Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
A heath History that Integrates the Assessment of Functional Health Patterns by
Gordon
Name: LSF Age: 58 Sex: Male Ward: Surgery Room & Bed No.: Isolation - 1
Admitting Diagnosis: Infected Wound ® cheek, T/C Buccal CA. Final Histopathology
Diagnosis: At Least Oral Epithelial Dysplasia Present Diagnosis: Pneumonia
Functional Prior to Hospitalization During Hospitalization
Health Patterns
Health Health Perception Health Perception
perception - ● Rated health as 5/10 due to ● Rated health as 8/10,
management persistent buccal lesions, expressing confidence in
difficulty eating, and anxiety medical care despite the
about the condition. condition.
● Believed the white patches on ● Accepts the diagnosis and
his right cheek was caused by understands surgery is not
spirits (“ginmulayan”) and an option.
relied on herbal healers for Health Management
treatment. ● Compliant with
Health Management medications and
● Avoided formal medical care, follow-ups at Northern
relying on traditional healers Samar Provincial Hospital
in Palapag, Laoang, Gamay, (NSPH) and Eastern Visayas
and Bobon. Regional Medical Center
● Used herbal oils, leaves, and (EVRMC).
burnt powdered leaves as ● Supported by children for
“pantapal”, with temporary hospital visits and financial
improvement but eventual needs.
recurrence. ● Community Resources,
● History of tobacco chewing utilizes local health centers
(“pagnganganga”) for 29 years, and Provincial Hospitals.
stopped in 2021 due to onset of Present Health Problem
small lacerations on the buccal ● A 58-year-old male with a
tissue. 2-year history of a
● Secretly continued tobacco mandibular mass.
chewing even during visits to ● Initial presentation: Small
herbal healers or initial medical white patches (leukoplakia)
check-ups until worsening of on the right cheek,
the lacerations and buccal progressing to oral epithelial
mass became noticeable in dysplasia confirmed by
early 2023. biopsy.
● Occasional alcohol use in ● Recent symptoms
younger years. (February 2025): Infection of
Expectations the lesion, with fever, chills,
● Expected complete healing of redness, swelling, and pain.
the wound and ● Current management:
reconstruction. Supportive care and
Previous Illnesses and medications for infection
Hospitalizations and discomfort.
● No prior hospitalizations Expectations
relative to other illnesses ● Accepts the current
except for the current condition. condition and focuses on
Developmental History symptom management.
Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
A heath History that Integrates the Assessment of Functional Health Patterns by
Gordon
● No record of childhood
immunizations.
● Admitted putting fingers in
mouth or having oral fixations
during younger years.
● Youngest of 9 siblings, with
inadequate nutrition during
childhood due to family poverty
as reported.
Nutritional
Metabolic ● Regular dietary intake with no ● Consumes blended foods
restrictions related to health or and porridge; avoids hard
religious beliefs. or non-soft foods to prevent
● Diet consisted of vegetables oral discomfort.
(especially greens), eggs, ● Eats slowly and does not
fish, rice, and meat. finish meals.
● Reported small lacerations in ● No prescribed dietary
the right cheek with white restrictions; self-selects
patches but continued to finish soft foods to minimize oral
meals. Admits eating less cavity injury.
during the worsening of the ● Reports never feeling full
wound. despite regular eating.
● Weight was roughly 43-45 kg in ● Current weight: 35 kg,
early 2023 during initial indicating significant weight
check-up in Mabuhay Health loss.
Center.
● No reported polydipsia, polyuria,
polyphagia, or heat and cold
tolerance.
Bowel
Elimination ● Regular bowel movements: 3–5 ● Bowel movement frequency:
times per week. Once since admission.
● Stool characteristics: Brown ● Stool characteristics:
and solid. Yellowish and soft.
● No history of diarrhea, ● No reports of pain,
constipation, or related constipation, or frequent
hospitalizations in the past five loose stools.
years.
● No reported pain, difficulty, or
discomfort during defecation.
Bladder
● Urination frequency: 3–4 times ● No significant changes in
daily. urination patterns or
● Urine characteristics: Light characteristics.
yellow, no history of
hematuria.
● No reported urinary urgency,
retention, or pain during
urination.
Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
A heath History that Integrates the Assessment of Functional Health Patterns by
Gordon
Activity
Exercise Occupation Activity Level
● Previously engaged in farming ● Remains in bed most of
until 2022; currently stays at the time due to reported
home performing household weakness.
chores such as washing Mobility
clothes and tending to plants ● Ambulates independently.
in the backyard. Self-Care
Lifestyle ● Requires minimal
● Supported financially by his assistance with feeding and
children and government activities of daily living
assistance. (ADLs).
Physical Activity
● No structured exercise routine
but reports walking in their
backyard every morning.
Leisure Activities
● Primarily watches television and
listens to the radio.
Social Interaction
● Spends time at home with
grandchildren while their
parents are at work.
Sleep - Rest
● Typically sleep from 9:00 PM to ● Adjusted to sleeping from
5:00 AM. 8:00 PM to 7:00 AM.
● Reported light, ● Improved significantly due
non-restorative sleep with to reduced pain and irritation
frequent awakenings during from prescribed medications.
the night. ● No frequent awakenings;
● Anxiety and pain from patches verbalizes feeling physically
on the right cheek occasionally and emotionally comfortable,
disrupted sleep. well-rested, and satisfied
with sleep quality.
Cognitive - Sensory
Perceptual Pain Perception
● No reported sensory deficits in
touch, temperature, taste, or ● No pain in the right buccal
feeling. area at rest; mild tinges of
● Uses reading glasses. pain (PRS 3/10) while
● Reports intact hearing. eating, but tolerable.
● Manages pain through
Cognitive distraction techniques, such
as listening to music or
● Admits occasional talking to his wife or
forgetfulness. daughter.
● Describes himself as firm in
decision-making but
acknowledges limited
Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
A heath History that Integrates the Assessment of Functional Health Patterns by
Gordon
knowledge, particularly in
medical matters.
Pain Perception
● Pain Rating Scale (PRS): 7/10
due to buccal patches and
mass.
● Reported anxiety about the pain
and worsening condition.
● Experienced associated
symptoms such as headache,
fever, and agitation prior to
admission.
Self -
Perception and ● Admits feeling anxious yet ● Feels like a burden to his
Concept laid-back about his condition, children due to the need for
primarily to avoid being a follow-ups and maintenance
burden to his children. after hospitalization.
● Occasionally views himself as ● Expresses worry about the
weak but receives positive physical outcomes and
support and validation from his long-term effects of his
wife and children. condition that might affect
his relationships and
self-esteem.
Role
Relationship ● Actively performed household ● Receives comfort and
chores and cared for his reassurance from loved
grandchildren to avoid being a ones, who affirm that his
burden to his family. condition does not
● Sought occasional farming jobs diminish his role as a
when available or needed to father.
help with financial needs. ● Continues to provide
emotional support and
guidance to his children,
grandchildren, and wife,
even while hospitalized.
Coping / Stress
Tolerance ● Coped with stress through ● Copes by praying,
prayer and open communicating with his wife,
communication with his family adhering to medical
about his feelings regarding his advice, and maintaining a
condition. positive mindset.
● Often experienced emotional
breakdowns (e.g., crying) but
was reassured and supported
by his daughter.
Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
A heath History that Integrates the Assessment of Functional Health Patterns by
Gordon
● Drew strength and emotional
support from his family,
particularly his wife.
Value - belief
● Believed that traditional ● Developed trust in
healing alone would resolve healthcare professionals
his condition. and their management of
● Lacked trust in healthcare his condition.
systems due to limited ● Demonstrated willingness
knowledge about hospitals or to take full responsibility
clinics, leading to hesitations in for his health, not only for
seeking medical care. himself but also for his
● Denied the severity of his family.
symptoms and continued ● Recognized the value of
unhealthy habits (e.g., life over indulgence and
chewing tobacco, the importance of
pagnanganga), ignoring signs prevention over cure.
of deteriorating health. ● Shifted trust from traditional
healing to faith in God and
the tools provided by
healthcare professionals for
his recovery.
Prepared by:
Rosalita Ayessa D. Rosalita, UEP – SN
of Group D2
