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Silliman University
Dumaguete City
Submitted by:
EREN BELLE H. ASENTISTA
PUBLIUS JOSEANGELO C. BRIONES
MITCHELL REYNALD L. MELITON
FUNCTIONAL
HEALTH PATTERN
NURSING HISTORY
Immunizations=Tetanus (2 doses)
BP=110/80mmHg
Medication(s) = FeSO4
Dilation = 1 cm
Effacemtn = 50%
Membrane Intact
3) ELIMINATION PATTERN
Client verbalized, “wala ra may problema sa akong
pag pangihi ug pag kalibang” FBC in place and patent; drained 325 cc A
BEFORE PREGNANCY of dark red urine during the shift
Bowel Elimination: Doctor’s Order:
Frequency – 1-3/day Bowel Elimination: -Remove FBC at 4pm today
Character – brown Frequency – 11/day -Refer if unable to void 4-6 hrs after
Consistency – formed Character – brown, sometimes yellowish removal
Discomfort - none Consistency – formed, sometimes formed Client verbalized, “hapdus kaayo akong
Urinary Elimination: Discomfort – most of the time none, feels feeling tungod sa cathetr; dili gyud ko
Frequency – at most 4/day uncomfortable because she experiences comfortable; mura siya’g manusok sa
Character – yellow constipation as claimed kasakit”
Discomfort – none Urinary Elimination:
Control Problem - none Frequency – 6-7/day
Character – yellowish in color
Discomfort – none
Control Problem - none
Client verbalized, “katong mga pila ka weeks na
ang niagi, mura kog ga constipation kay
maglisod kog kalibang pero nawala ra pod”
Client verbalized, “dili gyud ko comfortable
karon kay kaning akong catheter, may pagka
hapdus siya nya sakit pod”
4) ACTIVITY-EXERCISE PATTERN
Client verbalized, “tig exercise gyud ko even before Perceived Ability for: Perceived Ability for:
ko nagmabdus” Feeding – II Feeding – 0
Client verbalized, “tig walking ko every morning” Bathing – II Bathing – II
dili gyud ko tig exercise sukad sauna” Perceived Ability for: Toileting – II Toileting – II
Client doesn’t drink or smoke as claimed Feeding – 0 Bed Mobility – II Bed Mobility – 0
Perceived Ability for: Bathing – 0 Grooming – II Grooming – II
Feeding – 0 Toileting – 0 General Mobility – II General Mobility – 0
Bathing – 0 Bed Mobility – 0 Client verbalized, “kapoy…ganahan rako Client verbalized,”niarang-arang
Toileting – 0 Grooming – 0 matulog ug muhigda” naman akong paminaw, sakit pa
Bed Mobility – 0 General Mobility – 0 Client verbalized, “sakit ug hapdus kaayo gamay akong tiyan pero makaya ra”
Grooming – 0 Client verbalized, “kapoy akong paminaw, kutas ang feeling kaning naay catheter” Client verbalized, “compared
General Mobility – 0 kaayo, labi nag magdungan ug lihok ning Client verbalized, “okay ra man nuon gahapon, may nalang ning karon nga
Cooking – 0 kaluha…kaluoy sa ginoo, bug-at gyud sila” akong cesarian gabie, wala gani ko kabantay wala nakoy catheter”
Client verbalized, “usahay kung mag higda ko, nga nanganak na diay ko…after mga 2 hrs, Client varbalized, “maka lakaw-
Home Maintenance – 0
magtakilid ko kay bug-at gyud” nakagawas ra pod ko dayon sa delivery lakaw naman ko ginagmay padulong
room” sa CR pero may nalang kaysa
Client verbalized, “nahuwasan gyud ko gahapon, dili na kaayo sakit akong
nga nahumana na ang tanan” tahi sa pag opera”
5) SLEEP-REST PATTERN
Sleeps at 9-10 PM everyday and wakes up at 6- Client verbalized, “wala gyud koy klarong Client verbalized, “mas ganhan ko
7AM kaulog gabie, ga mata-mata ra gyud ko matulog ron, pero dili naman kaayo
Client doesn’t have any difficulty in sleeping or in sige…kung maja piyong man gani ko ron, kapoy pareha gahapon…mas okay
initaing sleep Sleeps at 11PM and wakes up at 7Am pagka tuod-tuod gamata na pod ko” okay nalang karon, bisag sakit pa
Client verbalized, “usahay maglisod kog katulog Client verbalized, “dili gyud ko kasabot sa gamay”
Client verbalized, “matulog ko ug mga 10 sa gabie kay bug-at man gud; samot nag magdungan ug feeling…nakuyawan ra gyud dagway ko”
dayon mumata ko ug mga 7 sa buntag” lihok ang duha …bug-at gyud nya maghigda ko Client verbalized, “ganahan ra ko
Client verbalized, “tig lantaw gyud kog TV ma gabie sa left side sige” muhigda kay kapoy dayon kutas, luya kaayo
before ko matulog” Client verbalized, “mas dugay-dugay ko akong lawas”
Experiences dreams and early awakenings makatulog ron kay bug-at gyud akong paminaw Client verbalized, “naluya gyud ko,
sometimes nya kapoy dayon kutasan ko dayon” ganahan sa ko mupahaway”
Client verbalized, “panalagsa ra man pod noun ko
damguhon”
No sleeping problems as claimed
Doesn’t have any difficulty initiating sleep as
claimed
Client verbalized, “dili ra man pod nuon ko
maglisod ug katulog, maka tulog ra man pod ko
dayon”
6) COGNITIVE-PERCEPTUAL PATTERN Concentration and alertness as observed Client verbalized, “mas ganhan ko
Client verbalized, “tig basa gyud kog libro; labi na
has decraesed compared to yesterday matulog ron, pero dili naman kaayo
nang mga pocket books, kalingawan namo na sa
because of her perceived pain sensations kapoy pareha gahapon…mas okay
college sauna”
Hears in a oderate vioce well and stress responses as claimed okay nalang karon, bisag sakit pa
Educational Attainment: College Undergraduate
Client verbalized, “karon, kutas gyud kaayo Closes eyes from time to time; ;lethargic gamay”
Client verbalized, “dili man pod nuon ko
akong paminaw, ganahan rako magpundo” Hears in a moderate voice well and is able Client verbalized,”niarang-arang
kalimtanon kaayo, usahay ra pero dili pod sige”
Client verbalized, “dili ko ganhan mag lihok- to respond appropriately in a slow-paced naman akong paminaw, sakit pa
Doesn’t have eyesight/hearing problems lihok” and moderately modulated voice gamay akong tiyan pero makaya ra”
Doesn’t wear eyeglasses/contact lenses/hearing Client’s over-all alertness is affected by her Client verbalized, ‘ganahan ra gyud ko Client verbalized, “compared
aids present condition (her perceived discomfort) muhigda kay kapoy, kutas, luya kaayo akong gahapon, may nalang ning karon nga
Finds that reading books/newspapers/magazines is lawas” wala nakoy catheter”
the best/fastest way for her to learn
Loves to watch the TV and keeps an update on new
movies as claimed
Client verbalized, “Ganahan ko mulantaw ug
movies, labi na nang mga new releases”
Has no difficulty in seeing (eyesight) and hearing
by far as claimed
7) SELF-PERCEPTION PATTERN
Client verbalized, “dili man nuon ko dali mangisog; Client verbalized, “dili gyud ko kasabot sa Client verbalized, “mas ganhan ko
taas kog pasensya” feeling…nakuyawan ra gyud dagway ko” matulog ron, pero dili naman kaayo
Client perceives herself or body image as just fine Client verbalized, “karon usahay saputon ko Client verbalized, “ganahan ra gyud ko kapoy pareha gahapon…mas okay
or just average as claimed dayon pero dili pod sige; naa ray times” muhigda kay kaoy, kutas, luya akong lawas” okay nalang karon, bisag sakit pa
Looks at herself or physical appearance (physique) Client verbalized, “naluya gyud ko, gamay”
as average and just right ganhan sa ko mupahaway” Client verbalized,”niarang-arang
Client verbalized, “ang daling maka palagot nako, naman akong paminaw, sakit pa
kanang dili dayon mutuo” gamay akong tiyan pero makaya ra”
Client verbalized, “compared
gahapon, may nalang ning karon nga
wala nakoy catheter”
Client’s bantay for today: mostly their Client verbalized, “may ra pod nga
8) ROLE-RELATIONSHIP PATTERN house healpe, her husband nianhi akong usa ka manghod ug
Family Structure : Nuclear Family
Client verbalized, “wala pa ko gi duaw sa akong mama kay para daghang
Client verbalized, “7 mi kabuok sa balay. Ako,
Primary Bantay: Husband/Boyfriend akong mama ug papa, ug sa kamagulangan mubantay sa twins”
akong mama, papa, duha ka manghod nga lake,
Client verbalized, “kabalo naman sila nga nakong anak kay klayo man gud pod ang Client’s mom, eldest daughter and
akong baye nga manghod ug akong
manganak ko karong gabie so basig muanhi sila Tayasan nya gaklase man pod si Samantha. younger brother came by to visit and
kinamagulangan nga anak”
ugma” Sa weekend na dagway mi magkita, puhon to look for her and her twins
Client verbalized, “nakuyawan ko, but at the if maka pauli nami” Client verbalized, “ni absent gani
Cristolo, 69 same time nalipay pod” Client verbalized, “ga plano gyud mi nga ni si Samantha kay excited na siya
FATHER muoli na pag ma discharge nami diri pero makakita sa iyang mga manghod”
Concordia
-known nausob na pod akong huna-huna…mag stay
, 54 sa lamang mi diri ug one month kay para dili
Hypertensive MOTHER na hassle nya mubalik na pod for check-up”
-has heart
problems
Theo- Si-
Died of dore mon
Samantha
Abortion
Nicole, 10
Client verbalized, “wala ra man mi gagamit ug basog successful ra ang akong cesarian unya” ipangalan nila…Theodire ug Simon
contraceptives pero para nako, igo na dagway ning kay fan gyud kog Chipmunks. Kung
3 ka anak” naay ika 3, Alvin unta iyang ngalan”
Client verbalized, ”kating pagkabalo nako nga
mabdus ko, mga 22 months na akong tiyan, wala
man ko gi regla maong ga pregnancy test ko”
10) COPING-STRESS-TOLERANCE
PATTERN Client verbalized, “kaya ra man pod nuon
Client verbalized, “dili ko daling mangisog; taas kog nakong agwantahon ang kasakit ug Client verbalized, “mas ganhan ko
pasensya” kahapdus, maluya lang ko dayon” matulog ron, pero dili naman kaayo
Client verbalized, “ang makapalagot ra gyud nako, kapoy pareha gahapon…mas okay
kanang dili mutuo” Client verbalized, “ang akong ganhan karon, okay nalang karon, bisag sakit pa
Client verbalized, “pag naa koy problems, ang first basog successful ra ang akong cesarian unya” gamay”
gyud nga akong buhaton…mag ampo” Client verbalized,”niarang-arang
naman akong paminaw, sakit pa
gamay akong tiyan pero makaya ra”
Client verbalized, “compared
gahapon, may nalang ning karon nga
wala nakoy catheter”