Nursing Related Learning Experience Manual
Name of Student Ryan Dave M. Saplad
Clinical Instructor Mrs. Reca Rose E. Tuban
Date of Exposure 7 / 8 / 2020
Functional Health Pattern Cue Cluster
1. Health Perception & Subjective: * he likes to listen
Management to loud “the louder the better “
rock music, using tight
earphones
* does wood working with loud
saws in his home
* He does not wear protective
ear plugs during these activities
* frequently attended music
concerts that were often loud,
and he still goes occasionally
Objective: * 28-year-old man
* Whisper test: Client unable to
repeat two-syllable whispered
word
Subjective: * Does wood
working with loud saws in his
home and he does not wear
protective ear plugs during these
activities
* He states he had one ear
infection several years ago and
had several ear infections as a
young child
* His last hearing examination
was as a child in grade school
* frequently attended music
concerts that were often loud,
and he still goes occasionally
Objective: *scarring noted on
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 Protection Ineffective Protection r/t High 2 High 2 because this
altered hearing as problem is one of the
manifested by does wood factors affecting the clients
working with loud saws in his hearing’s ability and if the
home and he does not wear
client does not aware of
protective ear plugs during these
activities and he likes to listen to
this, probably this will lead
loud “the louder the better “ to hearing loss
rock music, using tight
earphones
High 3
Ineffective health
maintenance r/t altered High 3 because not
hearing as manifested by maintaining oneself may
Ineffective health lead to total hearing loss
Does wood working with loud
maintenance
saws in his home and he does
not wear protective ear plugs
during these activities
* He states he had one ear
infection several years ago and
had several ear infections as a
young child
* His last hearing examination
was as a child in grade school
*scarring noted on left tympanic
membrane
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left tympanic membrane
*. Small amount of moist,
yellow cerumen in external
canals
2. Nutrition / Metabolism No significant cues
3. Elimination Pattern No significant cues
4. Activity / Exercise Subjective: *works in an
industrial plant as a supervisor
* he misunderstands his workers
when they are giving him
information about the projects
they are working on
Objective: * scarring noted on
left tympanic membrane
* unable to repeat two-syllable
whispered word
5. Sleep / Rest No significant cues
6. Cognitive / Perceptual Subjective: * He has noticed
lately that he is having trouble
hearing conversations with his
friends
* he misunderstands his workers
when they are giving him
information about the projects
they are working on
* he likes to listen to loud “the
louder the better “ rock music,
using tight earphones
* does wood working with loud
saws in his home
* He does not wear protective
College of Health Sciences Department of Nursing
Nursing Related Learning Experience Manual
*. Small amount of moist,
yellow cerumen in external
canals
NA NA NA NA
NA NA NA NA
Risk for activity Risk for activity Low 2 Low 2 since this is only a
intolerance intolerance r/t altered risk and need to intervene
hearing immediately
NA NA NA NA
Disturbed sensory Disturbed sensory High 1 High 1 because this is the
perception: auditory perception: auditory r/t main problem of the client
altered hearing as and reason why he seek
manifested by He has noticed medical professional. This
lately that he is having trouble inference affects the
hearing conversations with his client’s work and social
friends
* he misunderstands his workers
status.
when they are giving him
information about the projects
they are working on *Whisper
test: Client unable to repeat two-
syllable whispered word
* scarring noted on left
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 Nursing Related Learning Experience Manual

ear plugs during these activities tympanic membrane

* frequently attended music *Cone-shaped light reflex in 5-
concerts that were often loud, o’clock position in right ear and
and he still goes occasionally 7-o’clock position in left ear

Objective:
* Whisper test: Client unable to
repeat two-syllable whispered
word
* scarring noted on left
tympanic membrane
*Cone-shaped light reflex in 5-
o’clock position in right ear and
7-o’clock position in left ear
* Weber Test: sound lateralizes
to right ear. Rinne Test: air
conduction (AC)> bone
conduction (BC) both ears

7. Self – Perception / Self No significant cues NA NA NA NA

- Concept

8. Role / Relationship Subjective: He has noticed Risk for impaired verbal Risk for impaired verbal Low 1 Low 1 because this
lately that he is having trouble communication communication r/t problem is not yet
hearing conversations with his alteration of hearing occurring but there are risk
friends
* works in an industrial plant as
factors that will trigger to
a supervisor this problem.
* he misunderstands his workers
when they are giving him
information about the projects
they are working on

Objective: *Whisper test:

Client unable to repeat two-
syllable whispered word
* scarring noted on left
tympanic membrane

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

 Nursing Related Learning Experience Manual

9. Sexuality / Reproductive No significant cues NA NA NA NA

10. Coping – Stress No significant cues NA NA NA NA

Tolerance

11. Value Belief No significant cues NA NA NA NA

PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Disturbed sensory perception: auditory r/t 7 / 8 / 2020 5:20PM 7 / 8 / 2020
altered hearing as manifested by He has
noticed lately that he is having trouble hearing
conversations with his friends
* he misunderstands his workers when they are
giving him information about the projects they are
working on *Whisper test: Client unable to repeat
two-syllable whispered word
* scarring noted on left tympanic membrane
*Cone-shaped light reflex in 5-o’clock position in
right ear and 7-o’clock position in left ear

Ineffective Protection r/t altered hearing 7 / 8 / 2020 5:20PM 7 / 8 / 2020

as manifested by does wood working with loud
saws in his home and he does not wear protective
ear plugs during these activities and he likes to
listen to loud “the louder the better “ rock music,
using tight earphones

Ineffective health maintenance r/t altered 7 / 8 / 2020 5:20PM 7 / 8 / 2020

hearing as manifested by Does wood

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

 Nursing Related Learning Experience Manual

working with loud saws in his home and he does

not wear protective ear plugs during these
activities
* He states he had one ear infection several years
ago and had several ear infections as a young
child
* His last hearing examination was as a child in
grade school
*scarring noted on left tympanic membrane
*. Small amount of moist, yellow cerumen in
external canals

Risk for impaired verbal communication 7 / 8 / 2020 5:20PM 7 / 8 / 2020

r/t alteration of hearing

Risk for activity intolerance r/t altered 7 / 8 / 2020 5:20PM 7 / 8 / 2020

hearing

PRIORITIZATION OF PROBLEMS

Nursing Diagnosis Prioritization Rationale

Disturbed sensory perception: auditory r/t altered High 1 High 1 because this is the main problem of the client and reason
hearing as manifested by He has noticed lately that he is why he seek medical professional. This inference affects the client’s
having trouble hearing conversations with his friends work and social status.
* he misunderstands his workers when they are giving him
information about the projects they are working on *Whisper test:
Client unable to repeat two-syllable whispered word
* scarring noted on left tympanic membrane
*Cone-shaped light reflex in 5-o’clock position in right ear and 7-
o’clock position in left ear

Ineffective Protection r/t altered hearing as manifested High 2 High 2 because this problem is one of the factors affecting the
by does wood working with loud saws in his home and he does not clients hearing’s ability and if the client does not aware of this,
wear protective ear plugs during these activities and he likes to probably this will lead to hearing loss
listen to loud “the louder the better “ rock music, using tight

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

 Nursing Related Learning Experience Manual

earphones

Ineffective health maintenance r/t altered hearing as High 3 High 3 because not maintaining oneself may lead to total hearing
manifested by Does wood working with loud saws in his home loss
and he does not wear protective ear plugs during these activities
* He states he had one ear infection several years ago and had
several ear infections as a young child
* His last hearing examination was as a child in grade school
*scarring noted on left tympanic membrane
*. Small amount of moist, yellow cerumen in external canals

Low 1 Low 1 because this problem is not yet occurring but there are risk
Risk for impaired verbal communication r/t alteration of factors that will trigger to this problem.
hearing

Low 2 Low 2 since this is only a risk and need to intervene immediately
Risk for activity intolerance r/t altered hearing

NURSING CARE PLAN

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


Name of Patient Jack Jones
Address General Santos City
ASSESSMENT HEALTH
PATTERN
Subjective Cues:
* He has noticed lately
that he is having trouble
hearing conversations
with his friends
* he misunderstands his
workers when they are
giving him information
about the projects they
are working on
* he likes to listen to
loud “the louder the
better “ rock music,
using tight earphones
* does wood working
with loud saws in his
home
* He does not wear
protective ear plugs
during these activities
* frequently attended
music concerts that
were often loud, and he
still goes occasionally
Objective Cues
* Whisper test: Client
unable to repeat two-
syllable whispered
word
College of Health Sciences Department of Nursing
Nursing Related Learning Experience Manual
Rm/Bed No. 2C 204 Age 28 Chief Complaints Alteration of hearing
Admission Date 7 / 8 / 2020 Sex M Diagnosis Disturbed sensory perception: auditory r/t
altered hearing
NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
C Note: Use P-E-S format General Objective Independent Goal was met the
O client’s hearing
G Disturbed sensory Within a week patient *Stand or sit directly in front of client when ability returning to
N perception: auditory r/t achieves optimal communicating. Make sure adequate light is on normal and can
I altered hearing as functioning within limits of nurse's face, avoid chewing gum or covering effectively
T hearing impairment as mouth or face with hands while speaking, establish communicate to the
I
manifested by He has noticed evidence by ability to eye contact, and use nonverbal gestures. friends/workers
lately that he is having trouble
V communicate effectively with no difficulty
E hearing conversations with his and to engage in Rationale: These measures make it easier to read of hearing
friends
meaningful activities lips and see nonverbal communication, which is a
P * he misunderstands his workers large component of all communication
when they are giving him
E
R information about the projects Specific Objective * Keep background noise to a minimum. Turn off
they are working on *Whisper
C television and radio when communicating with
test: Client unable to repeat two-
E * Demonstrates client.
syllable whispered word
P understanding by a verbal,
T * scarring noted on left tympanic written, or signed response Rationale: Background noise significantly
U membrane interferes with hearing in the hearing-impaired
A *Cone-shaped light reflex in 5- *explains plan to modify client
L o’clock position in right ear and lifestyle to accommodate
7-o’clock position in left ear hearing impairment * Encourage client to wear hearing aid, but
P understand if he or she chooses to leave hearing
A *Clients hearing ability will aid out.
T Background Knowledge become stable
T Rationale: Hearing aids amplify all noise, and
E Hearing impairment is loud noises in the environment can be amplified to
R common among older adults an unbearable volume
N but may also occur as the
result of congenital exposure
to virus; during childhood * Speak distinctly in lower voice tones if possible.
after frequent ear infection or Do not over-enunciate or shout at client.
trauma; and during adulthood
as the result of trauma, Rationale: In many kinds of hearing loss, clients
infection, or exposure to lose the ability to hear higher-pitched tones but can
occupational and/or still hear lower-pitched tones. Over-enunciating
environmental noise. When makes it difficult to read lips. Shouting makes the
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 Nursing Related Learning Experience Manual

* scarring noted on left hearing loss is profound and words less clear and may be painful 
tympanic membrane precedes language
*Cone-shaped light development, the ability to * Instruct the patient in using safe
reflex in 5-o’clock learn speech and interact with techniques for cleaning ears.
position in right ear and hearing peers can be
7-o’clock position in severely impaired. When
left ear hearing is impaired or lost Rationale: Hearing impairment may from
* Weber Test: sound later in life, serious emotional buildup of earwax causing alteration in
lateralizes to right ear. and social consequences can hearing.
Rinne Test: air occur, including depression
conduction (AC)> bone and isolation. Some causes of Dependent
conduction (BC) both hearing loss are surgically * Refer to appropriate resources such as a speech
ears correctable. Many hearing and hearing clinic; audiologist; or ear, nose, and
assistive devices and throat physician. Refer children early for help.
services are available to help
the hearing impaired Rationale: Hearing loss can be treated with
individual. Nursing medical or surgical interventions or use of a
interventions with hearing hearing aid. Research demonstrates the positive
impaired are aimed at effects of early diagnosis and intervention on the
assisting the individual in social and cognitive development of hearing
effective communication impaired children
despite the loss of normal *Ear surgery.
hearing. a.Tympanoplasty (removal of dead tissue,
restoration of bones with prostheses)
Ref. b.mastoidectomy (removal of all or portions of the
nursingcareplan.blogspot.com middle ear structures)

Rationale: These surgeries are common surgical

treatments for hearing loss.

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN

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 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