data org

Data Organization and Norms and Standards
Functional Pattern Norms and Standards
Health Perception and Health
Management
Subjective:
• Her family’s traditional concept of
health and illness is an ice bag for
fever and citrus drinks for cold
• The client found no mass, lesions
tenderness and nipple .discharge in her
last self-breast examination.
• The client states, “nung last kong
nagpadental nagpabunot ako ng ngipin
ung sa 2
nd
right premolar ko kasi may
cavity caused siguro ng tartar.”
• The client started smoking during her
• The family passes on health patterns
and beliefs of to offspring. (Kozier and
Erb’s Fundamentals of Nursing 8
th
edition, volume 1, pg. 302)
• No tenderness, masses nodule, or
nipple discharge during palpitation in
the breast. (Kozier and Erb’s
Fundamentals of Nursing 8
th
edition,
volume 1, pg. 630)
• Dental caries and periodontal disease
are the two problem that most
frequently affect the teeth. Both
problem are commonly associated with
plagues and tartar deposits, (Kozier
and Erb’s Fundamentals of Nursing 8
th
1

6
th
grade and usually consumes
13sticks-2packs of cigarette/per day.
• The client drinks alcoholic beverages
every weekend usually 4 bottles.
• The client considers healthy as can do
work efficiently.
• Adolescents manage their cigarettes
use, including their active efforts to
maintain control over it, may be a part
of the typical adolescents process of
establishing independence, and
adolescents do not intend or desire to
become addicted to nicotine. Many
adolescents who limited smoking went
on to quit completely. (Kozier and Erb’s
th
edition,
volume 1, pg. 288)
• A number of studies have shown some
health benefits of moderate alcohol
consumption. Examples include
reduced risk of cardiovascular disease.
However, analysis of the literature
indicates that there are many flaws in
the research and it is too early to make
recommendations for the client. (Kozier
th
2

• The client drinks antihistamine for her
allergies and parasetamol for her fever.
• The client drinks caltrate plus and
centrum, self prescribe to keep her
healthy body.
• The client claims that she has complete
immunization.
Objective:
• The client is neat and clean.
• The client has no body and breath
odor.
• The client has health appearance.
• The client has a silky and resilient hair.
• The client has a moist skin.
• Health is defined in terms of the
individual’s ability to fulfill societal roles,
that is, to perform his or her work.
(Kozier and Erb’s Fundamentals of
Nursing 8
th
• A medication is a substance
administered for the diagnosis, cure,
treatment, or relief of a symptom or for
prevention of disease. (Kozier and
th
• Vaccines are among the greatest public
health achievements of the 20
th
century. Immunization can prevent
disability and death from infectious
disease for individuals and can help
control the spread of infection within
communities. (Kozier and Erb’s
th
edition,
3

volume 1, pg. 276)
• Adolescents are usually concern about
their body, their appearance, and their
physical abilities. Hair styling, skin care,
and clothes become very important.
Nursing 8
th
Nutrition and Metabolic
Subjective:
• The clients usual food intakes are
protein and vegetables with balance
diet with less salt and sugar.
• The client has discomfort in eating
seafood and red meat and her diet
restrictions would be being a pesco
vegetarian.
• The teenagers food choices related to
physical, social, and emotional factors
and impulses and may not be
influenced by teaching. (Kozier and
th
• The description of a pesco vegetarian
is use dairy products, eggs, and fish
but avoid all other red meat. (Kozier
th
4

• The client has lack of knowledge in
dental health and stated that, “hindi
siguro ako nagtotooth brush ng mabuti
kaya ako ng ka tooth decay. . hehe . . “
• The client prefers grilled and steamed
for her food preparation.
• The client claimed that her wounds
heals well.
Objective:
• The BMI is 20.2
• Certain clients are prone to oral
problems because of lack of knowledge
or the inability to maintain oral hygiene.
Nursing 8
th
• Cook meat by grilling, baking, broiling,
or microwaving rather than frying to
reduce dietary fat. (Kozier and Erb’s
th
edition,
volume 2, pg. 1246)
• Healing is a quality of living tissue; it is
also referred to as regeneration. The
phases are the sane for all wounds, but
the rate of healing depends on factors
such as the type of healing, the location
and size of the wound, and the health
of the client. (Kozier and Erb’s
th
edition,
volume 2, pg. 908)
5

• The clients teeth is only 29.
• The clients teeth are yellowish.
• The client has dental caries on her
• The client usually eats junk food and
soda for snacks
• The client is skipping meals.
• The normal BMI is range from 18.5-
24.9. (Kozier and Erb’s Fundamentals
of Nursing 8
th
edition, volume 2, pg.
1237)
• Normal finding is 32 adult teeth. (Kozier
th
• Teeth turns yellow in color as a part of
the aging process. Teeth is normally
off-white. With age, the enamel thins
and the yellow-gray color of the inner
portion of the teeth begins to show.
Nursing 8
th
• Formation of dental caries, or tooth
decay , is the result of breakdown of
enamel by acids produced by bacteria
on the tooth surface. Enamel is
nonliving and cannot repair itself.
(Essential of Anatomy and Physiology
6

• The clients fluid intake ranges to 1000-
1500 ml per day water alone.
6
th
edition, pg. 452)
• Teenagers have active lifestyles and
irregular eating pattern. They tend to
diet or snack frequently, often eating
high calorie foods such as doughnut,
soft drinks, ice cream, and fast-food.
Nursing 8
th
• During period of moderate activity at
moderate temperature, the average
adult drinks about 1500 ml per day but
needs 2500 ml per day, an addition
1000 ml. This added is acquired from
foods and from the oxidation of these
foods during metabolic processes.
Nursing 8
th
Elimination
Subjective:
• The client defecates every other day.
• The frequency of defecation is highly
individual, varying from several times
7

• The client defecates during the night.
• The client addresses that her feces are
brown in color and slightly moist with
no discomfort and pain.
• The client experience diarrhea and
maybe caused by excessive eating..
per day to two or three times per week.
Nursing 8
th
• Allow time to defecate, preferably at the
same time of the day. (Kozier and Erb’s
th
edition,
volume 2, pg. 1337)
• Normal feces are made of about 75%
water and 25% solid materials and
normally brown, chiefly due to the
presence of stecobilin and urobilin,
which are derived from bilirubin (a red
pigment in bile). (Kozier and Erb’s
th
edition,
volume 2, pg. 1325)
• When the caused of diarrhea is irritants
in the small intestine tract, diarrhea is
thought to be a protective flushing
mechanism. (Kozier and Erb’s
th
edition,
8

• The client stated, “ang alam ko lang
basta dumudumi ka normal na un and
para magkaroon ako ng normal na
defecation kumakain ako ng rich in
fiber na food at inom ng madaming
tubig effective siya.”
• The client urinates thrice an hour,
about 1-1 ½ litters per day. (1000-
1500ml)
• The client describes her urine as white
to yellowish color with faint aromatic..
• The client drinks a lot of water to
achieve normal urinary elimination.
volume 2, pg. 1329)
• Healthy defecation includes high fiber
foods, such as vegetables, fruits, and
whole grains, in diet. (Kozier and Erb’s
th
edition,
volume 2, pg. 1337)
• Average daily urine output by age of 14
years through adulthood is 1500 ml.
Nursing 8
th
• Normal urine characteristic is straw,
amber transparent in color and faint
aromatic in odor. (Kozier and Erb’s
th
edition,
volume 2, pg. 1293)
• When the amount of fluid intake
increases, therefore, the output
normally increase. (Kozier and Erb’s
th
edition,
volume 2, pg. 1288)
9

• The client has excessive perspiration
on her back after a vigorous activity.
Objective:
• The client has absence of arterial bruits
and friction rub and has audible bowel
sound.
• Perspiration varies depending on
factors such as environmental
temperature and metabolic activity.
Nursing 8
th
• Normal findings in auscultation of the
abdomen is audible bowel sounds,
absence of arterial bruits and friction
rub. (Kozier and Erb’s Fundamentals of
Nursing 8
th
edition, volume 1, pg.634)
Activity-Exercise
Subjective:
• The client is engage sports every
Monday-Friday about 1-1 ½ hours.
• The clients normally watch TV, shop
and play computer games during her
spare time.
• The clients physical complaints are
• In general, regular exercise is essential
for maintaining mental and physical
health. (Kozier and Erb’s Fundamentals
of Nursing 8
th
1113.)
• In commerce, this generation is seen
as an important target. Mobile phones,
contemporary popular music, movies,
10

drowsiness and lack of energy.
• The client said that she gets tired most
of the time but can recover for 30
minutes
Objective:
• The client has , parallel alignment and
coordinate movement.
• The client has erect posture.
• The clients skin springs back to
television programs, web sites, sports,
video games and clothes are heavily
marketed and often popular amongst
adolescents.
(http://en.wikipedia.org/wiki/Adolescenc
e)
• Proper body alignment and posture
bring body parts into position in the
manner that promotes optimal balance
and maximal body function whether the
client is standing, sitting, or lying down.
Nursing 8
th
edition, volume 2, pg.1106)
• Balance, smooth, purposeful
movement is the result proper
functioning of the cerebral cortex,
cerebellum, and basal ganglia. The
cerebral cortex initiates voluntary motor
activity, the cerebellum coordinates the
11

previous state within 2 seconds. motor activities of movement, and the
basal ganglia maintain posture. (Kozier
th
• The skin can atrophy as a result of
prolonged immobility. Shifts in the body
fluids between the fluids compartments
can affect the consistency and health of
the dermis and subcutaneous tissues in
dependent parts of the body, eventually
causing a gradual loss in skin elasticity.
Nursing 8
th
Sleep and Rest
Subjective:
• The client have a minimum of 4 hours
to a maximum of 10 hours of sleep; not
continuously.
• The client wakes up tired even though
• Adolescents requires 9 to 10 hours of
sleep each night; however, few actually
get that much sleep. (Kozier and Erb’s
fundamentals of Nursing 8
th
edition,
volume 2, pg. 1168).
• Environment can promote or hinder
12

having an environment with good
lighting and ventilation.
• The client suffers from insomnia cause
by difficulty falling asleep.
• Listening to music helps her fall asleep
for her to relax.
Objective:
• The client has eye bags
• The client sometimes have an
adequate sleep but still is feels tired
when waking up according to her sleep
diary.
sleep. Discomfort from environment
temperature and lack of ventilation can
affect sleep Light level can be another
factor. (Kozier and Erb’s Fundamental
of Nursing 8
th
1171)
• Women suffer sleep loss in connection
with hormonal change. (Kozier and
th
• The person’s ability to relax before a
retiring is an important factor affecting
the ability to fall asleep.(Kozier and
th
Skin discoloration under the eyes affects
just about everybody at some time or
another. For some of us, however, these
“dark circles” are a near-constant bother.
13

While these conditions are occasionally
symptomatic of other illnesses, the usual
cause is allergies, tiredness, or,
unfortunately, heredity
(http://www.wikihow.com/Get-Rid-of-Black-
Circles-Under-Your-Eyes)
Cognitive-Perception
Subjective:
• The client has a mild hearing problem
due to listening to too loud music.
• The client verbalize, “siguro medyo
lumabo mata ko kalalaro ng computer
games.”
• The client said the she only have
problem in her taste and smell every
time she has a cold.
• The client said, “minsan makakalimutin
ako siguro dahil ayokong gawin or
talagang nawala sa isip ko.”
• She learns by watching or simple
• Loud noises or explosions can damage
the eardrum (acoustic trauma).
(http://health.yahoo.com/hearing-
overview/ear-problems-and-injuries-
age-12-and-older/healthwise--
earp4.html)
• The most common causes for loss of
sense of taste and smell are the result
of a nasal obstruction, such as the
common cold, breathing allergies and
nasal congestion from irritants like
cigarette smoke and pollutants.
(http://american-
14

observing things.
Objective:
• The client can read article.
• The client has a 20/20 vision.
• The client can hear the ticking of the
clock.
• The client can hear normal voice.
rhinologic.org/patientinfo.loss.phtml)
• It is easier for a human to remember a
visual explanation than series of words.
(http://www.presentersuniversity.com/vi
sual_visual_not_firstais.php)
• Normal finding are can red article,
20/20 vision can hear ticking of the
clock and can hear normal voice.
Nursing 8
th
edition, volume 1, pg. 529;
557)
Self-perception and Self-Concept
Subjective:
• The client describes herself as a cryptic
person and doesn’t feel good about
herself most of the time.
• The client sees herself as better than in
relation to other people.
• The person ‘s self-identity
encompasses perception of self as a
separate and distinct entity alone and
in interactions with others. (Kozier and
Erb’s Fundamentals of Nursing 8th
• People who value “how I perceive me”
15

• The client has a usual happy or
annoyed mood.
• The client expresses herself whenever
mood changes through a ferocious look
in the eye and irritated body
movement.
• The client describe herself as a
negative person.
• The client stated, “I think that I’m a
positive person but I manifest my
negative character therefore I’m a
negative person.”
above “how others perceive me” can be
termed me-centered. They try herd to
live up to their own expectation and
compete only with themselves, not
others. (Kozier and Erb’s
th
edition,
volume 2, pg.1003)
• Personality, a complex concept that is
difficult to define, can be consider as
the outward (interpersonal) expression
of the inner (intrapersonal) self. It
compasses a person’s temperament,
feelings, character traits,
independence, self-esteem,self-
concept, behavior, ability to interact
with others, and ability to adapt to life
change.
• Individuals who have poor self-concept
may express feelings of worthlessness,
self-dislike, or even self-hatred. (Kozier
16

• The client stated that she is rejected
always because she feels that people
don’t like her because she is a short-
tempered person.
• Her goal for the next five years are to
be a profession with house and a car
and to achieve it she studies hard.
Objective:
• The client has confidence in the
interview.
• The client can answer each question
without second thought.
• The client becomes irritated in the last
minute of the interview.
th
edition, pg.1003)
• Many adolescents experience
temporary difficulty in developing a
positive self-image. This due to
dramatic changes in body structures
and function as well as greater
expectations to assume
responsibilities. (Kozier and Erb’s
th
edition,
volume 1, pg. 385)
• The adolescents has unlimited
imagination and ambition and aspires
to great accomplishment. (Kozier and
th
• Self-confidence is having confidence in
oneself when considering a capability.
(http://en.wikipedia.org/wiki/Confidence
17

)
• To rouse to impatience or anger;
annoy: a loud bossy voice that irritates
listeners.
(http://www.thefreedictionary.com/irritat
ed)
Role-Relationship
Subjective:
• The client lives with her nuclear and
extended family.
• The clients families usual activity is
celebrating when there are occasions.
• The clients is always reminded by her
mother to do her chores.
• The clients family problem is being hot
tempered.
• In some families, member of the
extended family live with the nuclear
family. (Kozier and Erb’s Fundamentals
of Nursing 8
th
429)
• Children of all ages and of any ability
are welcome, supervised by a great
team that will inspire you with 100%
confidence. You can just lie back, safe
in the knowledge that your children are
playing as hard as they want, or, of
course, spend some special time as a
family
18

• The client consider her mother, brother
and friends as her significant other.
• The client says what she wants to say
to her family.
(http://www.neilson.co.uk/Beach-
Families.aspx)
• The family is a basic unit of society. It
consists of those individuals, male or
females, youth or adult, legally or not
related, genetically or not genetically
related, who are considered by others
to represent their significant person
• The effectiveness of family
communication determines the family’s
ability to function as a cooperative ,
growth-producing unit. Family that
communicate effectively transmit
message clearly. (Kozier and Erb’s
th
edition,
volume 2, pg. 434)
Sexuality-Reproduction
Subjective:
• the client expresses her womanhood
by doing girl stuff like shopping and
• Women are expected to express their
emotions freely and to be gentler on
19

dressing up with no difficulty in
expressing it.
• The client shows affection by being
sweet, thoughtful and true to a person.
• The client 1
st
menstruation when she
was 11 years old.
• The client said that she has a 28 days
menstrual cycle
• The client hasn’t been involve in any
sexual intercourse.
their physical responses; they also
have broader choice of clothing than
men. (Kozier and Erb’s Fundamentals
of Nursing 8
th
1023)
• The first sign of puberty typically
appears between 11 and 13 years of
age in girls, and the process is largely
completed by age 16. Puberty in
females is marked by the first episode
of menstrual bleeding, which is called
menarche. (Essentials of Anatomy and
physiology 6
th
edition, pg. 561).
• Typically the menstrual cycle is about
28 days long, although can be short as
18 day or as long as 40 days.
(Essentials of Anatomy and Physiology
6
th
edition, pg. 562)
• Individual also have freedom of their
sexual thoughts, feelings, and
20

Objective:
• The clients breast is round, right is
slightly larger than the left.
• The client breast has not tenderness,
has no masses and lesions.
• The client has no nipple discharge.
fantasies. Sexually healthy people are
ethically motivated to exercise
behavior, emotional, economical and
social responsible for themselves
Nursing 8
th
1023).
• Normal findings in breast are rounded
shape; slightly unequal in size;
generally symmetric.. no lesion and
tenderness; no nipple discharge.
Nursing 8
th
edition, volume 1, pg.628-
629)
Coping-Stress
Subjective:
• The client handles stress by
contemplating, eating and playing
computer games, shopping, praying
and drinks alcohol whenever desire
• Family coping mechanism are the
behavior use to deal with stress or
changes imposed from either within or
without. Coping mechanism can be
21

because these makes her relax.
• The client biggest change in her life is
the death of her grandmother.
• The clients’ mother is the most
effective and accessible in talking
things over because to her, her mother
is the only one who can understand her
that much.
viewed as an active method of problem
solving developed to meet life’s
challenges. (Kozier and Erb’s
Fundamentals Of Nursing 8
th
edition,
volume 1, pg. 435)
• The death of a family member often
has a profound effect in the family.
Individual members experience a
sense of loss. They grieve for the lost
person, and they grieve for the family
that once was. (Kozier and Erb’s
Fundamentals og Nursing 8
th
edition,
volume 1, pg. 430)
• Some main function of the family
includes developing a sense of family
purpose and affliction, adding and
socializing new member, and providing
and distributing care and service to
members
Values-Belief
Subjective:
22

• For the client a health mind and body
makes a person health.
• The clients’ spiritual practice is pure
faith.
• According to the client the most
important things to her is her mother,
brother and friends.
• The client doesn’t go to church.
• In mind-body therapies, individuals
focus on realigning or creating balance
in mental process to bring about
healing.
• Faith refers to believe and expectations
about life, ourselves and others it is a
sense of letting do go of the need to
control while trusting and waiting for the
moment when answer come. (Kozier
and Erb’s fundamentals of nursing 8
th
edition, volume1, pg. 340
23

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