affect their behaviour and their concept towards learning. Thus she plans to sign up for some parenting program how to communicate effectively with her children, and also will look for motivation program for them.

COPING AND STRESS
LT verbalised that she has good support network from colleagues, old school friends, but her eldest sister is her referral and listening ears when she needs to make important direction in life. Her eldest sister will guard her through and analyse critically her condition for her. She thinks she and her husband has stable income for their living and support their own parents. The big challenges she is facing now is whether to migrate to X country as her husband has the intention of doing so. She has been dealing with this stress since 3 months ago, that she is not willing to leave her family and career, and she prefers her children to complete their education here. There are no finalise answer and discussion with her husband on this issue as his work profile may change from time to time.
In time of stress, she will ventilate to relevant people, go swimming and prays. Her family will go tour twice a year to recharge energy and relax.

VALUES AND BELIEFS
Things in life are important to the client
What the client like to accomplish in lifreis a religious faith important to the client

Refs: Gordon, M. (1994) Nursing Diagnosis: Process and application (3rd ed.). St Louis: Mosby.
Gordon, M. (2014) Manual of Nursing Diagnosis (13th ed.). Jones & Bartlett Learning.

NURS5034 Comprehensive Health Assessment