COLLEGE OF NURSING

Silliman University
Dumaguete City

FUNCTIONAL HEALTH
PATTERN and
NURSING CARE PLAN

Submitted by: Francesca Margarita J. Gonil D1- Mrs. Cabatit

Submitted to: Asst. Prof. Osel Sherwin Y. Melad

 DEMOGRAPHIC DATA

Name: Villegas, Ivan Niccolai U.

Age: 20 yrs. old

Sex: Male

Civil Status: Single

Occupation: Student

Educational Attainment: High school Graduate of Silliman University

Address: 81 Rovira road Bantayan Dumaguete city

Date of Admission: March 20, 2019

Time of Admission: 1230 pm

Chief Complaint: Torn anterior cruciate ligament (ACL) on right knee

Doctor in Charge: Dr. Eric Graham

 FUNCTIONAL HEALTH PATTERNS
I. Health Perception – Health Management Pattern

USUAL PATTERN INITIAL APPRAISAL

 Can hardly bear weight on right knee
 Health in the past few years was good.  Patient rates pain of knee at 2 if he is
 Exercises 2-3 times a week in the gym at rest and a 7 when walking.
 Does not smoke  Sought admission due to severe pain in
 Does not take recreational drugs right knee while walking
 Goes out for drinks (alcoholic  Due for ACL reconstruction surgery
beverages) once or twice a month Vital Signs:
 No previous Hospitalizations - T: 37 ˚ C
- BP: 120/75 mm Hg
 Known Heredo-Familial disease: - PR : 80 bpm
- RR: 16 cpm
 Diabetes (Mothers side) Medications
Ibuprofen
Can easily comply with doctors orders and Intra-articular and pre-articular local anesthetic
given prescriptions as well as nurses Laboratory Examinations
suggestions WBC = 10,000/cumm
U/A = no significant findings
Fecalysis = No significant findings
RBS = 160 mg/dl

II. Nutritional-Metabolic Pattern

USUAL PATTERN INITIAL APPRAISAL

 Usual food intake  Patient has just eaten
KIND OF FOOD QUANTITY  Verbalized that he is thirsty
Breakfast:
 Rice  I cup and a half
 Spam  3 pcs
 Egg  1 pc
Lunch:
 Meat  6pcs chopped
 Rice  1 cup
Snacks:
 Skyflakes  3pcs
Dinner:
 Rice  1 cup
 meat  4pcs chopped
 Usual fluid intake
KIND QUANTITY
Breakfast:
 Water  500 ml
Lunch:
 Soda  240 ml
Snacks:
 Brewed
coffee  1 cup
Dinner:
 Water  250 ml

Appetite: EXCELLENT
Food Restrictions: NONE
Supplements: NONE
Weight Changes in the last 6 months: NONE
III. Elimination Pattern

USUAL PATTERN INITIAL APPRAISAL

Bladder
 No problems, no assistive device
 Usual daily output: 1500 ml/day
 Urine is amber in color
Bowel
 No problems, no assistive devices
 Defecates 4-6 times a week
 Stool formed, brown in color
Skin
 No problems
Bladder
 No problems, no assistive device
 Usual daily output: 1800 ml/day
 Urine is amber in color
Bowel
 No problems, no assistive devices
 Defecated once upon admission
 Stool formed, brown in color
Skin
 No problems

IV. Activity-Exercise Pattern

USUAL PATTERN INITIAL APPRAISAL
 Exercises at the gym 2-3 times a week  Trouble walking due to pain on right
 Usual daily routine: knee
7:30-8:20 prepare for school  Verbalized that he is worried he won’t
8:20-8:30 travel to school be able to go about his daily activities
8:30-5:00 school
 Has not exercised within the week
5:00-7:00 workout at the gym
7:00-8:00 watch tv, play games
8:00-8:30 dinner
8:30-9:30 study
9:30 sleep
 Leisure activities: Watching tv, playing
games on phone
V. Sleep-Rest Pattern
USUAL PATTERN INITIAL APPRAISAL
 Usual sleep pattern  Slept for about 8 hours
Onset: 9:30 pm  No use of sleeping aids
Awakening: 7:30 am  No sleeping problems
Sleep interruptions: none

# of hours of sleep: 10 hours

 Sleep aids: None
 Sleep problems: None

VI. Cognitive-Perceptual Pattern

USUAL PATTERN
 No sensory perception deficits
 Highest educational attainment: High
school Graduate
 Can easily learn what is being taught
 No problems regarding memory
INITIAL APPRAISAL
 Can easily understand instructions from
doctors and nurses
 Able to rate the pain as 7 on a scale of
1-10
 Complains of pain when standing
VII. Self Perception-Self Concept Pattern
USUAL PATTERN
 Describes self as a person with a
Adventurous personality
 Feels physically fit at this point of his
life
INITIAL APPRAISAL
 Feels physically fit at this point of his life
but is put down due to his injury
 Is positive that he will recover

VIII. Role-Relationship Pattern

USUAL PATTERN INITIAL APPRAISAL
 Language/dialects spoken at home:  Speech is clear and relevant
English,Cebuano  Has a good social life
 Father and Mother are both from  Is accompanied by parents in the hospital
Dumaguete
 Lives with parents and siblings along
with 2 house maids
 Turns to parents when help is needed
 No difficulties in relating with members
of the family
 Has many close friends
IX. Sexuality-Reproductive Pattern

USUAL PATTERN INITIAL APPRAISAL

 Gender: Male  Circumcised
 Circumcised  Girlfriend is present in the hospital
 Verbalized that he has had a girlfriend for
3 years up to the present
 No history of STD

X. Coping-Stress Tolerance Pattern

USUAL PATTERN INITIAL APPRAISAL
 When under stress, he goes for a jog or  Is stressed out due to knee injury
work outs at the gym.  Wants to be able to perform daily
 Has heavy school work load activities at ease as soon as possible
 Always asks for help from parents in  Nurses and other members of the health
making decisions team are very helpful in his recovery
 Is mostly relaxed

XI. Value-Belief Pattern

USUAL PATTERN INITIAL APPRAISAL
 Prayer is the first thing he does when he  Reads scriptures from the Bible
wakes up and the last thing he does before  Good health is important to him
bed
 God is his source of strength
 Goes to church every Sunday
 Religion: Roman Catholic