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FHP Pedia
FHP Pedia
COLLEGE OF NURSING
Dumaguete City
2. Nutritional-metabolic pattern
Consumes food given by the hospital: Consumes food given by the hospital:
Mother verbalized that she breastfed her child - rice, fruit/vegetable, meat - rice, fruit/vegetable, meat
during birth until 12 months, then bottle fed the Child’s appetite is good and doesn’t have any Child’s appetite is good
child with bearbrand. Estimates intake of child 2 feeding discomfort. Has abdominal pain after eating
bottles per day. Child’s usual 24-hour intake of nutrients during Child’s usual 24-hour intake of nutrients
Child’s appetite was good and did not have any hospital stay: carbohydrates from rice, protein during hospital stay: carbohydrates from
feeding discomfort. Child’s usual 24-hour intake from meat, vitamins and minerals from fruits and rice, protein from meat, vitamins and
of nutrients include carbohydrates from rice, vegetables minerals from fruits and vegetables
protein from meat, vitamins and minerals from Supplements include medications for current Supplements include medications for current
fruits and vegetables condition condition
Supplements include, Ascorbic Acid Ceelin Plus
and Cherifer
Eating behavior:
B. Observation: C. Observation:
- “ Anad na ni siya mokaon og bisan unsa, dili siya
pilian.Pero naa panahon nga iyang isuka iyang
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
Child wasn’t able to defecate whole morning
Child do not defecate more often ever since No elimination/ no observation of stool
Bowel symptoms occurs
Child usually defecates 2x a day but there are days Color is dark brown and stool is hard and ball- Urine
when she feels like eating a lot and becomes full, formed, no discomfort during elimination Urinated 3x – estimated less than usual
she defecates more than the usual Able to ambulate when going to the bathroom amount of urine eliminated.
Color is brown and formed, no discomfort during during elimination Urine has no strong and smelling odor
elimination Has no difficulties in urinating
During infancy, diaper is changed twice a day Urine
Usual daily output is 3-4x a day – estimated less Skin
Urine Less sweating/ dryness
Usual daily output is 5-8x a day – estimated 500- than usual amount of urine eliminated.
Urine has no strong and smelling odor No unusual odor during perspiration
1000 ml/day.
Urine is amber and no unusual odor. Has no difficulties in urinating
No difficulties in urinating Skin
Sometimes awaken at night due to urinating Less sweating/ dryness
Skin No unusual odor during perspiration
no excessive 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 Feels rested when waking up in the morning Feels rested after waking up
Sleeps whatever time he likes Slept for approximately 9 hours and takes a nap Slept for approximately 9 hours and takes a
Does not snore and doesn’t have any nightmares for about 2 hours nap for about 2 hours
Feels rested upon waking up Does not have any nightmares. Did not have any nightmares.
Usually rests when tired Sleep interruptions : Vital signs taking and intake Sleep interruptions : Vital signs taking and
B. Parent (self) : of medicine intake of medicine
Took nap after after eating
Usual sleep pattern: 10 hours, from 9 PM to 7 AM Usual sleep pattern: 10 hours, from 9 PM to 7 AM Usually interrupted when child demands for
Usually interrupted when child demands for something during nigh time
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: observation, child still loves exploring new things, curious of his surroundings.
Child responds with sense and really enjoys his and is very curious of his surroundings. The child The child is not afraid even staying at the
surrounding. He explores the things around him, is not afraid even staying at the hospital. hospital.
and is very active to learn new things Child is able to follow instructions without crying Child is able to follow instructions
Mother teaches him child with basic words, and and be intimidated. Able to respond correctly to people and with
the alphabet Able to respond correctly to people and with things.
Likes watching cartoon movies things.
7. Self-perception-self-concept pattern
COLLEGE OF NURSING
Silliman University
Dumaguete City
NURSING CARE PLAN
CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: Independent:
“The client’s father stated Constipation related After 8 hours of duty, the Determine stool color, Assists in identifying After 8 hours of duty, the
“Wala pa gyud ni siya to poor eating client will establish or consistency, frequency and causative or client established and was
nakalibang since na admit siya. return to normal patterns amount. contributing factors and able to return to normal
habits of bowel functioning as patterns of bowel
Makabati man pud ni siya og appropriate
kasakit sa tiyan kada human og evidenced by: interventions functioning as evidenced
Constipation related by:
kaon” Auscultate bowel sounds Bowels sounds are
Able to eliminate
to decreased dietary generally decreased in
soft ,formed stool Able to eliminate soft
OBJECTIVE: intake constipation.
perceived as normal ,formed stool perceived
by the patient in the as normal by the patient
weak in appearance Constipation related Encourage increased fluid Sufficient fluid intake is
next 24 hours in the next 24 hours
The client has a pale intake of 2500 – 3000 ml/day necessary for the bowel
conjunctiva , lips and palms to dehydration to absorb sufficient
States relief from Stated relief from
discomfort of amounts of liquid to discomfort of
constipation. promote proper stool constipation.
Vital Signs (3/9/20): consistency.
o T: 37oC Patient/ significant Patient/ significant
P: 107 bpm other identifies Recommend Avoiding gas- Decrease gastric distress other identified
R: 20 cpm measures that forming foods such as nuts, and abdominal measures that prevent
BP: 90/60 mmHg prevent or treat peas and spicy foods. distension. or treat constipation.
constipation. Fiber resists enzymatic Patient/ significant
COLLABORATIVE: digestion and absorbs
Patient/ significant other verbalized
other verbalizes liquids in its passage measures that will
measures that will Consult with dietitian to along the intestinal tract prevent recurrence of
prevent recurrence provide well-balanced diet high and thereby produces constipation.
of constipation. in fiber and bulk. bulk, which acts as a
Discuss use of stool softeners, stimulant to defecation.
mild stimulants, bulk forming Facilitates defecation
laxatives or enemas as when constipation is
indicated. Monitor present.
effectiveness.
PHYSICAL ASSESSMENT
3 Priority Systems
I. INTEGUMENTARY
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.
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
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