Silliman University

COLLEGE OF NURSING
Dumaguete City

FUNCTIONAL HEALTH PATTERN

AND
NURSING CARE PLAN
Submitted by: Tiffany V. Ragas, S.N.

Submitted to: Asst. Prof. Mary Nathalie Cataal

I. Demographic Data
Name: __Nobleta ,Clark___________________________ Sex: _M___ Age: ___2_____ Civil Status: ___Single____________________
Address: _Maglinao, Basay, Negros Oriental_________ Educational Attainment: _None___Occupation: _None_______
Room and Bed number: ____466-E_________ Nationality: ___Filipino___________Religion: ___Pentecostal_____
Date and time of admission: __Mach 27, 2020 @ 2:40 PM___________________
Chief complaint: ___Abdominal Pain___________________
Admitting Diagnosis: _Constipation R/O UTI_____
History of present illness: 1 month prior to admission, patient experienced abdominal discomfort after meals. 1 week before admission, severe abdominal pain is
experienced, associated with vomiting and decreased frequency of defecating, with hard stools. Consulted the local health unit and received prescription of medicines
to relieve symptoms. 3 days prior to admission, there is an onset of fever, consulted again to local health unit, prescribed lactulose and alsium to relieve constipation,
however, there are no relief of symptoms. Condition persisted thus prompting to admission here in the medical center.

II. Functional Health Pattern

USUAL FUNCTIONAL PATTERNS INITIAL APPRAISAL ONGOING APPRAISAL

1. Health-perception – Health –management
pattern
 Mother verbalized that she delivered her baby last
February 25,2018 via cesarean section. Baby’s
weight is 3100 grams.
 There were no illness and complications during
antepartum, intrapartum, and postpartum. Baby is
considered healthy at birth
 Months after birth, child was diagnosed with
pneumonia but recovered after days of
examination and treatment in the Negros
Provincial Hospital.
 Mother was able to sent child for scheduled
 According to the mother, the child feels better  Child feels better compared to yesterday
compared to the past few days since admission  No abnormal results on urinalysis
 Mother verbalized that she doesn’t know the
possible cause of her child’s illness VITAL SIGNS 3/10/20
 There are no abnormal results on urinalysis Time Temp. PR RR
 Abnormal results on CBC: 8 AM 36.70C 94 20
- Hemoglobin : 11.30 gm%; Normal : 13-16
- Hematocrit: 35.50% ; Normal: 42-50  General appearance of the child:
- WBC: 27270/cumm; Normal: 4500-11000 - eating on bed
 Medications: - Appearance is clean, and overall hygiene is
- Cefuroxime (Stanxime) 400 mg q8h ANST completely monitored by the mother.
- Paracetamol ( CALPOL) 5 MI q4h PRN for T > - Student nurse provides morning care.
38oC  General appearance of both parents:
Able to answer questions with eye-contact
 immunization in their Barangay Health Center in
Bais
 Child is fully immunized:
- BCG, Hep B vaccine, OPV ,MMR, measles vaccine,
PCV
 Usually has cough and colds but manageable
 During infancy, parents change the diaper twice
every day, but now the child doesn’t use diaper
 Child still not able to care for self. Still needs
assistance from both of the parents– bath, dress,
groom, feed or going to the bathroom.
 Both parents doesn’t smoke or have any vices.
 There were no frequent accidents and even
dangerous things around the house,concerning the
toddler. Knives, and other sharp objects are stored
safely away from the child’s reach.
 Toys are kept after child plays.
 Safety practices include:
- Keeping sharp objects away from child’s reach
-
2. Nutritional-metabolic pattern
 Mother verbalized that she breastfed her child
during birth until 12 months, then bottle fed the
child with bearbrand. Estimates intake of child 2
bottles per day.
 Child’s appetite was good and did not have any
feeding discomfort. Child’s usual 24-hour intake
of nutrients include carbohydrates from rice,
protein from meat, vitamins and minerals from
fruits and vegetables
 Supplements include, Ascorbic Acid Ceelin Plus
and Cherifer
 Eating behavior:
- “ Anad na ni siya mokaon og bisan unsa, dili siya
pilian.Pero naa panahon nga iyang isuka iyang
VITAL SIGNS 3/09/20 contact observed, eyes are not weak and drowsy.
Time Temp. PR RR Appearance is clean .
4 PM 37 C 0
107 20
 General appearance of the child:
- Asleep and resting on bed
- Appearance is clean, and overall hygiene is
completely monitored by the mother.
- Nurse constantly provides morning care.
 General appearance of both parents:
Able to answer questions with eye-contact contact
observed, eyes are not weak and drowsy. Appearance
is clean .
 Consumes food given by the hospital:  Consumes food given by the hospital:
- rice, fruit/vegetable, meat - rice, fruit/vegetable, meat
 Child’s appetite is good and doesn’t have any  Child’s appetite is good
feeding discomfort.  Has abdominal pain after eating
 Child’s usual 24-hour intake of nutrients during  Child’s usual 24-hour intake of nutrients
hospital stay: carbohydrates from rice, protein during hospital stay: carbohydrates from
from meat, vitamins and minerals from fruits and rice, protein from meat, vitamins and
vegetables minerals from fruits and vegetables
 Supplements include medications for current  Supplements include medications for current
condition condition
B. Observation: C. Observation:
 pagkaon since baby pa siya.” (as verbalized by  Skin color is light brown; no sign of dehydration;  Skin color is light brown; no sign of
mother) no rashes and lesions visible to child’s skin dehydration; no rashes and lesions visible to
 Child likes sweets, and his favorite milk is bear child’s skin
brand.
 Does not have any difficulties with eating,
chewing or swallowing
 No changes in appetite
 No food allergies
 Usually eats what is available
 There are no diet restrictions; eat foods that she
loves
 Has no skin lesions and rashes

3. Elimination pattern
Bowel
 Child usually defecates 2x a day but there are days
when she feels like eating a lot and becomes full,
she defecates more than the usual
 Color is brown and formed, no discomfort during
elimination
 During infancy, diaper is changed twice a day
Urine
 Usual daily output is 5-8x a day – estimated 500-
1000 ml/day.
 Urine is amber and no unusual odor.
 No difficulties in urinating
 Sometimes awaken at night due to urinating
Skin
 no excessive sweating/ dryness
 No unusual odor during perspiration
 Child wasn’t able to defecate whole morning
 Child do not defecate more often ever since  No elimination/ no observation of stool
symptoms occurs
 Color is dark brown and stool is hard and ball- Urine
formed, no discomfort during elimination  Urinated 3x – estimated less than usual
 Able to ambulate when going to the bathroom amount of urine eliminated.
during elimination  Urine has no strong and smelling odor
 Has no difficulties in urinating
Urine
 Usual daily output is 3-4x a day – estimated less Skin
 Less sweating/ dryness
than usual amount of urine eliminated.
 Urine has no strong and smelling odor  No unusual odor during perspiration
 Has no difficulties in urinating
Skin
 Less sweating/ dryness
 No unusual odor during perspiration

4. Activity-exercise pattern
  Child received morning care from the nursing  Child received morning care from the student
A. Parent’s report: assistants like bed bath nurse
 Child takes a bath in the bathroom and uses  Typical days activity during stay in the hospital  Typical days activity done:
safeguard as soap include: - walks around the room, and watches movies
 Typical days activity include: - when he wakes up, he walks around the room, and and plays games on phone,received care from the
- when he wakes up,he goes outside to play with his watches movies, received care from the medical medical personnel, then takes his breakfast and
friends, then his grandmother will call him for personnel, then takes his breakfast and medicines, medicines, then interact with other kids around.
breakfast. After that, he will watch his favorite then interact with other kids around.
cartoons, the play again with his friends outside.
 Child is active and always wants to do something C. Observation
that he loves B. Observation
 Parents’ perception of their baby is smart. VITAL SIGNS 3/10/20
 The child stays in his grandmother during VITAL SIGNS 3/09/20 Time Temp. PR RR
weekdays, then stay with his parents during Time Temp. PR RR 0
8 AM 36.7 C 94 20
weekends. 0
4 PM 37 C 107 20

5. Sleep-rest pattern
A. Parent’s report:
 Usual sleep pattern: 7 or more hours
 Sleeps whatever time he likes
 Does not snore and doesn’t have any nightmares
 Feels rested upon waking up
 Usually rests when tired
B. Parent (self) :
 Usual sleep pattern: 10 hours, from 9 PM to 7 AM
 Feels rested when waking up in the morning
 Slept for approximately 9 hours and takes a nap
for about 2 hours
 Does not have any nightmares.
 Sleep interruptions : Vital signs taking and intake
of medicine
 Usual sleep pattern: 10 hours, from 9 PM to 7 AM
 Usually interrupted when child demands for
something during nigh time
 Feels rested after waking up
 Slept for approximately 9 hours and takes a
nap for about 2 hours
 Did not have any nightmares.
 Sleep interruptions : Vital signs taking and
intake of medicine
 Took nap after after eating
 Usually interrupted when child demands for
something during nigh time

6. Cognitive-perceptual pattern
 Child is asleep but according to mother’s  Child loves exploring new things, and is very
A. Parent’s report:
 Child responds with sense and really enjoys his
surrounding. He explores the things around him,
and is very active to learn new things
 Mother teaches him child with basic words, and
the alphabet
 Likes watching cartoon movies
observation, child still loves exploring new things,
and is very curious of his surroundings. The child
is not afraid even staying at the hospital.
 Child is able to follow instructions without crying
and be intimidated.
 Able to respond correctly to people and with
things.
curious of his surroundings.
 The child is not afraid even staying at the
hospital.
 Child is able to follow instructions
 Able to respond correctly to people and with
things.

7. Self-perception-self-concept pattern

A. Parent’s report:  Child is asleep during interview. A. Parent’s report:

 Child’s mood is always bright and bubbly, but
there are times that he wants to be alone, and
doesn’t want to interact with others
B. Child’s report
 Mood is bright and friendly
 He has few friends
 There are times she feels lonely and wants to be
alone
 He fears of heights
8. Role-relationship pattern
A. Parent’s report
 Parents are married
 Family structure: Child is living with his lola
during weekdays, then stays with his parents in
Basay during weekends.
 Relationship with the family: “okay rami and
happy ra sad kayo mi sa akong family” (as
verbalized)
 Spends time with the family during weekends by
eating meals together or by going to the church.
 Child does have record of temper tantrums
especially when there are things that the child
wants but wasn’t given .
C. Observation  Child wants to be alone, and doesn’t want to
interact with others
 No eye contact during the interview.
D. Parent (self)
 Parents see themselves as competent in being good
parents to their son, despite having difficulties in life,
and being busy in their work as elementary teachers,
they’re still able to provide the needs of their child.
D. Observation
B. Observation  Child was awake
 Child was asleep
E. Parent (self)
C. Parent (self)  Parents engages themselves in teaching and
 Parents engages themselves in teaching and nurturing nurturing their child because they want him to
their child because they want him to grow up being grow up being courageous and independent
courageous and independent
 Both father and mother are working as teachers in
DEPED.
 9. Sexuality-reproductive pattern
A. Parent’s report
 Child doesn’t understand what are the differences of
boy and girl.
B. Parent (self)
 There are no problems between husband and wife
regarding their sexual satisfaction
 Uses condom for family planning
10. Coping stress tolerance pattern
A. Parent’s report
 Child copes up with problems or frustrations by
watching his favorite cartoon movies, splays
outside with his friends.
 Stressors: not having what he wants
B. Parent (self)
 Strategies to handle problems with child include:
- don’t stop him from achieving what the child wants
- complimenting child whenever he do good things
 Support system is her husband
 Life stressor include: financial problem
11. Value-belief pattern
A. Parent (self)
 Things that are important to her life is her husband
and their relationship to one another. The future of
her two child is also very important to her, that’s why
as early as today, she wants to nurture her child and
mold them .
COLLEGE OF NURSING
 Child was asleep
 Child copes up with problems or frustration of being
in the hospital by strolling inside the room
 Strategies to handle current situation include:
- being optimistic and believing that God will heal their
child
- encouraging her child to always be grateful despite of
being sick
 Mother said, that what is important to her right now is 
the health of his son, and his recovery. She doesn’t
want his son to suffer like this in a young age.
 The child’s current disease affected the child’s
interaction with the world. Mother feels that his son
was being isolated with the world.
Silliman University
Dumaguete City
 Child is awake
 Parents develop mutual understanding even
during hospitalization of their son
 Child copes up with problems or frustration of
being in the hospital by strolling inside the room
 Strategies to handle current situation include:
- being grateful always and believing that God will
heal their child
- encouraging her child to always be grateful despite
of being sick
Mother said, that what is important to her right
now is the health of his son, and his recovery.
She doesn’t want his son to suffer like this in a
young age.


CUES/EVIDENCES
SUBJECTIVE:
“The client’s father stated
“Wala pa gyud ni siya
nakalibang since na admit siya.
Makabati man pud ni siya og
kasakit sa tiyan kada human og
kaon”
OBJECTIVE:
 weak in appearance
 The client has a pale
conjunctiva , lips and palms
Vital Signs (3/9/20):
o T: 37oC
P: 107 bpm
R: 20 cpm
BP: 90/60 mmHg
NURSING CARE PLAN
NURSING DIAGNOSIS OBJECTIVES
Independent:
 Constipation related After 8 hours of duty, the
to poor eating client will establish or
return to normal patterns
habits of bowel functioning as
evidenced by:
 Constipation related
 Able to eliminate
to decreased dietary
soft ,formed stool
intake
perceived as normal
by the patient in the
 Constipation related
next 24 hours
to dehydration
 States relief from
discomfort of
constipation.
 Patient/ significant
other identifies
measures that
prevent or treat
constipation.
COLLABORATIVE:
 Patient/ significant
other verbalizes
measures that will
prevent recurrence
of constipation.
INTERVENTIONS
 Determine stool color,
consistency, frequency and
amount.
 Auscultate bowel sounds
 Encourage increased fluid
intake of 2500 – 3000 ml/day
 Recommend Avoiding gas-
forming foods such as nuts,
peas and spicy foods.
 Consult with dietitian to
provide well-balanced diet high and thereby produces
in fiber and bulk.
 Discuss use of stool softeners,
mild stimulants, bulk forming  Facilitates defecation
laxatives or enemas as
indicated. Monitor
effectiveness.
RATIONALE EVALUATION
 Assists in identifying After 8 hours of duty, the
causative or client established and was
contributing factors and able to return to normal
patterns of bowel
appropriate
interventions functioning as evidenced
by:
 Bowels sounds are
generally decreased in
 Able to eliminate soft
constipation.
,formed stool perceived
as normal by the patient
 Sufficient fluid intake is
in the next 24 hours
necessary for the bowel
to absorb sufficient
 Stated relief from
amounts of liquid to discomfort of
promote proper stool constipation.
consistency.
 Patient/ significant
 Decrease gastric distress other identified
and abdominal measures that prevent
distension. or treat constipation.
 Fiber resists enzymatic  Patient/ significant
digestion and absorbs
other verbalized
liquids in its passage measures that will
along the intestinal tract prevent recurrence of
constipation.
bulk, which acts as a
stimulant to defecation.
when constipation is
present.
PHYSICAL ASSESSMENT

3 Priority Systems
 I. INTEGUMENTARY

HEALTH HISTORY PHYSICAL EXAMINATION SCORE

Mother said that patient vomits food after every SKIN NAILS HAIR
eating. There is loss of appetite and doesn’t want to
drink any fluids. Child needs to be forced to drink or Skin color is dark Nails are Hair color is black,
eat. There are no past lesions or any recent change in brown and warm transparent, straight and smooth
skin color. There are also no allergies. when touched. smooth and No presence of
Skin appears dry convex dandruff and any
and has poor Surrounding lesions
turgor when cuticles are dry,
touched. Skin intact and without
gets back in 3 inflammation
seconds after Nail beds are
being pinched. reddish
No active lesions
and no pallor.

II. HEAD AND NECK

HEALTH HISTORY PHYSICAL EXAMINATION SCORE

Mother said that patient has eating EYES EARS AUDITORY NOSE MOUTH PHARYNX NECK
problems. Sometimes refuses to eat ACUITY
and drink and just wants to play -Able to blink -Color is same -Sound is heard -Shape is -Sign of -Pink and - Trachea is
games on the phone. Vomits every normally. as facial skin, on both ears symmetrical to pallor and smooth placed
after eating. No problems in visual -Whitish size is face, color is dryness of posterior wall midline of
and auditory acuity. conjunctiva, no symmetrical, same to facial lip of neck
presence of and auricle skin -20 teeth, oropharynx - Thyroid
lesions. aligned with -Slight discharges dental caries, -No gland not
-No tenderness outer canthus of from nose pink gums discharges on visible on
on nasolacrimal the eye -Tenderness when -Tongue is in tonsils inspection
duct -Palpated firm palpated central -Elicit gag and lobes not
-Color of pupil and non-tender -No tenderness on position, reflex palpated
is dark brown, auricle, pinna sinuses whitish -
symmetrical recoils after color, no
-Pupils are round folded lesions,
and reacts to raised
light papillae,
-When looking moves freely
straight ahead, and no
patient can see tenderness
objects in
periphery
-Eyes are
coordinated,
moves in unison
with parallel
alignment

III. ABDOMINAL EXAMINATION

HEALTH HISTORY PHYSICAL EXAMINATION SCORE

Mother said that patient has INSPECTION AUSCULTATION DEEP PALPATION LIGHT PALPATION PERCUSSION
eating problems. Sometimes
refuses to eat and drink and just -Able to blink -Color is same as -Sound is heard on -Shape is symmetrical -Sign of pallor and
wants to play games on the normally. facial skin, size is both ears to face, color is same dryness of lip
phone. Vomits every after eating. -Whitish symmetrical, and to facial skin -20 teeth, dental caries,
No problems in visual and conjunctiva, no auricle aligned with -Slight discharges pink gums
auditory acuity. presence of outer canthus of the from nose -Tongue is in central
lesions. eye -Tenderness when position, whitish color, no
-No tenderness -Palpated firm and palpated lesions, raised papillae,
on nasolacrimal non-tender auricle, -No tenderness on moves freely and no
duct pinna recoils after sinuses tenderness
-Color of pupil folded
is dark brown,
symmetrical
-Pupils are
round and reacts
to light
-When looking
straight ahead,
patient can see
objects in
periphery
-Eyes are
coordinated,
moves in unison
with parallel
alignment