Nursing Related Learning Experience Manual
Name of Student Ryan Dave M. Saplad
Clinical Instructor Mrs. Reca Rose E. Tuban, RN
Date of Exposure 7 / 6 / 2020
Functional Health Pattern Cue Cluster
1. Health Perception & Subjective: Supposed to take
Management Synthroid daily for "my low
thyroid" but cannot afford to get
the prescription filled.
*she has been nibbling on
crackers, lunch meat, and sodas
daily.
*Exercise is out of the question
because she lacks energy, and
she is rarely able to get through
a day without one or two 30-
minute naps.
Objective: Lethargic and
walks slowly and dry flaking
skin
*Her scalp hair and nail are dry
and breaks easily
*Her cuticles are dry and torn.
Her toenails are thick and
yellow
2. Nutrition / Metabolism Subjective: expresses concern
about "fly-away hair that I can't
do anything with" and about
brittle, easily broken fingernails
Objective: multiple bruises on
forearms and anterior lower
legs, Dry skin (yellow tinged),
brittle hair, fingernails are dry;
her cuticles are dry and torn.
Her toenails are thick and
yellow
College of Health Sciences Department of Nursing
Yr & Sec BSN – 1B
Area
Hospital NDDU
GORDON’S FUNCTIONAL HEALTH PATTERN
Inference Diagnostic Statement Priority Rationale
Ineffective health Ineffective health High 2 High 2 because not taking
maintenance maintenance r/t Economic the prescription giving by
difficulties as manifested by the health practitioner may
Supposed to take Synthroid results to serious problem.
daily for "my low thyroid" but
cannot afford to get the
prescription filled, she has been
nibbling on crackers, lunch
meat, and sodas daily and
Exercise is out of the question
because she lacks energy, and
she is rarely able to get through
a day without one or two 30-
minute naps, Lethargic and
walks slowly and dry flaking
skin
and Her scalp hair and nail are
dry and breaks easily
Impaired skin integrity Impaired skin integrity r/t High 1 High 1 because this
facial edema and problem is the main
Imbalanced nutritional state concerned with the client
as manifested by Dry skin, and causes her to seek
brittle hair, nail easily health practitioner.
breaks and multiple bruises on
both forearms and anterior lower
legs and her cuticles are dry and
torn. Her toenails are thick and
yellow
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Subjective: she has been
nibbling on crackers, lunch
meat, and sodas daily.
Objective:
3. Elimination Pattern NA
4. Activity / Exercise Subjective: Exercise is out of
the question because she lacks
energy
* She is rarely able to get
through a day without one or
two 30-minute naps
* she has been nibbling on
crackers, lunch meat, and sodas
daily
Objective:
5. Sleep / Rest NA She is rarely able to get
through a day without one or
two 30-minute naps
6. Cognitive / Perceptual NA
7. Self – Perception / Self Subjective: She states that she
- Concept has cut down on her cosmetic
sales appointments because "I
look like I never use my own
products”
College of Health Sciences Department of Nursing
Imbalanced nutrition: less
than body requirements
NA
Sedentary lifestyle
Activity intolerance r/t
decreased metabolic state//
pathophysioloigy of
disease process
NA
NA
Disturbed body image
Imbalanced nutrition: less
than body requirements r/t
poor appetite as manifested
by she has been nibbling
on crackers, lunch meat,
and sodas daily
NA
Sedentary lifestyle r/t lack
of energy as manifested by
Exercise is out of the question
because she lacks energy and
she is rarely able to get through
a day without one or two 30-
minute naps
NA
NA
Disturbed body image r/t
skin conditions (edema &
dry skin) as manifested by
She states that she has cut down
on her cosmetic sales
Nursing Related Learning Experience Manual
High 3
High 3 because inadequate
intake of nutritious foods
can affect several body
system of the client.
NA NA
High 4 High 4 because sedentary
lifestyle can cause many
different diseases such as
anxiety, cardiovascular
disease, diabetes, etc.
NA NA
NA NA
Medium 1 Medium 1 because this is
not a life threatening
problem but it affects the
social status of the client.
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 Nursing Related Learning Experience Manual

*Alteration in social appointments because "I look

function like I never use my own
products”
Objective:
8. Role / Relationship Subjective: She has cut Social isolation Social isolation r/t skin Medium 2 Medium 2 because this is
down on her cosmetic sales condition that alters skin not a life threatening
appointments because "I look appearance as manifested problem but it affects the
like I never use my own
products."
by She has cut down on her social status of the client.
cosmetic sales appointments
because "I look like I never use
Objective: my own products."
9. Sexuality / Reproductive NA NA NA NA NA

10. Coping – Stress NA NA NA NA NA

Tolerance

11. Value Belief NA NA NA NA NA

PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Impaired skin integrity r/t facial edema 7 / 6 / 2020 10:48 PM 7 / 6 / 2020
and Imbalanced nutritional state as
manifested by Dry skin, brittle hair, nail
easily breaks and multiple bruises on both
forearms and anterior lower legs and her cuticles
are dry and torn. Her toenails are thick and yellow

Ineffective health maintenance r/t 7 / 6 / 2020 10:48 PM 7 / 6 / 2020

Economic difficulties as manifested by

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Supposed to take Synthroid daily for "my low

thyroid" but cannot afford to get the prescription
filled, she has been nibbling on crackers, lunch
meat, and sodas daily and Exercise is out of the
question because she lacks energy, and she is
rarely able to get through a day without one or
two 30-minute naps, Lethargic and walks slowly
and dry flaking skin
and Her scalp hair and nail are dry and breaks
easily

Imbalanced nutrition: less 7 / 6 / 2020 10:48 PM 7 / 6 / 2020

than body requirements r/t poor appetite
as manifested by she has been nibbling on
crackers, lunch meat, and sodas daily
7 / 6 / 2020 10:48 PM 7 / 6 / 2020
Sedentary lifestyle r/t lack of energy as
manifested by Exercise is out of the question
because she lacks energy and she is rarely able to
get through a day without one or two 30-minute
naps
Disturbed body image r/t skin conditions 7 / 6 / 2020 10:48 PM 7 / 6 / 2020
(edema & dry skin) as manifested by She
states that she has cut down on her cosmetic sales
appointments because "I look like I never use my
own products”

Social isolation r/t skin condition that 7 / 6 / 2020 10:48 PM 7 / 6 / 2020

alters skin appearance as manifested by
She has cut down on her cosmetic sales
appointments because "I look like I never use my
own products."

PRIORITIZATION OF PROBLEMS

Nursing Diagnosis Prioritization Rationale

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Impaired skin integrity r/t facial edema and Imbalanced High 1 High 1 because this problem is the main concerned with the client
nutritional state as manifested by Dry skin, brittle hair, nail and causes her to seek health practitioner.
easily breaks and multiple bruises on both forearms and anterior
lower legs and her cuticles are dry and torn. Her toenails are thick
and yellow.
Ineffective health maintenance r/t Economic difficulties as High 2 High 2 because not taking the prescription giving by the health
manifested by Supposed to take Synthroid daily for "my low practitioner may results to serious problem.
thyroid" but cannot afford to get the prescription filled, she has been
nibbling on crackers, lunch meat, and sodas daily and Exercise is
out of the question because she lacks energy, and she is rarely able
to get through a day without one or two 30-minute naps, Lethargic
and walks slowly and dry flaking skin and Her scalp hair and nail
are dry and breaks easily.

Imbalanced nutrition: less High 3 High 3 because inadequate intake of nutritious foods can affect
than body requirements r/t poor appetite as manifested several body system of the client.
by she has been nibbling on crackers, lunch meat, and
sodas daily

Sedentary lifestyle r/t lack of energy as manifested by High 4 High 4 because sedentary lifestyle can cause many different
Exercise is out of the question because she lacks energy and she is diseases such as anxiety, cardiovascular disease, diabetes, etc.
rarely able to get through a day without one or two 30-minute naps

Disturbed body image r/t skin conditions (edema & dry Medium 1 Medium 1 because this is not a life threatening problem but it
skin) as manifested by She states that she has cut down on her affects the social status of the client.
cosmetic sales appointments because "I look like I never use my
own products”

Social isolation r/t skin condition that alters skin Medium 2 Medium 2 because this is not a life threatening problem but it
appearance as manifested by She has cut down on her affects the social status of the client.
cosmetic sales appointments because "I look like I never use my
own products."

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

NURSING CARE PLAN

Name of Patient Evelyn Vaughn Rm/Bed No. 1C 140 Age 47 Chief Complaints Impaired skin condition
Address General Santos City Admission Date 7 / 6 / 2020 Sex F Diagnosis Impaired skin integrity r/t facial edema and
Imbalanced nutritional state

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN
Subjective Cues:
Expresses concern
about "fly-away
hair that I can't do
anything with" and
about brittle, easily
broken fingernails.
Objective Cues
College of Health Sciences Department of Nursing
N Note: Use P-E-S format General Objectives Independent Goal was met;
U Impaired skin integrity r/t client’s skin
T facial edema and After a 4days Regains * Monitor site of skin impairment at least remains intact
R Imbalanced nutritional state integrity of skin surface once a day for color changes, redness, without the
I presence of
T
as manifested by Dry skin, and remains intact, as swelling, warmth, pain, or other signs of dryness, bruises
I brittle hair, nail easily evidenced by the infection. Determine whether client is and edema.
O breaks and multiple bruises absence of dry flanking experiencing changes in sensation or pain.
N on both forearms and skin, bruises and
A anterior lower legs and her edema. Rationale: Systematic inspection can
L identify impending early problems.
cuticles are dry and torn.
M Her toenails are thick and
E yellow. * Encourage/Take adequate nutrition and
T hydration (2000 to 3000 kcal/day and Fluid
A Specific Objectives intake of 2000 mL/day unless medically
B restricted)
O * Encourage nutritious
L meal and hydration Rationale: Sufficient hydration and
I Background Knowledge
C nutrition help maintain skin turgor,
Defined as alteration in the * Describes measures to moisture, and suppleness, which provide
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Multiple bruises on
forearms and
anterior lower legs,
Dry skin (yellow
tinged), brittle hair,
fingernails are dry;
her cuticles are dry
and torn. Her
toenails are thick
and yellow.
College of Health Sciences Department of Nursing
P epidermis and/or dermis.
A The skin is subject to injury
T lesion
T
from a variety of external
E and internal factors.
R Extremes of heat and cold;
N pressure, shearing, and other
mechanical forces;
allergens; chemicals;
radiation; and excretions
and secretions such as those
from an ostomy or a
draining wound are all
potentially damaging
conditions and substances
that exist in the external
environment. Internal
factors include emaciation,
drugs, altered circulation
and impaired oxygen
transport, altered metabolic
state, and infections. The
skin is the largest organ in
the human body and is a
protective barrier. It protects
the body from heat, light,
injury, and infection. Skin
integrity relates to skin
health. A skin integrity
problem might indicate the
skin is damaged, exposed to
injury or inefficient to repair
and recover normally. The
key marker of quality care is
the maintenance of skin
integrity and prevention of
pressure ulcers. With this,
Nursing Related Learning Experience Manual
protect and heal the skin resilience to damage caused by pressure.
and to care for any skin Patients with limited cardiovascular
reserve may not be able to tolerate much
* Demonstrates fluid.
understanding of plan to
heal skin and prevent re * Clean, dry, and moisturize skin, twice
injury. daily or as indicated by incontinence or
sweating. Avoid hot water. If powder is
desirable, use medical grade cornstarch;
avoid talc.
Rationale: Smooth, supple skin is more
resistant to injury. These measures prevent
evaporation away from skin. Avoid talc
which may cause lung injury.
*Apply warm compress (facial edema)
Rationale: to promote the movement of
fluid buildup
* Encourage the implementation of a
turning schedule, restricting time in one
position to 2 hours or less, if the patient is
restricted to bed.
Rationale: Turning every 2 hours is the
key to prevent breakdown. Head of bed
should be kept at 30 degrees or less to
avoid sliding down on bed.
Dependent
*Communicate with a dietician as
appropriate.
Rationale: The dietician can aid the patient
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 Nursing Related Learning Experience Manual

the nurse must be aware of and family in food preferences to meet

identifying at-risk adequate nutritional and hydration goals.
individuals and the myriad
factors that place patients at *Administered medications as ordered:
risk for skin damage.
Ref. //nurselabs.com a.anticonvulsants
b. nonsteroidal anti-inflammatory drugs
c. ferrous sulfate
d. thyroid hormones, and vitamins

Rationale: These medications can help

diminish and/or eliminate adverse
integumentary outcomes.

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Name of Student Yr & Sec

Clinical Instructor Area
Date of Exposure Hospital

DIAGNOSTIC EXAMINATIONS
Name of Patient Rm/Bed No. Age Chief Complaints
Address Admission Date Sex Diagnosis
Diagnostic
Date Ordered Normal Values Result Significance
Examination

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY