Functional Health

Pattern
1. Health
Perception
Health
management
pattern

Clue Cluster
-

Diagnostic
Statement
Ineffective Self
Health
Management r/t
sedentary
lifestyle as
manifested by
verbal reports

Priority

Rationale

Low 2

It is rated as low-2
because this is modifiable
if the main problems such
as pain, difficulty of
breathing is catered.

Able to manage
simple activities
needed for her
daily living like
bathing,
walking
and
grooming.
Wala man ko
perminte
ginahimo
kay
dili man ko
pwedi makapoy
ingun
sang
doktor,
as
verbalized
by
the patient.

Ineffective
Self Health
Management

Usahay dili ko
maka inom ug
tambal kay
damo man
kaayo usahay
wala man
kwarta, as
verbalized by
the patient.

Ineffective
therapeutic
regimen
management

Ineffective
therapeutic
regimen
management
r/t economic
difficulties

Low 4

Low-4 in
prioritization
because this requires long
term health education of
the patient and this is
difficult to modify because
this
requires
financial
support.

Weighs 64.2 Kg
With
generalized
edema.
With IVF of
PNSS 1 L KVO
Subong ni

Excess Fluid
Volume

Excess Fluid
Volume r/t
decreased renal
perfusion as
manifested by
generalized

High 3

It is rated as High-4
priority because theres an
increased isotonic fluid
retention inside the body
which may lead to further
complication.

2. Nutritional and
Metabolic
pattern

Inference

106

3. Elimination
pattern

4. Activity and
Exercise
Pattern

hupung ko
tungud sa
akoang lupus,
as verbalized
by the patient
permenti ko ga
ihi, daghan ug
medyo
sakit
pud
as
verbalized
by
the patient.
Voids 13-15
times/day with
moderate
amount
Stool loose in
consistency
Nalisdan ko
mag ihi kay
usahay sakit
,napansin pud
nako na damo
ug perminti
akong pag ihi
as verbalized
by the patient.

Able to perform
ADL and personal
hygiene
without
assistance
Easily gets tired
(+) nonproductive
cough

edema
Impaired skin
integrity

Impaired skin
integrity r/t
changes in fluid
status

Medium 1

It is rated as Medium-1
since the problem will be
resolve if the causes of
the impaired skin integrity
have been resolved.

Impaired
urinary
elimination

Impaired urinary
elimination r/t
anatomical
obstruction
(kidney) as
manifested by
pain in urination

Medium 2

It is rated as medium-2
because the patient is at
risk for having an increase
in normal frequency of
defecation.

Activity
intolerance

Activity
intolerance
r/t imbalance
between oxygen
supply and
demand

Low 1

Low- 1 priority because

this is brought about by
the pain, discomfort and
fatigue. If those problems
are catered, the patient
will be able to tolerate
activities in her daily living.
107

5. Sexuality and
reproductive
Pattern

(+) dyspnea and

crackles.
(+) use of
accessory muscle
in breathing
RR of 28
breaths/min.

Appears weak

wala ko kaayo
gina himo kay
tungud sa akoang
kondisyon dali pud
ko makapoybiskan
wala ko gina
himo ., as
verbalized by the
patient.

Does not have

STD
With 4 children
The husband and
the patient are
contented
and
happy to have 4

Ineffective
airway
clearance

Ineffective airway
clearance
r/t retained
secretions as
manifested by
unproductive
cough and
crackles

High-1

It is rated as High-1
priority because it hinders
the patients ability to
breath.
According
to
Moslows hierarchy of
need, physiologic need
should be the first to cater
before anything else. If not
given immediate attention,
it may cause discomfort to
the patient and could lead
to further complication.

Fatigue

Fatigue
r/t poor physical
condition

Medium 4

Strength

Strength

It is rated as medium-4
priority
because
this
problem is cause by the
impaired comfort and pain
brought about by the
increase
in
water
retention. This problem will
be resolve if the problems
in which causes pain is
resolve.
This is strength since the
client has no sexual
dysfunction.

108

wonderful children.
6. Cognitive
Perceptual
Pattern

7. Role
Relationship
Pattern

(+)
Flank
pain
during urination
permenti ko ga ihi,
daghan ug medyo
sakit
pud
as
verbalized by the
patient.

Impaired
comfort

Impaired comfort
r/t pain

Medium 3

This is rated as medium-3

because this problem will
be resolve if the problem
in
impaired
urinary
elimination is resolve.

Facial grimace
noted
Guarding
behaviour noted
(+) chest pain
With Pain Scale of
7 where 10 is the
highest
pain
perceived and 1 is
the lowest.
Bag-o ko naadmit,
medjo lisuran ko
mag ginhawa un
medyo sakit akong
dughan
as
verbalized by the
patient.

Acute Pain

Acute Pain r/t

decreased
myocardial blood
flow as
manifested by
chest pain and
facial grimace

High 2

It is rated as High-3
priority because it causes
an unpleasant sensation
to the body, thus, making
our patient uncomfortable.
When neglected, acute
pain may become chronic
and persistent. However,
the airway must be
prioritized first.

Dili ko maka
trabaho kayo kay
dili
ko
pwedi
makapoy
ingun
sang doctor. Dili
pud ko makaluto
ug kan-on sa aga

Impaired
parenting

Impaired
parenting r/t
physical illness

Low 3

Low- 3 in prioritization
because the patient will be
able to do her maternal
responsibilities
if
the
problems
in
pain,
breathing and discomfort
109

8. Self
Perception
and Self
concept
pattern

9. Coping and
Stress pattern

amo
nga
ang
akong
kamagulangan na
naga luto para sa
iya mga utod, as
verbalized by the
patient.
Lisuran pud ko
nga makita ang
akoang
subang
mag trabaho sang
akoang
responsibilidad, as
verbalized by the
patient.

is catered.

She was optimistic

before she was
diagnosed
with
SLE.
She has a positive
outlook in her
hospitalization
despite her present
condition.
Gusto japon nako
muayo para sa
akoang mga anak
biskin wala tambal
para sa akoang
sakit,
as
verbalized by the
patient.

Strength

Strength

Patient is able to perceive

a positive outlook about
herself despite her current
condition.

Receives
emotional,

Strength

Strength

Patient is able to cope

with problems with the

mental

110

10. Sleep and

Rest Pattern

11. Value Belief

Pattern

and
physical
support from her
family.
Copes up with fear
to
health
care
provider
when
rapport
is
established

help of her family.

She has difficulty in Readiness for

Readiness for
sleeping
and
enhance
enhance sleep r/t
experiences
a
sleep
willingness to
feeling of tiredness
enhance sleep
even
after
sleeping.

gusto na nako
makatulog
ug
tarong sa gabii, as
verbalized by the
patient.

Her religion is
Roman Catholic
Goes to church
thrice a month to
attend mass.

Strength

Strength

Low

Patient is able to gain

adequate
energy
to
recover from weakness.

Patient
is
on
well
established and strong
spiritual belief.

111

Problem
Ineffective airway clearance
Acute Pain
Excess Fluid Volume
Impaired skin integrity
Impaired urinary elimination
Impaired comfort
Fatigue
Activity intolerance
Ineffective Self Health
Management
Impaired parenting
Readiness for enhance
sleep

Date Identified
January 29,2013
January 29,2013
January 29,2013
January 29,2013
January 29,2013
January 29,2013
January 29,2013
January 29,2013
January 29,2013

Time
11:00am
11:00am
11:00am
11:00am
11:00am
11:00am
11:00am
11:00am
11:00am

Date Resolved
Not yet resolve
Not yet resolve
Not yet resolve
Not yet resolve
Not yet resolve
Not yet resolve
Not yet resolve
Not yet resolve
Not yet resolve

January 29,2013
January 29,2013

11:00am
11:00am

Not yet resolve

Not yet resolve

Nursing Diagnosis

Prioritization

Ineffective airway clearance

Impaired comfort

High 1
High 2
High 3
Medium 1
Medium 2
Medium 3

Fatigue

Medium 4

Activity intolerance

Low
Low
Low
Low

Acute Pain
Excess Fluid Volume
Impaired skin integrity
Impaired urinary elimination

Ineffective Self Health Management

Impaired parenting
Readiness for enhance sleep

1
2
3
4

112