I.

Nursing History

A. Past Health History

1. Childhood illness
The mother verbalized that her daughter had measles when he was three years
old. Addition to that, the mother said that her daughter is frequently having tonsillitis.
The mother stated that she is in doubt if her daughter had a complete
immunization.

2. Allergies
According to the client’s mother, her son is not allergic to any foods or drinks.
The mother added that her daughter had recovered from having tonsillitis, her
daughter became reactive to softdrinks. If he had consumed softdrinks, his body
reacts to it and manifests swelling of his whole body and pain in the abdomen. The
client stressed it at the epigastic part.

3. Accidents
According to the client’s mother, her daughter doesn’t experience any major
accidents in her life.

4. Hospitalization
When the client is experiencing fever, the mother verbalized that she brings her
son immediately to Hospital to be treated urgently.

5. Medications used or currently taken

6. Foreign Travel
The mother said that the client did not have any foreign travel.

B. History of Present Illness

C. Family History
The mother stated that their family has a history of hypertension in the mother
side. On the other hand, the father side, the mother stated that the uncle of his son had
been diagnosed to have Heart Enlargement.

II. Pattern of Functioning

A. Psychological Health
1. Coping Patterns

When the client feels bored because she has limitations in doing other things
because of her condition, she watches television.

2. Interaction Patterns
 His relationship with her mother is better compared to his father. His mother
plays and goes with him almost all the time. They watch television together. Wherever
he goes, his mother constantly accompanies him.
In terms of his relationship with his father, he is not that close because his father
spends most of his time doing his work.
She has some friends in the neighbour. Almost all her playmates are girls. She
seldom talks to the boys because she is shy being with them.

3. Cognitive Patterns

The client never goes to school because of her condition. She can able to
understand language spoken but she cant able to speak.

4. Self-concept

5. Emotional Patterns

She gets angry easily to people who did bad things to him. She gets angry easily
but loses this feeling easily too. She just keeps his feelings to herself. She feels hurt
when his father scolds him.

6. Family Coping Patterns

B. Socio-Cultural Patterns ??wag na to?

1. Cultural Patterns
2. Significant Relationships
3. Recreation Patterns
4. Environment
5. Economic
Interpretation:
Analysis:

C. Spiritual Patterns
1. Religious Beliefs and Practices
The client is catholic. The client’s mother said that she brought her daughter to
the church during infancy up to toddler but as when she gets bigger they stop
doing it because they cant able to bring her to the church.
2. Values and Valuing

Interpretation:
Analysis:

III. Activities of Daily Living

ADL Interpretation and Analysis

1. Nutrition The foods eaten by her INTERPRETATION:
family are cooked by her
mother and sometimes bought ANALYSIS:
in carinderias near their An adequate food intake
 house. Before knowing that
she has a disease, she likes
drinking softdrinks. She likes
eating pork sinigang, fried
chicken, unripe mangoes.
consists of a balance of
essential nutrients: water,
carbohydrates, proteins, fats,
vitamins and minerals.
(Health Promotion in Nursing
process)

Normal fluid intake should be

up to 8 to 10 glasses a day.
(Kozier et.al. 2008.
Fundamentals of Nursing, 8th
edition). Singapore: Pearson
Education Asia Pte Ltd).

Proper nutrition encompasses

the study of nutrients and how
they are handled by the body
as well as the impact of
human behavior and
environment on the process of
nourishments. Foods that
provides nutrition for both
body and mind.
(Fundamentals of Nursing by
Taylor)
2. Elimination He defecates once a day INTERPRETATION:
during afternoon. His stool is The urine output of the
brown in color, soft, and foul- client is little in amount.
smelling. She has no difficulty
in defecating. ANALYSIS:
He urinates 5 times a day. Normal Feces
His urine is clear light yellow, Color: Adult: brown
and little in amount. She has Consistency: soft, formed and
no problems or any difficulty in moist
urinating. Shape: cylindrical
Amount varies with diet
Aromatic in smell
(Kozier, et al. 2008.
Fundamentals of Nursing)

Urine
About 1200-1500 ml
Straw, amber or transparent
in color
Odor: faint aromatic
Sterility: No microorganisms
present
Ph:4.5-8
(Kozier, et al. 2008.
Fundamentals of Nursing)

3. Exercise The client cannot perform
any form exercises because
of her impaired mobility
because of her condition. She
only stays in her bed watching
television.
Frequency of defecation is
highly individual, varying from
several times per day or 2-3
times a week.
Normal feces are made of
about 75% water and 25%
solid waste materials.
Normal feces require a normal
fluid intake; feces that contain
less water may be hard and
difficult to expel.
(Kozier, et al. 2008.
Fundamentals of Nursing)
INTERPRETATION:
The client is in immobility
and cannot perform specific
tasks.
ANALYSIS:
The amount of exercise
you need depends on the type
of lifestyle you want to
maintain. For beginners, most
experts recommend at least
20 minutes of exercise three
times a week. These 20
minutes can be a combination
of four 5-minute sessions of
exercise, two 10-minute
sessions or 20 continuous
minutes. Just doing something
is better than no exercise at
all. Remember, 20 minutes is
considered the minimum
prescribed amount of exercise
for one day. As your body
adjusts to this level of
exercise, you should increase
the amount of exercise that
you are doing to continue
receiving the maximum
benefits.

4. Hygiene The client takes a bath only INTERPRETATION:
twice a week. She brushes
her teeth every after eating proper hygiene in some ways.
but sometimes forgot it in the
evening.
5. Sleep and Rest She usually sleeps 10 pm at
night up to 8am in the morning
. After waking up, She has no
problem falling asleep. The
room is well ventilated and
with lights.
(Kozier et.al. 2008.
Fundamentals of Nursing, 8th
edition). Singapore: Pearson
Education Asia Pte Ltd)
The client is not doing
ANALYSIS:
Hygiene is the self-care by
which people attend to such
functions as bathing, toileting,
general body hygiene and
grooming. It involves care of
the skin, hair, nails, teeth, oral
and nasal cavities, eyes, ears
and perineal-genital areas.
(Kozier & Erb. Fundamentals
of Nursing. 8th Edition. Volume
1)
INTERPRETATION:
The client has adequate
sleep.
ANALYSIS:
Adolescence require 8-10
hours of sleep each night with
no disturbance to prevent
undue fatigue.
(Fundamentals of Nursing By
Kozier Et. Al 8th Ed)
Sleep is a basic human need;
it is a universal biological
process common to all people.
Human requires sleep for
many reasons: to cope with
daily stresses, to prevent
fatigue, to conserve energy, to
restore mind and body, and to
enjoy life more fully.
(Fundamentals of Nursing By
Kozier Et. Al 8th Ed)
Environment can promote or
hinder sleep. Any change-for
example, noise in the
environment can inhibit sleep.
Discomfort from
 environmental temperature
(e.g. too hot or too cold) and
lack of ventilation can affect
sleep.

IV. Physical Assessment

V. Laboratory and Diagnostic Examinations Results
VI. Medications
VII. Pathophysiology
VIII. Ecologic Model
A. Hypothesis
B. Predisposing Factors
1. Host
2. Agent
3. Environment
C. Ecologic Model
D. Analysis
E. Conclusion and Recommendations
IX. Prioritized List of Nursing Problems

Date Nursing Problems Cues Justification

Identified

CUE DIAGNO ANALY GOAL AND NURSING RATIONA EVALUATI

S SIS SIS OBJECTIVES INTERVENTION LE ON

X. Nursing Care Plan

NURSING DIAGNOSIS COMMUNICATION, impaired, verbal

May Be Related to: Inability to trust others
Withdrawal into self
Organic brain dysfunction
Inadequate sensory stimulation; maternal
deprivation
Possibly Evidenced by: Lack of interactive communication mode;
does
not use gestures or spoken language
Absent or abnormal nonverbal
communication; lack of eye contact or
facial expression

Desired Outcomes/Evaluation Criteria—
Client Will:
Peculiar patterns in form, content, or
speech production (if speech is present)
Impaired ability to initiate or sustain
conversation despite adequate speech
Use sounds, words, or gestures in an
interactive
way with others.
Communicate needs/desires to significant
others/caregivers.
Initiate verbal or nonverbal interaction
with others.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Maintain consistency in caregivers assigned to child. Familiarity helps child to develop
trust and helps
caregivers to learn ways child attempts to
communicate.
Anticipate and fulfill needs until communication can Reduces frustration while child is
learning
be established. communication skills. Some therapists
believe
this process should be limited to force
verbal requests for wants beyond basic
needs.
Assess previously used words or sounds. Seek Facilitates recognition of speech efforts.
These
validation and clarification to decode communication techniques are useful in
determining accuracy of
attempts. messages received.
Use face-to-face (eye-to-eye) approach to convey Expresses genuine interest in, and
respect for,
correct nonverbal expressions by example. client.
Reinforce eye contact with something acceptable to Eye contact is essential to capture
child’s attention,
the child (e.g., food, object). to successfully initiate conversation.
Repeat and reinforce approximations of sounds or “Shaping” gives child information
about the
words whenever used by child. caregiver’s expectations and may
encourage
attempts to communicate.
Engage in alternative forms of communication such Three-fourths of children trained in
the picture
as picture exchange, sign language, or use of exchange communication system
eventually
computers for children with minimal language communicate by speech or by speech with

development. pictures. Signing may produce less anxiety

than
verbal expression for some children, and
the use of
computers can be helpful to engaging the
child in
interaction.
Collaborative
Refer for assessment and testing in cooperation with Provides for treatment planning
with appropriate
special education teachers and speech pathologists. specialized
interventions/techniques.