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Republic of the Philippines
EASTERN SAMAR STATE UNIVERSITY
COLLEGE OF NURSING
Community Organizing
Participatory Action Research (CHN)
Related Learning Experience (RLE)
Family Nursing Care Process
(FNCP)
With Individualized Nursing Care Process
(NCP)
Submitted by:
Dechimo, Kimberly Mae P.
Submitted to:
Mr. Ray Dominic Ladera
Instructor
Date
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FORM B: Family Nursing Care Process (FNCP) Format
Major Components of FNCP:
I.
II.
III.
Family Demographic Profile
Individualized Nursing Care Process (NCP)
Family Nursing Care Plan
a. Health Teaching Plan
b. Monitoring and Evaluation Plan
Specific Components
I.
Family Demographic Profile
a. Head of the family: Bejar, Clarissa
b. Address: Purok 1-A, Brgy. Siha Borongan E. Samar
c. Type of family:
- Nuclear
d. Profile
- Ms. Clarissa Bejar is a 38 years old Filipino Citizen, currently living in Purok 1-A Barangay
Siha Borongan Eastern Samar. She is a single parent, blessed with three daughters and
two sons. They sometimes eat 2 times a day because of financial problems. They don’t
have their own toilet.
No.
Name
Family
Role
Age
1.
Bejar,
Clarisaa
Mother
38
2.
Bejar,
Roselina
Daughter
16
3.
Bejar, John
Cristian
Son
12
4.
Bejar, Angel
Daughter
7
5.
Bejar, Riane
Shell
Daughter
3
Date of
Birth
Civil
Status
Nursing
Diagnosis
(*from
individual
NCP)
April-04Separated *Imbalanced
1977
nutrition: less
than
body
requirements.
August-09Single
*Imbalanced
1999
nutrition: less
than
body
requirements.
DecemberSingle
*Imbalance
30-2003
nutrition: less
than
body
requirements
*Imbalance
SeptemberSingle
24-2008
nutrition: less
that
body
requirements
September24-2012
Single
UNABLE
ASSESS
TO
e. Floor plan (sketch of family living space)
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Figure A. Sketch of living space of family _______
II.
Individualized Nursing Care Process (NCP) – (note: every member of the family
should have an individualized NCP)
A. Assessment:
1. Demographic profile
Name: Bejar, Roselina
Age: 16
Sex: Female
Nationality: Filipino
Religion: Roman Catholic
Occupation: Student
Civil status: Single
Educational attainment: High school student
2. Nursing History
1. History of Present Illness
- According to Ms Bejar, she doesn’t have any serious disease at this moment in
time. She also stated that she doesn’t have any allergies.
2. past Health History
- According to Ms. Bejar, she doesn’t have any history of serious diseases, she
doesn’t have any allergies in foods or substances
3. Family Health History
-
According to Mrs Duzon, her father doesn’t have any history of serious disease or
allergies but her mother suffered from asthma.
-
Ms. Bejar states that she has no allergies.
4. Allergies
3. Gordon’s Typology of 11 Functional Health Patterns (*use the assessment tools provided to you
during NCP lecture)
1. Health-perception/health-management pattern
- Ms. Bejar describes her usual health as good and she is satisfied with her health,
she is not using tobacco or alcoholic drinks. She also states that she doesn’t have
any history of chronic disease; she never sought for healthcare assistance for the
past years. She is currently studying; she is now a grade 8 student. She is not
suffering any difficulty in doing the household chores and etc., she doesn’t have
any history of falls, and she’s not experiencing any ringing of the ear.
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2. Nutritional/Metabolic pattern.
- Ms. Bejar loss weight because she barely eat’s. Sometimes she east’s root crop
(Kamote,) and bread when they don’t really have rice. She drinks 9-10 glass of
water per day; she describes her lifestyle as active. She doesn’t have any chronic
health problems. She also states that he wants to gain weight.
Food Items
Kamote
Approximate Edible Calories Total
Measurement Portion
Calories
(weight
in
Grams)
3 pcs.
3 pcs.
852
852
Bread
3pcs.
Rice
2 cups per 2 cups 460
day
per
day
3pcs.
217.7
217.7
460
3. Elimination pattern.
- According to Ms. Bejar Her bowel movement is normal, she didn’t or never uses
any bowel movement aids. She doesn’t have any history of diarrheal, constipation,
incontinence and recent travel, her usual voiding pattern is thrice a day.
4. Activity/exercise pattern.
- According to Ms Bejar, she is completely independent in doing the following; going
to bed, to the bathroom, taking a bath, dressing, home maintenance and cooking.
She uses one pillow when she sleeps, she can walk without experiencing any
difficulty, and she doesn’t have any history of falls. She is still a student, after
school she always go to the farm to help her aunt. She can move herself from site
to site without experiencing any difficulty.
Functional
Level
Classification
1. Perceived ability for bed
mobility
2. Perceived ability for
general mobility
3. Perceived ability for
dressing
4. Perceived ability for
bathing.
5. Perceived ability for
grooming
6. Perceived ability for
toileting
Findings/Assessment
0
0
0
0
0
0
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7. Perceived ability for 0
home maintenance
8. Perceived ability for 0
shopping
9. Perceived ability for 0
cooking
Legend;
0= complete independent.
1= requires use of equipment or device.
2= requires help from another person for assistance,
supervision, or teaching.
3= requires help from another person and equipment
or device.
4= complete dependent.
5. Sleep and rest pattern.
- Ms. Bejar her usual sleep is 8-9 hours. She has difficulty going to sleep for no
reason; her method in promoting sleep is drinking water.
6. Cognitive/perceptual pattern.
- Ms. Bejar states that she was not suffering any pain. She also states that she has
difficulty in making decision.
7. Self-perception/self-concept pattern.
- Ms. Bejar major problem at the current time is where to get money to buy food and
everyday uses, she has no problem in her academics. Her usual view of herself is
positive, her scale in her perception of her level of control is 3. She never
experienced a loss.
8. Role/relationship pattern.
- Ms. Bejar lives with her mother and 4 siblings. She doesn’t have any losses in the
past years, and she didn’t verbally experiencing sadness. She rates her usual
activity as active, and she is comfortable in social situation. She is not using
alcohol or drugs.
9. Sexuality/reproductive pattern
- She is single; she started puberty at the age of 12 years old.
10. Coping/stress tolerance pattern
- Ms. Bejar already experienced traumatic event, when their father
left them she was only 6 years old that time. She rate her usual
handling of the stress as good, her primary way of dealing the
stress or problems is praying asking for guidance and courage to
face their difficulties in life.
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11. Value/belief pattern.
- Ms. Bejar said that she’s contented and happy of the life God
gave her, she also believe that God will always guide them as
they continue their life without their father.
4.Physical assessment (Head-to-Toe assessment)
assessment tools provided to you during NCP lecture)
Areas
1.
GENERAL SURVEY:
2.
SKIN:
3.
HEAD:
4.
EYES:
(*use
Assessment Findings
 Ms. Bejar appears to be oriented and
cooperative

Ms. Bejar skin is normal in color,
texture and color. No presence of any
foul odor.

Ms. Bejar head is round and scalp is normal.

Eyebrows are symmetrically aligned and have an
equal
movement
when
raised
and
lower
eyebrows. Pupils equally round, reactive to light
and accommodation. Sclera and conjunctiva is
5.
normal. Eyelids have no presence of discharge or
EARS:
discoloration.

6.
Auricles are symmetrical and have the same color
of the face. Pinna recoils when folded. No
NOSE:
secretion.
7.
MOUTH:
8.
PHARYNX:
9.
NECK:
10.

Nose appeared to symmetric and uniform in color.

Lips are uniformly light brown, there is no lesion.

UNABLE TO ASSESS

Neck muscles are equal in size. There’s no
presence of hyperthyroidism. Can move without
CHEST AND LUNGS:
any discomfort. Trachea is in the middle of the
neck.
11.
HEART:

The chest wall is intact and no tenderness or
masses. Manifested quiet, rhythmic and effortless
respiration.
12.
BREAST
AND

UNABLE TO ASSESS
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
the
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AXILLAE:

UNABLE TO ASSESS

No cyanosis, clubbing, or edema are noted.
Peripheral pulses in the femoral, anterior
tibial, dorsalis pedis, brachial, and radial
areas are normal.
GENITO-URINARY:

UNABLE TO ASSESS
16.
NEUROLOGICAL
EXAMINATION

Neurological status: oriented to time, place,
person, and events, facial expressions
correlates with state of health and topic being
discussed (appears somewhat sad and
anxious). Speech clear, coherent. Questions
answered appropriately. Long-term and shortterm memory intact. Cooperative throughout
interview. Asked appropriate questions
relevant to illness and answered all questions
posed.
17.
MENTAL STATUS:

Can express oneself by speech or sign. Oriented
to place, date and time.
18.
GLASGOW
COMA
SCALE:
CRANIAL NERVES:

UNABLE TO ASSESS.

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS
13.
ABDOMEN:
14.
BACK
EXTREMITIES:
15.
19.
Olfactory:
Optic:
Oculomotor,
Abducens:
Trigeminal:
Facial:
Vestibulocochlear:
Glossopharyngeal:
Vagus:
Accessory
Hypoglossal:
20.
AND
Trochlear,
REFLEXES:
Pathologic Reflexes:
21.
MOTOR/CEREBELLAR:

UNABLE TO ASSESS
22.
SENSORY:

UNABLE TO ASSESS
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5.
Vital signs / Measurable cues / Anthropometric Data (use graphs; line, bar, pie charts for multiple
reading)
Parameter
Height
Normal
Value
5’3
Actual
Findings
4’11
Weight
54.5
36
BMI
BP
Procedure
A quality stethoscope. 120/80
An appropriately sized mmHg
blood pressure cuff. A
blood
pressure
measurement
instrument such as an
aneroid
or
mercury column
sphygmomanometer
or
an
automated
device with a manual
inflate mode. The
patient is relaxed by
allowing 5 minutes to
relax before the first
reading. The patient
should sit upright with
their
upper
arm
positioned so it is
level with their heart
and feet flat on the
floor. Remove excess
clothing
that
might interfere
with
the
BP
cuff
or
constrict blood flow in
the arm. Be sure you
and the patient refrain
from talking during the
reading. Place the
BP cuff on the
patient's
arm: Palpate/locate
the brachial artery
and position the BP
cuff so that the
ARTERY
marker
points to the brachial
100/80 mmHg
Analysis and
Interpretation
Her height is
not normal for
her age
She is
underweight,
which is not
normal for her
age.
Her
BP
is
normal. There’s
no
sign
of
hypertension
and
hypotension.
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artery. Wrap the BP
cuff snugly around the
arm. Position the
stethoscope: On the
same arm that you
placed the BP cuff,
palpate the arm at the
antecubical
fossa
(crease of the arm) to
locate the strongest
pulse sounds and
place the bell of the
stethoscope over the
brachial artery at this
location. Inflate the
BP
cuff: Begin
pumping the cuff bulb
as you listen to the
pulse sounds. When
the BP cuff has
inflated enough to
stop blood flow you
should
hear
no
sounds through the
stethoscope.
The
gauge should read 30
to 40 mmHg above
the person's normal
BP reading. If this
value is unknown you
can inflate the cuff to
160 - 180 mmHg. (If
pulse sounds are
heard right away,
inflate to a higher
pressure.)Slowly
Deflate
the
BP
cuff: Begin deflation.
The
AHA
recommends that the
pressure should fall at
2 - 3 mmHg per
second,
anything
faster may likely result
in
an
inaccurate
measurement. Listen
for
the
Systolic
Reading: The
first
occurrence
of
rhythmic
sounds heard
as
blood begins to flow
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through the artery is
the patient's systolic
pressure. This may
resemble a tapping
noise at first. Listen
for the Diastolic
Reading: Continue to
listen as the BP cuff
pressure drops and
the sounds fade. Note
the gauge reading
when the rhythmic
sounds stop. This will
be
the
diastolic
reading
Pulse Rate
Gently place 2 60 to
bpm
fingers of your
other hand on
this artery. Do not
use your thumb,
because it has its
own pulse that you
may feel. Count
the beats for 30
100 85 bpm
Pulsation is in
normal range.
seconds, and then
double the result
to get the number
of
beats
per
minute.
Respiration Rate




Explain to the patient 12-20 bpm
what you are about to
do -even if the patient
is unconscious;
Ensure the patient is
comfortable;
Make sure the patient
is as relaxed as
possible;
Observe if the patient
is distressed in any
way;
It is best to monitor
and
record
the
respirations
immediately
after
taking the pulse; this
will aid in a more
accurate recording, as
the patient will not be
aware that you are
19 bpm
Respiration is
normal, with no
sign of dyspnea
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




Temperature
observing
respirations.
Awareness
that
respirations are being
recorded can make
people
alter their
breathing;
Observe the rise and
fall of the chest
(inspiration
and
expiration)
this
counts as one breath;
The
respirations
should be counted for
a full minute in order
to have an accurate
recording;
Note the pattern of
breathing and the
depth of the breaths;
Document
your
findings
on
the
patient’s observation
chart,
note
any
changes and report to
the medical team;
Before
leaving,
ensure the patient is
comfortable.
A digital thermometer 36.5-37.0
may be used to take Degree
an
axillary Celsius
temperature. Remove
plastic cover. Clean
the
pointed
end
w/cotton and rubbing
alcohol in a circular
motion. Put the tip of
the
thermometer
securely in the armpit.
Hold the arm tightly at
the side. Keep the
thermometer in the
armpit until the digital
thermometer beeps.
Record the result.
36.5
Degree Temperature is
Celsius
normal, with no
signs
of
Hyperthermia
and
hypothermia.
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Form A: Gordon’s Functional Health Pattern
Gordon’s
Functional
Health Pattern
Nursing History
Subjective
Health
Perception and
Health
Management
Nutrition and
Metabolism
-
Elimination
-
-
PE
Objective
Laboratory
(if available
or if
diagnosed)
Nursing
Diagnosis
(at least one
diagnosis per
typology)
Justification for
the Nursing
Diagnosis
Imbalance
nutrition:
less
than
body
requirements
Her weight is 36
kilograms,
For
an
adolescent
that is under
weight.
NONE
Ms. Bejar loss weight
because she doesn’t
eat the right amount of
food that
she
is
required.
Due
to
financial
problems
sometimes she only
eats root crops.
According to Ms. Bejar
Her bowel movement is
normal. She doesn’t
have any history of
diarrheal, constipation,
incontinence, her usual
voiding pattern is thrice
a day.
- Ms. Bejar is thin, NONE
appears to
oriented
cooperative.
weight
is
kilograms,
height is 4’10.
UNABLE
ASSESS
be
and
Her
36
her
TO NONE
Readiness
for
Her usual
enhance urinary voiding pattern is
elimination
thrice a day.
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Activity and
Exercise
-
According to Ms Bejar, -She is thin, but NONE
she
is
completely she can do her
independent in doing everyday routine.
the following; going to
bed, to the bathroom,
taking a bath, dressing,
home
maintenance
and cooking. She can
walk
without
experiencing
any
difficulty,
and
she
doesn’t
have
any
history of falls. She is
still a student, after
school she always go
to the farm to help her
aunt. She can move
herself from site to site
without
experiencing
any difficulty.
Cognition and
Perception
-
She also states that
she has difficulty in
making decision.
UNABLE
ASSESS
Sleep and
Rest
-
Ms. Bejar her usual
sleep is 8-9 hours. She
-Facial
Readiness
enhanced
care
for She
is
self- independent in
doing
her
everyday
activities.
TO NONE
Decisional
Conflict (Specify)
She has difficulty
in
making
decision.
is NONE
normal,
She
speaks clearly
Readiness
for
enhanced sleep
She has no
difficulty in
sleeping, she
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has difficulty going to
sleep for no reason;
her
method
in
promoting sleep is
drinking water.
when
answering the
questions.
- Her usual view of UNABLE
herself is positive, her ASSES
Self-Concept
TO NONE
scale in her perception
of her level of control is
3.
She
never
experienced a loss.
Roles and
Relationship
-
Ms. Bejar lives with her
mother and 4 siblings.
She doesn’t have any
losses in the past
years, and she didn’t
verbally experiencing
sadness. She rates her
usual activity as active,
and she is comfortable
in social situation. She
is not using alcohol or
drugs.
-Ms. Bejar is a NONE
good Sister to
her
siblings.
There’s
no
sign
of
violence in the
family. She is
cooperative in
answering the
questions.
sleeps 8-9
hours.
Readiness for
enhanced SelfConcept
Her usual view
of
herself
is
positive,
her
scale
in
her
perception of her
level of control is
3. She never
experienced
a
loss
Readiness in for She is a good
enhanced family Sister to her
processes
siblings,
she
supports them in
their
daily
activities.
She
helps her mother
in raising her
siblings.
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Sexuality and
Reproductive
Function
-
She is single; she
started puberty at the
age of 12 years old.
UNABLE
ASSESS
TO NONE
NONE
Stress and
Stress
Response
-
Ms. Bejar already experienced
traumatic event, when their father
left them she was only 6 years
old that time. She rate her usual
handling of the stress as good,
her primary way of dealing the
stress or problems is praying
asking for guidance and courage
to face their difficulties in life.
UNABLE
ASSESS
TO
Values and
Beliefs
-
Ms. Bejar said that she’s
contented and happy of the life
God gave her, she also believe
that God will always guide them
as they continue their life without
their father.
UNABLE
ASSESS
TO NONE
UNABLE TO
ASSESS
UNABLE TO
ASSESS
Readiness
for
enhance coping
She is still
coping from the
traumatic event
that she and her
siblings
experienced.
Readiness
for She is ready for
enhanced
every
problem
spiritual
well- that they will
being
encounter.
Prioritization of identified problem (use Maslow’s Hierarchy of Needs)
Health Problem
Cues
Justification
*states
the
Identified *list of supporting information based on *normal findings according to published study
abnormal
findings
or the assessment
maladaptation
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Form A: Summary of Gordon’s Functional Health Pattern
Assessment
Nursing Diagnosis

Nursing History
-
-
The patient is
underweight for
her age.
Less
intake
than
recommended
daily
allowances;
Lack of food
Imbalanced
nutrition: less
than
body
requirements
related
to
biological and
psychological
factors;
Insufficient
finances
Planning
-
-
-
PE
-
Definition
- Intake
of
nutrients
insufficient to
meet
Ms. Bejar is
metabolic
thin, appears to
needs.
be oriented and
cooperative.
Her weight is
Demonstrate
progressive
weight
gain
toward goal.
Verbalize
understanding
of
causative
factors when
known
and
necessary
interventions.
Demonstrate
behaviours,
lifestyle
changes
to
regain and/or
maintain
appropriate
weight
Intervention
-
Determine
lifestyle
factors that may affect
weight.
Rationale:
- Socioeconomic
resources, amount
of money avaible for
purchasing
food,
proximity of grocery
store, and available
storage space for
food are all factors
that may impact
food choices and
intake.
-
Explore
specific
eating habits, the
meaning of food to
the
client,
and
individual
food
preferences
and
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
-
-
-
Was able
to
demonstr
ate
weight
gain
toward
goal.
Able
to
verbalize
understan
ding
of
causative
factors
when
known
and
necessar
y
interventi
ons.
Able
to
demonstr
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36 kilograms,
her height is
4’10.
intolerance/aversion
s
Rationale
-Identifies eating practices that
may need to be corrected and
provides insight into dietary
interventions that may appeal
to the client.
ate
behaviour
s, lifestyle
changes
to regain
and/or
maintain
appropriat
e weight
Diagnostic
Examination/Laborator
y
Worksheet C (Health Teaching Plan - Individual)
Teaching
Objectives
derived from nursing
care plan
*
Strategies
Learning Content
Time
Duration
Resources
* with reference
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
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References: (very important, DO NOT FORGET to include this)
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Page 19 of 44
III. Family Nursing Care Plan
A. Initial Data Base for Family Nursing Practice
a.
b.
c.
d.
e.
Family structure, characteristics, and dynamics
Socio – cultural and Cultural Characteristics
Home and Environment
Health status of each Family Member
Values, habits, practices on health promotion, maintenance and
disease prevention
B. Family Nursing Problems - Summary of First – Second Level Assessment
Cues/Data
“Danay
kami
diri
nakaon kay
waray nam
iparalit”
Stated
by
the mother.
Family Nursing Problems
A. Faulty eating habits
- Health treat
-
1. Inability
to
recognize
the
presence of the problem due to
financial problems.
2. Inability to make decisions with
respect to taking appropriate
action due to:
Failure to comprehend the nature of the problem
Lack of/inadequate knowledge/insight as to
alternative courses of action open to them
3. Inability to provide adequate
nursing care to the sick, disabled,
dependent or at risk member of
the family due to inadequate
family
resources
for
care
specifically:
Absence
of
responsible member and financial
constraints.
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Page 20 of 44
“Dako
talaga an
epekto han
bagbaya
han ak
asawa
haam”
During my
observation
, the mother
has
Poliomyeliti
s
B. Divorce or Separation
-Health Deficits
1. Inability to recognize the presence of the condition
or problem due to traumatic event.
2. Inability to make decisions with respect to taking
appropriate health action due to failure to
comprehend the magnitude of the problem.
3. Inability to provide adequate nursing care to the sick,
disabled dependent or at risk member of the family
due to Significant person’s unexpressed feelings
which disable his/her capacities to provide care.
C. Poliomyelitis
-Health Deficits
1. Inability to recognize the presence of condition or
problem due to Lack of knowledge.
2. Inability to make decisions with respect to taking
appropriate health action due to:
- Failure to comprehend the nature of the
problem
- Negative attitude towards the health
conditions.
3. Inability to provide adequate nursing care to the sick,
disabled dependent or at risk member of the family
due to Lack of knowledge about the disease or
health condition.
C. Problem – Priority Setting
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A. Faulty eating habits
Criteria
Computation
1. Nature of the problem
2. Modifiability
problem
of
2/3x1
the 2/3x2
3/3x1
Actual Score
0.67
The problem is a health
threat it may affect the
family’s health
1.3
The problem is not that
to resolve and the
resources are not that
easily to get
1
The problem can be
prevented
temporarily
but
it
affects
the
community.
0.67
The family recognize the
problem
and
needs
immediate care.
3. Preventive potential
4. Salience
of
the 2/3
problem
Total Score
Justification
3.66
D. List of Prioritized Family Nursing Problems
Family Nursing Problem
1.
Score
* from highest score to the lowest
2.
3.
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E. Family Nursing Care Plan
Health Problem
Family Nursing
Problems
*First level – second
level assessment
Goals and
Objectives
Interventions
Resources
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Evaluation
Page 23 of 44
F. Family Health Teaching Plan
Teaching
Objectives
derived from nursing
care plan
*
Strategies
Learning Content
Time
Duration
Resources
* with reference
References: (very important, DO NOT FORGET to include this)
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
Page 24 of 44
IV.
Individualized Nursing Care Process (NCP)
Name: Bejar, John Christian
Age: 12
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Occupation: Student
Civil status: Single
Educational attainment: Elementary Level
2. Nursing History
1. History of Present Illness
- According to Mr. Bejar, John, he is in a good health. He has no present illness.
2. Past Health History
-Mr. Bejar stated that he doesn’t have any chronic disease.
3. Immunization status
- He fully immunized
4. Family Health History
-
According to Mr. Bejar, he doesn’t know if his father has any disease.
5. Allergies
- Mr. Bejar states that he has no allergies.
3. Gordon’s Typology of 11 Functional Health Patterns (*use the assessment tools provided to you during NCP lecture)
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1. Health-perception/health-management pattern
-
Mr. Bejar describes her usual health as good and she is satisfied with her health, she is not using
tobacco or alcoholic drinks. She also states that she doesn’t have any history of chronic disease; she
never sought for healthcare assistance for the past years. She is currently studying; she is now a grade 8
student. She is not suffering any difficulty in doing the household chores and etc., she doesn’t have any
history of falls, and she’s not experiencing any ringing of the ear.
2. Nutritional/Metabolic pattern.
-
Mr. Bejar loss weight because he barely eats’. Sometimes he east’s root crop (Kamote) when they don’t
really have rice and sometimes bread to. He drinks 7-9 glass of water per day; he describes his lifestyle
as good. He doesn’t have any chronic health problems. He also states that he wants to gain weight.
Food Items
Kamote
Approximate Edible Calories Total
Measurement Portion
Calories
(weight
in
Grams)
3 pcs.
3 pcs.
852
852
Bread
3pcs.
Rice
2 cups per 2 cups 460
day
per day
3 pcs.
217.7
217.7
460
3. Elimination pattern.
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Page 26 of 44
-
According to Mr. Bejar his bowel movement is normal, he didn’t or never uses any bowel movement aids.
He doesn’t have any history of diarrheal, constipation, incontinence and recent travel, His usual voiding
pattern is thrice a day.
4. Activity/exercise pattern.
-
According to Mr. Christian John Bejar he is completely independent in doing the following; going to bed,
to the bathroom, taking a bath, dressing, home maintenance and cooking. He uses two pillows when he
sleep, he can walk without experiencing any difficulty, and he doesn’t have any history of falls. He can
move himself from site to site without experiencing any difficulty. He plays basketball every morning
Functional
Level Findings/Assessment
Classification
V. Perceived ability for bed 0
mobility
VI. Perceived ability for 0
general mobility
VII. Perceived ability for 0
dressing
VIII. Perceived ability for 0
bathing.
IX.
Perceived ability for 0
grooming
X.
Perceived ability for 0
toileting
XI.
Perceived ability for 0
home maintenance
XII.
Perceived ability for 0
shopping
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XIII.
Perceived ability for 0
cooking
Legend;
0= complete independent.
1= requires use of equipment or device.
2= requires help from another person for assistance,
supervision, or teaching.
3= requires help from another person and equipment
or device.
4= complete dependent.
5 .Sleep and rest pattern.
-
Mr. Bejar states that his usual sleep is 8:00 pm until 5:00 am. He complete the required 8 hours of sleep
without using any sleeping aids and drinking coffee.
6 Cognitive/perceptual pattern.
-
Ms. Bejar states that she was not suffering any pain. He also states that he has difficulty in making
decision of his young age.
7 Self-perception/self-concept pattern.
-
Mr. Bejar states that he doesn’t have any major problem especially in school .He never experienced a
loss.
8 Role/relationship pattern.
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-
Mr. Bejar lives with his mother and 4 siblings, He doesn’t have any losses in the past years, and he didn’t
verbally experiencing sadness. He rate his usual activity as active, and he is comfortable in social
situation. He is not using alcohol or drugs.
9 Sexuality/reproductive pattern
-
He is single.
10. Coping/stress tolerance pattern
-
Mr. Bejar experienced traumatic event, when their father left them. He rate he usual handling of the
stress as good, his primary way of dealing the stress or problems is praying asking for guidance and
courage to face their difficulties in life.
11. Value/belief pattern.
-
Ms. Bejar said that he’s contented and happy of the life God gave him, he also believe that God will always
guide them as they continue their life without their father.
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4. Physical assessment (Head-to-Toe assessment)
Areas
23.
GENERAL SURVEY:
24.
SKIN:
25.
HEAD:
26.
27.
Assessment Findings
 Mr. Bejar appears to be oriented and
cooperative

Mr. Bejar skin is normal in color, texture and
color. No presence of any foul odor.

Ms. Bejar head is round and scalp is normal.

Eyebrows are symmetrically aligned and have
an equal movement when raised and lower
eyebrows. Pupils equally round, reactive to
EYES:
EARS:

28.
NOSE:

29.
MOUTH:
light and accommodation. Sclera and
conjunctiva is normal. Eyelids have no
presence of discharge or discoloration.
Auricles are symmetrical and have the same
color of the face. Pinna recoils when folded.
No secretion.
Nose appeared to symmetric and uniform in
color.
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30.
31.
32.
33.
PHARYNX:

Lips are uniformly light brown, there is no
lesion.

UNABLE TO ASSESS

Neck muscles are equal in size. There’s no
NECK:
CHEST AND LUNGS:
presence of hyperthyroidism. Can move
without any discomfort. Trachea is in the
middle of the neck.
HEART:

The chest wall is intact and no tenderness or
masses. Manifested quiet, rhythmic and
effortless respiration.
AXILLAE:

UNABLE TO ASSESS
35.
ABDOMEN:

UNABLE TO ASSESS
36.
BACK
EXTREMITIES:

No cyanosis, clubbing, or edema are noted.
Peripheral pulses in the femoral, anterior
tibial, dorsalis pedis, brachial, and radial
areas are normal.
37.
GENITO-URINARY:

UNABLE TO ASSESS
38.
NEUROLOGICAL

Neurological status: oriented to time, place,
34.
BREAST
AND
AND
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EXAMINATION
39.
MENTAL STATUS:
40.
GLASGOW
COMA
SCALE:
CRANIAL NERVES:
41.
Olfactory:
Optic:
Oculomotor,
Abducens:
Trigeminal:
Facial:
Vestibulocochlear:
Glossopharyngeal:
Vagus:
Accessory
Hypoglossal:
Trochlear,
person, and events, facial expressions
correlates with state of health and topic being
discussed (appears somewhat sad and
anxious). Speech clear, coherent. Questions
answered appropriately. Long-term and shortterm memory intact. Cooperative throughout
interview. Asked appropriate questions
relevant to illness and answered all questions
posed.

Can express oneself by speech or sign.
Oriented to place, date and time.

UNABLE TO ASSESS.

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS

UNABLE TO ASSESS
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42.
REFLEXES:
Pathologic Reflexes:
5.

UNABLE TO ASSESS

UNABLE TO ASSESS
43.
MOTOR/CEREBELLAR:

UNABLE TO ASSESS
44.
SENSORY:

UNABLE TO ASSESS
Vital signs / Measurable cues / Anthropometric Data
Parameter
Procedure
Height
Normal
Value
4’9 foot
Actual
Findings
4’8 foot
Weight
41.5
39.5
Analysis and
Interpretation
His height is
normal for his
age
His weight is
not normal to
his age.
BMI
BP
Pulse Rate
Gently
place
2
60 to
bpm
100 90 bpm
Pulsation is in
normal range.
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Page 33 of 44
fingers of
your other
hand on
this artery.
Do
not
use your
thumb,
because it
has
its
own pulse
that you
may feel.
Count the
beats for
30
seconds,
and then
double
the result
to get the
number of
beats per
minute.
Respiration Rate
Explain to the 12-20 bpm
patient what
19 bpm
Respiration is
normal, with no
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Page 34 of 44




you are about
to do -even if
the patient is
unconscious;
Ensure
the
patient
is
comfortable;
Make
sure
the patient is
as relaxed as
possible;
Observe
if
the patient is
distressed in
any way;
It is best to
monitor and
record
the
respirations
immediately
after taking
the pulse; this
will aid in a
more
accurate
recording, as
the
patient
will not be
aware
that
you
are
observing
respirations.
sign of dyspnea
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Page 35 of 44




Awareness
that
respirations
are
being
recorded can
make people
alter
their
breathing;
Observe the
rise and fall
of the chest
(inspiration
and
expiration) this counts as
one breath;
The
respirations
should
be
counted for a
full minute in
order to have
an accurate
recording;
Note
the
pattern
of
breathing and
the depth of
the breaths;
Document
your findings
on
the
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Page 36 of 44

Temperature
patient’s
observation
chart,
note
any changes
and report to
the medical
team;
Before
leaving,
ensure
the
patient
is
comfortable.
A
digital 36.5-37.0
thermometer Degree
may be used Celsius
to take an
axillary
temperature.
Remove
plastic cover.
Clean
the
pointed end
w/cotton and
rubbing
alcohol in a
circular
motion. Put
the tip of the
thermometer
securely
in
the
armpit.
36.9
Degree Temperature is
Celsius
normal, with no
signs
of
Hyperthermia
and
hypothermia.
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Page 37 of 44
Hold the arm
tightly at the
side.
Keep
the
thermometer
in the armpit
until
the
digital
thermometer
beeps.
Record
the
result.
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Page 38 of 44
Form A: Gordon’s Functional Health Pattern
Gordon’s
Functional
Health
Pattern
Nursing History
Subjective
PE
Objective
-
UNABLE TO ASSESS
Laboratory
(if available
or if
diagnosed)
NONE
Health
Perception
and Health
Management
-
He describes his health
as good.
Nutrition and
Metabolism
-
Mr. Bejar loss weight - Mr. Bejar is thin, appears to be NONE
because he doesn’t eat oriented and cooperative. Her weight
the right amount of is 36 kilograms, her height is 4’10.
food
that
he
is
required.
Due
to
financial
problems
sometimes he only
eats root crops.
Elimination
-
According to Mr. Bejar
His bowel movement is
normal. He doesn’t
have any history of
UNABLE TO ASSESS
NONE
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Nursing
Diagnosis
(at least one
diagnosis
per typology)
Readiness
for
enhanced
self-health
management
Imbalance
nutrition:
less
than
body
requirements
Justification
for the
Nursing
Diagnosis
Her weight is
36
kilograms,
For
an
adolescent
that is under
weight.
Readiness
His
for enhance usual voiding
urinary
pattern
is
elimination
thrice a day.
Page 39 of 44
diarrheal, constipation,
incontinence, her usual
voiding pattern is thrice
a day.
Activity and
Exercise
-
According to Mr Bejar, -He is thin, but he can do his everyday NONE
she
is
completely routine.
independent in doing
the following; going to
bed, to the bathroom,
taking a bath, dressing,
home
maintenance
and cooking. He can
walk
without
experiencing
any
difficulty,
and
he
doesn’t
have
any
history of falls. He can
move himself from site
to
site
without
experiencing
any
difficulty.
Cognition
and
Perception
-
He also states that she
has difficulty in making
decision because of his
young age.
UNABLE TO ASSESS
NONE
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Readiness
for
enhanced
self-care
He
is
independent
in doing his
everyday
activities.
Decisional
Conflict
(Specify)
He
has
difficulty in
making
decision.
Page 40 of 44
Sleep and
Rest
-
Mr. Bejar his usual
sleep 8 pm to 5 am. He
has difficulty going to
sleep for no reason; his
method in promoting
sleep is drinking water.
is normal, He speaks NONE
clearly when answering the
questions.
-Facial
- His usual view of UNABLE TO ASSES
Self-Concept
NONE
himself is active, his
scale in his perception
of her level of control is
2.
He
never
experienced a loss.
Roles and
Relationship
-
Mr. Bejar lives with his
mother and 4 siblings.
He doesn’t have any
losses in the past
years, and he didn’t
verbally experiencing
sadness. He rates her
usual activity as active,
and he is comfortable
in social situation. He is
-Ms. Bejar is a good Sister to her NONE
siblings. There’s no sign of
violence in the family. He is
cooperative in answering the
questions.
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Readiness
for
enhanced
sleep
Readiness
for
enhanced
Self-Concept
He has no
difficulty in
sleeping, he
sleeps 8 pm
to 5 am
hours.
His
usual
view
of
herself
is
positive, his
scale in his
perception of
his level of
control is 3.
He
never
experienced
a loss
Readiness in He is a good
for
Sister to his
enhanced
siblings, he
family
supports
processes
them in their
daily
activities. He
helps
his
mother and
older sister
in
raising
their siblings.
Page 41 of 44
not using alcohol or
drugs.
Sexuality
and
Reproductive
Function
Stress and
Stress
Response
Values and
Beliefs
-
He is single
UNABLE TO ASSESS
-
Mr. Bejar already experienced
traumatic event, when their father
left them. He rate her usual
handling of the stress as good,
her primary way of dealing the
stress or problems is praying
asking for guidance and courage
to face their difficulties in life.
UNABLE TO ASSESS
-
Mr. Bejar said that he’s contented
and happy of the life God gave
her, he also believe that God will
always guide them as they
continue their life without their
father.
UNABLE TO ASSESS
NONE
NONE
NONE
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
UNABLE TO
ASSESS
UNABLE TO
ASSESS
Readiness
He is still
for enhance coping from
coping
the traumatic
event that he
and his
siblings
experienced.
Readiness
for
enhanced
spiritual wellbeing
He is ready
for every
problem that
they will
encounter.
Page 42 of 44
Form A: Summary of Gordon’s Functional Health Pattern
Assessment

Nursing History
-
Nursing Diagnosis
Less
intake
than
recommended
daily
allowances; Lack of
food
Imbalanced
nutrition:
less
than
body
requirement
s related to
biological
and
psychologic
al factors;
Insufficient
finances
PE
Planning
-
-
-
-
Mr.
Bejar
loss weight
because he Definition
- Intake
of
doesn’t eat
nutrients
the
right
insufficient
amount
of
to
meet
food that he
metabolic
is required.
Demonstrate
progressive
weight gain
toward goal.
Verbalize
understandin
g
of
causative
factors when
known and
necessary
interventions.
Demonstrate
behaviours,
lifestyle
changes to
regain and/or
maintain
appropriate
weight
Intervention
-
Determine
lifestyle
factors
that
may
affect weight.
Rationale:
- Socioeconomic
resources,
amount of money
avaible
for
purchasing food,
proximity
of
grocery store, and
available storage
space for food are
all factors that
may impact food
choices
and
intake.
-
Explore specific
eating habits, the
meaning of food
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
-
-
Was
able to
demonst
rate
weight
gain
toward
goal.
Able to
verbaliz
e
understa
nding of
causativ
e factors
when
known
and
necessa
ry
intervent
Page 43 of 44
Due
to
financial
problems
sometimes
he only eats
root crops.
needs.
to the client, and
individual
food
preferences and
intolerance/aversi
ons
Rationale
-Identifies eating practices
that may need to be
corrected
and
provides
insight
into
dietary
interventions
that
may
appeal to the client.
Diagnostic
Examination/Laboratory
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
-
ions.
Able to
demonst
rate
behavio
urs,
lifestyle
changes
to regain
and/or
maintain
appropri
ate
weight
Page 44 of 44
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015