Nursing Related Learning Experience Manual

Name of Student Ryan Dave M. Saplad Yr & Sec BSN 1B

Clinical Instructor Mrs. Reca Rose E. Tuban Area
Date of Exposure 7 / 8 / 2020 Hospital NDDU

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Pattern Cue Cluster Inference Diagnostic Statement Priority Rationale
1. Health Perception & Subjective: * he likes to listen Ineffective Protection Ineffective Protection r/t High 2 High 2 because this
Management to loud “the louder the better “ altered hearing as problem is one of the
rock music, using tight manifested by does wood factors affecting the clients
earphones working with loud saws in his hearing’s ability and if the
* does wood working with loud home and he does not wear
saws in his home
client does not aware of
protective ear plugs during these
* He does not wear protective activities and he likes to listen to
this, probably this will lead
ear plugs during these activities loud “the louder the better “ to hearing loss
* frequently attended music rock music, using tight
concerts that were often loud, earphones
and he still goes occasionally
Objective: * 28-year-old man
* Whisper test: Client unable to
repeat two-syllable whispered
word

Subjective: * Does wood High 3

working with loud saws in his Ineffective health
maintenance r/t altered High 3 because not
home and he does not wear
protective ear plugs during these hearing as manifested by maintaining oneself may
Ineffective health lead to total hearing loss
activities Does wood working with loud
maintenance
* He states he had one ear saws in his home and he does
infection several years ago and not wear protective ear plugs
had several ear infections as a during these activities
young child * He states he had one ear
* His last hearing examination infection several years ago and
was as a child in grade school had several ear infections as a
* frequently attended music young child
concerts that were often loud, * His last hearing examination
and he still goes occasionally was as a child in grade school
*scarring noted on left tympanic
Objective: *scarring noted on membrane

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 Nursing Related Learning Experience Manual

left tympanic membrane *. Small amount of moist,

*. Small amount of moist, yellow cerumen in external
yellow cerumen in external canals
canals

2. Nutrition / Metabolism No significant cues NA NA NA NA

3. Elimination Pattern No significant cues NA NA NA NA

4. Activity / Exercise Subjective: *works in an Risk for activity Risk for activity Low 2 Low 2 since this is only a
industrial plant as a supervisor intolerance intolerance r/t altered risk and need to intervene
* he misunderstands his workers hearing immediately
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 NA NA NA NA

6. Cognitive / Perceptual Subjective: * He has noticed Disturbed sensory Disturbed sensory High 1 High 1 because this is the
lately that he is having trouble perception: auditory perception: auditory r/t main problem of the client
hearing conversations with his altered hearing as and reason why he seek
friends
* he misunderstands his workers
manifested by He has noticed medical professional. This
when they are giving him lately that he is having trouble inference affects the
information about the projects hearing conversations with his client’s work and social
friends
they are working on
* he misunderstands his workers
status.
* he likes to listen to loud “the when they are giving him
louder the better “ rock music, information about the projects
using tight earphones they are working on *Whisper
* does wood working with loud test: Client unable to repeat two-
saws in his home syllable whispered word
* He does not wear protective * 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

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 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

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 Nursing Related Learning Experience Manual

Name of Patient Jack Jones Rm/Bed No. 2C 204 Age 28 Chief Complaints Alteration of hearing
Address General Santos City Admission Date 7 / 8 / 2020 Sex M Diagnosis Disturbed sensory perception: auditory r/t
altered hearing

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN
Subjective Cues: C Note: Use P-E-S format General Objective Independent Goal was met the
O client’s hearing
* He has noticed lately G Disturbed sensory Within a week patient *Stand or sit directly in front of client when ability returning to
that he is having trouble N perception: auditory r/t achieves optimal communicating. Make sure adequate light is on normal and can
hearing conversations I altered hearing as functioning within limits of nurse's face, avoid chewing gum or covering effectively
with his friends 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
* he misunderstands his lately that he is having trouble
workers when they are 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
giving him information friends
about the projects they meaningful activities lips and see nonverbal communication, which is a
P * he misunderstands his workers large component of all communication
are working on when they are giving him
* he likes to listen to E
R information about the projects Specific Objective * Keep background noise to a minimum. Turn off
loud “the louder the they are working on *Whisper
C television and radio when communicating with
better “ rock music, test: Client unable to repeat two-
E * Demonstrates client.
using tight earphones syllable whispered word
P understanding by a verbal,
* does wood working T * scarring noted on left tympanic written, or signed response Rationale: Background noise significantly
with loud saws in his U membrane interferes with hearing in the hearing-impaired
home A *Cone-shaped light reflex in 5- *explains plan to modify client
* He does not wear L o’clock position in right ear and lifestyle to accommodate
protective ear plugs 7-o’clock position in left ear hearing impairment * Encourage client to wear hearing aid, but
during these activities P understand if he or she chooses to leave hearing
* frequently attended A *Clients hearing ability will aid out.
music concerts that T Background Knowledge become stable
were often loud, and he T Rationale: Hearing aids amplify all noise, and
still goes occasionally 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.
Objective Cues after frequent ear infection or Do not over-enunciate or shout at client.
trauma; and during adulthood
* Whisper test: Client as the result of trauma, Rationale: In many kinds of hearing loss, clients
unable to repeat two- infection, or exposure to lose the ability to hear higher-pitched tones but can
syllable whispered occupational and/or still hear lower-pitched tones. Over-enunciating
word environmental noise. When makes it difficult to read lips. Shouting makes the

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* 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

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 Nursing Related Learning Experience Manual

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