Family Nursing Care Plan & Community DX

A Family Case Study of the A.
Family
IN PARTIAL FULFILLMENT OF THE COURSE REQUIRMENT IN NCM 102 RLE IN COMMUNITY HEALTH NURSING BACHELOR OF SCIENCE IN NURSING
Presented to the Faculty Of Manila Doctors College, College of Nursing
Buzon, Myra Katrina R. Caberte, Iris D. Jinno, Chieri D.
Group 31
March 2010 Acknowledgement The students would like to extend their profound gratitude to the following people who have generously shared their help in the completion of this study: First and foremost, God Almighty for giving us unending intelligence and strength to finish every task to facilitate and is dedicated for us to finish. Our parents for providing us their never ending support in this study. And last but not the least, to our clinical instructor, Mr. Nyl Rafols Patangan, RN, who is never weary of providing us encouragement and guidance all throughout the making of this study. He has always been accessible and approachable every time when we are in need of help.
Dedication This family nursing care plan is intended for the improvement and betterment in terms of health of our host family, the Atienzas. We dedicate this presentation to their family who gave us their cooperation and whole-heartedly accepted our favour of giving us an ample amount of time for us to conduct our interviews and for responding to us with complete honesty. We give our full efforts to make this care plan the best and most appropriate one to improve their health. Lastly we ask God, the Father Almighty to always guide the Atienzas in their future endeavours more practically in the terms of their health.
Abstract A family nursing care plan is the blue print of the care that the nurse designs to systematically minimize or eliminate the identified health and family nursing problems through explicitly formulated outcomes of care (goals and objectives) nd deliberately chosen set of interventions, resources and evaluation criteria standards, methods and tools. Features of Family Nursing Care Plan: 1. The nursing care plan focuses on actions which are designed to solve or minimize existing problem. The plan is a blueprint for action. The core of the plan are the approaches, strategies, activities, methods and materials which the nurse hopes will improve the problem situation. 2. The nursing care plan is a product of a deliberate systematic process. the planning process is characterized by logical analyses of data that are put together to arrive at rational decisions. The interventions the nurse decides to implement are chosen from among alternatives after careful analysis and weighing of available options. 3. The nursing care plan, as with all plans, relates to the future. It utilizes events in the past and what is happening in the present to determine patterns. It also projects the future scenario if the current situation is not corrected. 4. The nursing care plan is based upon identified health and nursing problems. The problems are the starting points for the plan, and the foci of the objectives of care and intervention measures. 5. The nursing care plan is a means to an end, not an end in itself. The goal in planning is to deliver the most appropriate care to the client by eliminating barriers to family health development. 6. Nursing care planning is a continuous process, not a one-shot-deal. The results of the evaluation of the plans effectiveness trigger another cycle of the planning process until the health and nursing problems are eliminated.
Table of Contents Acknowledgement Dedication Abstract Table of Contents I. II. Introduction Background of Study 4-6 A. B. III. IV. V. VI. Study Locale Spot Map 1 1 2 3 4
Family Background 7 Socio-Economic Data 7 Home and Environment 8 Family Functional Assessment by Gordons 9 - 15 A. B. C. D. E. F. G. H. I. J. K. Health Perception-Health Management Pattern Nutritional Metabolic Pattern Elimination Pattern Activity and Exercise Cognitive Perception Sleep and Rest Self-Perception/Self Concept Role-Relationship Pattern Sexuality-Reproductive Coping Stress Tolerance Pattern Values Beliefs Pattern
VII. VIII.
Physical Examination 15 - 25 Typology of Nursing Problems A. 1st Level Assessment B. 2nd Level Assessment 26
IX.
Problem Scoring
27 -28
X. XI. XII. XIII. XIV.
Priority Setting Family Nursing Care Plan 32 Action Plans 35 Evaluation Recommendation
29 30 33 36 37 38 -
Appendices 53 Appendix A Appendix B Appendix C I. Introduction
A family nursing care plan is the blue print of the care that the nurse designs to systematically minimize or eliminate the identified the identified health and family nursing problems through explicitly formulated outcomes of care (goals and objectives) nd deliberately chosen set of interventions, resources and evaluation criteria standards, methods and tools. The use of the family nursing process will result in a care plan describing the needs and care for each client. An organized sequence of problem solving steps used to identify and to manage the health problems of clients. II. Background of the Study A. Study Locale About Barangay Talon Dos Barangay Talon Dos in the City of Las Pias was created on April 3, 1978 by virtue of Presidentiable Decree No. 1335 signed by then President Ferdinand Marcos. Predominantly Residential Components The decree ordered that the subdivisions of BF resort, Sta. Cecilia, Sarino, Mother Earth and Camella be detached from the mother Barangay Talon to form Barangay Talon Dos. Today this Barangay is composed of 26 residential villages and sectors. Demography
Talon Dos is one of the twenty barangays of Las Pias City with a population of 47, 479 (2007 PopGen) and land area of 391.61 hectares. It is situated on the southern side of the midsection of Las Pias. It is bounded on the north by ZapoteAlabang Road and Barangay Pamplona Dos; on the west by the Zapote River, Bacoor, and Cavite; on the east by Barangay Talon Cuatro and on the south by Barangay Talon Cinco. Health and Sanitation Barangay Talon Dos provides health and nutrition and social welfare services such as the Barangay Health Centers and Days Care Centers.
Barangay Health Centers Two health centers are found in BF Resort Village and Barangay Hall compound provide primary health care for minor medical and dental problems, immunizations and pre-natal care. Day Care Centers A Day Care Center is a community work place facility providing a full range of health, nutrition, early education, psychosocial and other services to children below 6 years old. Day care centers in Talon Dos are found in Carnival Park A and B, Manggahan, Satima and Vatican Dulo River Side. Feeding and Multivitamin Enhancement A barangay nutrition scholar and barangay health workers provide primary delivery of nutrition information and services in the community together with the regular feeding and multivitamin supplementation programs of the committee on health and sanitation. Anti-Rabies Vaccination To protect dogs and humans from the ill-effects of rabies, the barangay, in the cooperation with the Department of Agriculture conducts annual anti-rabies vaccination of dogs. Waste Management
The proper management of solids and wastes protects public health and the environment; thus; Barangay Talon Dos does its part by composting and bio-digesting wet garbage. Talon Dos Waste Management Facility Wet wastes collected from homes by the barangay biomen are processed into compost as soil conditioners into biogas for cooking at the Waste Management Facility in BF Resort Village. The facility is a project of Sen. Manny Villar and Con. Cynthia Villar, in cooperation with Barangay Talon Dos and BF Resort Village Homeowners Association.
B. Spot Map
BARANGAY LAS PIAS
TALON DOS CITY
Figure 1
Talon Dos is one of the twenty barangays of Las Pias City with a population of 47, 479 (2007 PopGen) and land area of 391.61 hectares. It is situated on the southern side of the mid-section of Las Pias. It is bounded on the north by ZapoteAlabang Road and Barangay Pamplona Dos; on the west by the Zapote River, Bacoor, and Cavite; on the east by Barangay Talon Cuatro and on the south by Barangay Talon Cinco.
III.
Family Background The head of the family is Herminia D. Green. She was born on June 7, 1942 at Bulacan and is 67 years old. She is a Bachelor of Science in Education and was a former Filipino teacher. She currently earns income through a tricycle business. She owns three tricycles and earns money 8
through boundaries paid to her and usually owns P3, 000.00 a month. She owns a bungalow type house at #24 Alice Crisostomo St., BR Resort Village, Talon II, Las Pias City. They have been living there for 15 years already. The primary dialect that they use is tagalong. They also use other dialects such as, English, Ilonggo, Bicol, and Kapampangan. Dante D. Atienza Jr. (Herminias son) is a 38 year old father of three children. He was born on May 19, 1971 and is 38 years old. He worked as an FX driver, but is currently not working. He is helping his wife managing the food store where his wife is working. His wife, Lucila S. Atienza, 47 years old, is a high school graduate who was born on October 30, 1963. She earns about P1500.00 a day (5 days a week). They have three children who are currently studying. Hannah Grace S. Atienza is their eldest daughter. She was born on August 7, 1994 and is 15 years old. She is a third year high school student at Saint Francis of Assisi College. Jay Marvin S. Atienza is the second among the siblings. He was born on December 12, 1995 and is 14 years old. He is a freshmen student at St. Marks Academy. The youngest of the sibling is John Oliver S. Atienza. He was born on November 3, 1996 and is 13 years old. All of them are Roman Catholics. IV. Socio Economic Data According to the priorities for expenditure, the family prioritizes food first. The next is health, followed by education, house bills and then clothing. Their primary source of income is the food business that Lucila is currently in. She earns about P13, 000.00 a month (minus the rental fee and other expenditures in the food store). Other sources of income include the tricycle business Herminia is in, where she earns P3, 000.00 monthly. When Dante works as a FX driver he earns P20, 000.00 monthly, making their average monthly income P36, 000.00. Now that Dante is currently jobless, the average monthly income they earn as of now is P16, 000.00. The familys monthly expenses reaches as much as P15, 000.00 P20,000.00 monthly; making their earnings short for paying expenses. The family recognizes the Barangay Captain as one of the first persons they know to be leader of the community. Some of the projects that the community has are Clean and Green Project, Proper Segregation Program and Lighting System. The family is aware of these projects and are utilizing it. V. Home and Environment 9
Herminia owns the land and house they are living at. The house is made of light materials and concrete. The house is well-ventilated and use electricity as a source of light. The familys source of drinking water is commercially prepared. They have their drinking water delivered from a nearby water station. They store their drinking water in clean bottles and pitchers which are usually covered. Their water supply is supplied by Nawasa, and if water is not available, they have it delivered. The type of toilet the family owns is a flush type toilet. The sewerage system is a blind drainage and its condition is free flowing. The family practices waste segregation. They used a covered trashcan as a container used for garbage collection. Garbage is collected once a week, during Thursdays. Herminia owns three love birds. She keeps them in a cage and feed them every day. Roaches an flies are present in their household. They control these pests by using pesticide to kill them. The health programs that are present in the community are free consultation and weighing , EPI, Ligtas Tigdas, Well-baby clinic , pre-natal checkups, Anti-rabies vaccine. The family is aware of the health programs present in the community but does not utilize it at once. The first person that the family consults in times of illness is the neighbourhood albularyo and they only consult the doctor whenever the illness becomes severe.
Formula for Ventilation: Total window area (cm.sq) X 100 Total floor area (cm.sq) Total window area (TWA) = window length x window width Total floor area (TFA) = floor length x floor width Results: Well ventilated: >20% Fair: 18 19% Poor: <17%
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VI.
Family Functional Assessment by Gordons A. Health Perception-Health Management Pattern 1. History The familys general heath has been good in the last few years. The children in the family experience cough and colds, but not very often. Hannah Grace and John Oliver have also had fever 2 months ago, once at the same time during the Christmas break. Luckily these illnesses didnt affect the childrens school attendance. In cases like these, Herminia and Lucila call their neighbourhood albularyo for help. They only consult the doctor in cases where in sickness becomes severe. Lucila, started having hypertension, September last year. She was given prescription by her physician and has been taking her Diovan (Valsartan) medications for hypertension 80mg once a day, every day, since then as maintenance. The family takes vitamins to keep themselves healthy. Herminia and Lucila also tidy the house daily to keep the house clean and keep themselves away from an environment that may cause sickness to them. None of the family members drink alcohol, take prohibit drugs or smoke. The children have complete immunizations since they were 8 years old. The client states that it has been easy to find ways to follow suggestions of doctors, nurses, social workers. 2. Examination The general appearance of the familys home environment is conducive to their health. It is clean and tidy, has well-ventilation and lighting, and the family can control the presence of pests and vectors such as flies and cockroaches. Lucila stores the available medications at home in a safe place which is unreachable by her children. She and Herminia make sure that hazards are eliminated such as knives on the counters, are put back to their appropriate places so that they are out of reach to the children.
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B. Nutritional Metabolic Pattern 1. History Lunch Rice and pork with water or juice + fruits Rice and fish with water or juice + fruits Rice and chicken with water or juice + fruits Lugaw added with tofu/Macaroni soup added with milk, with coffee Rice and beef with water or juice + fruits or water Pancakes with milk, coffee or water Rice and fish with water or juice Rice and beef with water or juice Merienda Bread, Pancit canton with soft drinks, juice, coffee or water BananaQue with soft drinks, coffee or water Rice and chicken with water or juice Dinner Rice and beef with water
Breakfast Bread, fried egg with tomatoes, fried rice, with water or coffee Bread, beef noodles/mami with added rice, with water or coffee Bread, Champorado with added milk and dried fish, with water or coffee Bread, left over foods from last night (may be beef, pork or chicken), with
water or coffee (May have any of these meal patterns. Meal patterns change every day.) The family makes it sure that each member drinks 6 8 glasses of water daily. The client says that usually, the elders never fail to have a cup of coffee daily. The children are given juice and milk. They also drink soft drinks. The family usually eats meaty foods such as beef, pork and chicken. They do not cook vegetables that much because the children dislike eating it. All the family members have a good appetite, except for Herminia who eats only small quantities of food per meal.
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The children have regular dental check-ups, twice a year. The family doesnt have any problems with regards to the skin, and wound healing.
2.
Examination The refrigerator mostly contains food stocks of beef, pork, and
chicken. Bottles of drinking water and dairy products are also present. Fruits such as apples, bananas, oranges and avocado are placed on top of the refrigerator. Vegetables such as tomatoes, string beans, cauliflower, carrots, cabbages, and eggplants are also found. The family usually eats adobo, nilaga, champorado, pancit, chicken curry, kare-kare, pork/beef sinigang, afritada, fried pork/chicken, beef steak. C. Elimination Pattern 1. History All members of the family sighted no abnormalities observed in their stool. The family members regularly have normal defecation patterns: Herminia: Every other day at around 5 in the morning Dante: Every day at night time Lucila: Every other day in the afternoon Hannah: Every other day in the afternoon Jay: Every other day in the afternoon Oliver: Everyday in the morning The family practices waste segregation. They used a covered trashcan as a container used for garbage collection. Garbage is collected once a week, during Thursdays. Herminia owns three love birds. Their wastes are disposed every other day, outdoors. Roaches and flies are present but are controlled through the use of pesticides (baygon). 2. Examination
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The family has 3 functional toilets at home. The toilet bowls are all flush type and kept clean. Garbage disposal doesnt seem to be a problem and the pet cages are also kept clean. Flies and roaches are not considered as a problem. D. Activity and Exercise 1. History Lucila and Herminia consider doing everyday household chores as their form of exercise. Oliver and Jay are members of their school basketball team, and have drills and training every Monday, Wednesday, Friday and Saturday. Hannah Grace on the other hand is a member of her schools volleyball team and is a team A player. Her drills and training schedule take place during Monday, Wednesday and Friday afternoon and Tuesday, Thursday and Saturday in the morning. Dante does no form of exercise at all. The family doesnt experience problems in housekeeping, budgeting for food education and clothes. 2. Examination The home is well organized and clean. Personal belongings of each member are appropriately arranged and maintained by Lucila and Herminia. E. Sleep and Rest 1. History Generally, each family member is well-rested and ready for school or work at the start of the day. Herminia has her own room where she sleeps in. She sleeps using a banig topped by a comforter. Lucila and Dante share their room with Oliver and Jay, with Lucila and Dante using a floor mattress topped by a comforter for sleep and Oliver and Jay sharing the King sized bed. Hannah sleeps on a separate room. She sleeps on a wooden bed topped by a soft mattress. Usually the children wake up at around 5:00 AM to get ready for school. Lucila also wakes up at 5:00 AM to assist the needs of her children such as preparing breakfast for the whole family, boiling water for a warm bath, and checking if her childrens school needs are all prepared. Dante wakes up at around 6:00 AM. He gets himself 14
prepared to give his children a ride to school. Herminia also wakes up at 6:00 AM and starts doing the household chores. The family usually sleeps at around 9:00 PM. 2. Examination The sleeping space is adequate for each family member and is also appropriately arranged. F. Cognitive Perception 1. History No family member has hearing problems however; Lucila and Herminia have visual problems. Herminia has a vision of 275(Left)/250(Right), while Lucila has 120(Left)/120(Left). They both have personal reading glasses.
2.
Examination The primary dialect that they use is tagalong. They also use
other dialects such as, English, Ilonggo, Bicol, and Kapampangan. G. Self Perception-Self Concept 1. History Herminia states that the family feels good most of the time. They normally have their own family problems like every other family and tend to help each other at times of family crisis. The show the children that they feel happy most of the time, to lessen the stress that the children have in studying for school. Herminia, Dante and Lucila feel anxious sometimes because of Dante being jobless at the moment. With Dante jobless, they are worrying about the monthly expenses that they have to pay for. Examples of things that may affect their mood are quarrels or misunderstandings between their members, when the children become stubborn at times and problems regarding finances. 2. Examination General mood state: rate is 3 because Herminia presents herself to be fine at the moment of interview when their family is under a state of crisis. She is cooperative but gets serious at times. Her mood 15
changes whenever she talks about the current financial problems in the family. Members are generally assertive. Rate given is 5 because during interview, questions. H. Role-Relationship Pattern 1. History Relationship to the head of the family Head of the Family Son Daughter-in-law Granddaughter Grandson Grandson Age 68 38 47 15 14 13 Sex F M M F M M Educational Attainment College BSE Graduate College Undergrad High School Graduate Still Studying Still Studying Still Studying interviewee is cooperative and honest in answering
Name Herminia D. Green Dante D. Atienza Jr. Lucila S. Atienza Hannah Grace S. Atienza Jay Marvin S. Atienza John Oliver S. Atienza
The Atienzas are an extended type of family. Regarding the familys role-relationship pattern, Herminia states that they sometimes get rough with the kids and sometimes experience a hard time in disciplining them; most usually with Hannah and Oliver. They may sometimes answer back at any of their elders. They also find it hard to make Hannah and Oliver cooperate with helping in the household during their free time. Herminia states that all they do sometimes is laze around all day after doing their school activities. Jay is however a responsible child, sharing his part in doing the household chores at home. However like Oliver, they may stay in computer shop late up until midnight. Herminia also states that even though they have a hard time in disciplining the kids, their relationship as brother and sister remain equal. The family also considers themselves as a part of their community and keep contact/socialize with their neighbours.
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2.
Examination The family communicates during meals. The elders and Jay help
each other out in doing household chores. The siblings help each other out in times of need, such a help in school assignments. The family is an extended type and it I. Sexuality-Reproductive 1. History Lucila and Dante are still sexually active. They say that their sexual relationship is satisfying. The parents are using the BBT method for family planning since Lucila is still not menopausal. They still dont educate their children about topics regarding sex and reproduction. They feel that it is inappropriate for them to discuss that topic to their children. J. Coping Stress Tolerance Pattern 1. History
The family is adjusting to the financial problem that they are currently facing. The family tries to help each other as possible. When family problems arise, the elders first discuss regarding what steps they will have to take in solving the problems, and then they will discuss these to the family members. They take things slowly and think of resolutions they may do to solve the problem. Lucila experiences hypertension once tension in situations rises. She resolves this by taking her Diovan medications, deep breathing and drinking plenty of water. The other family members only cool off for a moment and just try to relax to decrease the tension. When all members have cooled down, the family then goes back to discussion of how to solve the conflict. Herminia states that her methods are successful most of the time. K. Values-Beliefs Pattern 1. History The family members do not get everything they want because of current financial problems. One of the parents goals is to let their children be able to get a college degree, stay healthy and live a harmonious life. Only Herminia participates in religious activities of the community, such as attending afternoon sessions of praying the rosary at the community grotto. She and Lucila try their best to get Dante and the kids attached to religion. They usually go to Church every Sunday afternoon. Religion is very important to them once problems arise
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since they call God and ask for guidance to help them during crisis in the family arises. VII. Physical Examination Herminia D. Green Age: 68 y/o Weight: 125 lbs Height: 52
1. Skin I: The clients skin is fair in color evenly, decrease elasticity, wrinkled and moles scattered on facial skin and on upper and lower extremities and only small healed scars are present. Skin is intact, and no reddened areas. P: There are no masses palpated. Skin temperature is warm and clammy and skin is dry.
2. Nails I: Nails are clean, thick, and slightly pink in color, convex curvature, nails are evenly cut; tissue surrounding the nails is intact with beaus line. P: Nails are hard and immobile. Capillary refill is present at 2 sec, smooth texture.
3. Head, Face and Neck I: Head and neck is symmetrically aligned, head is normocephalic, held still and upright. Neck has slight cervical curvature, decrease flexes without bulging mass. Symmetric facial movements, Hair is short and a mixture of brown, gray and white in color, thin but evenly distributed, no presence of flakes. Facial wrinkles are prominent, mouth is drawn inward. P: No lumps or masses, no inflammation of lymph node in the face, there is presence of pulsations on temporal artery.
4. Eyes I: Eyebrows are brown in color and symmetrically aligned, no discharges, pupils are equally round and reactive to light and accommodation. There is no discoloration of the eye, sclera appears white, and eyes are at the level of the ears, can follow the six ocular movements. Yellowish nodules on bulbar conjunctiva on medial side of iris are present. The vision of client is 275/270 she is near sighted.
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P: Absence of masses and tenderness and discharges on inner and outer cantus upon palpation
5. Ears I: Color same as facial skin, both are symmetric and evenly aligned to the head and auricle of the ear aligns with aligned to the corner of the eye. Can react to sounds or noises, normal voice tone audible, able to hear snapping fingers on both ears. P: No tenderness, no lesions and masses
6. Nose and Sinuses I: upon assessment the nose is symmetrical and able to sniff through each nostril, no discharges or nasal flaring, same color of the face, no lesions and deformities P: No tenderness and masses felt over bony prominence above each eye and maxillary sinuses.
7. Mouth and Pharynx I: Lips are pinkish in color, all are false teeth slightly yellow stained. Gums are pink and tight. No bulging masses. Tongue is pinkish in appearance and is in midline, moves freely up, down and sideward. Uvula hangs freely in the midline. Hard palate is pale with transverse rugae. P: The client elicits gag reflex. And tongue offers strong resistance on up, down, and side to side tongue pressure.
8. Spine I: The patient has a slight curvature of the thoracic spine. The spine is vertically aligned right and left clavicles and hips are at the same height and moves symmetrically. P: No masses or tenderness noted.
9. Thorax/Chest I: the posterior and anterior thorax is uniform in color. No lesions or bulging mass noted. No respiratory distress noted. Ratio of AP diameter is 1:2.
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Pa: No masses or tenderness are present. Has uniform body temperature. Has symmetric chest expansion. Pe: normal resonance sounds is elicited upon percussion of the thorax/chest. A: Lung sounds are clear to auscultation bilaterally. No abnormal breath sounds was heard.
10.Cardiovascular and Peripheral Vascular/Heart I: There are no heaves noted on the chest of the patient. No pulsations noted. A: No bruit was noted. No extra heart sounds noted. P: No masses or tenderness palpated.
11.Breast and Axilla - refused
12.Abdomen I: Presence of striae and small healed on the skin of the abdominal area. Inverted umbilicus, color is symmetric to the upper extremities and face. A: Bowel sounds heard Pe: Pa: abdomen is soft and with doughy texture, warm to touch, no masses present. No pain is elicited.
13.Extremities I: Varicosities are present in both legs and feet and back of the hands; scars are present on arms and legs. P: Has equal pulsations in both sides of lower and upper extremities 14.Genitals refused
15.Rectum and Anus - refused . 16.Neurologic Exam Patient was conscious, oriented, and coherent. She was aware on what is happening around her. She was actively voluntarily cooperative. She was able to identify objects with open and closed eyes. She can also answer questions appropriately and she was oriented. 20
Dante D. Atienza Jr. Age: 38 y/o Weight: 170lbs Height:56
1. Skin I: Skin is dark in color evenly, skin is elastic, and moles scattered on skin on upper and lower extremities and only small healed scars are present. Skin is intact, and no reddened areas. P: There are no masses palpated. Skin temperature is warm and clammy and skin is moist.
2. Nails I: Nails are clean, slightly pink in color, convex curvature, nails are evenly cut; tissue surrounding the nails is intact. Some nails on feet have darkened in color (light brown) and with beaus line. P: Nails are hard and immobile. Capillary refill at 2 sec, smooth texture.
3. Head, Face and Neck I: Head and neck is symmetrically aligned, head is normocephalic, held still and upright. Neck is without bulging mass. Symmetric facial movements, Hair is short and black in color some strands of hair are white, thick and evenly distributed, no presence of flakes. P: No lumps or masses, no inflammation of lymph node in the face, there is presence of pulsations on temporal artery.
4. Eyes I: Eyebrows are black in color and symmetrically aligned, no discharges, pupils are equally round and reactive to light and accommodation. There is no discoloration of the eye, sclera appears white, and eyes are at the level of the ears, can follow the six ocular movements P: Absence of masses and tenderness and discharges on inner and outer cantus upon palpation
5. Ears I: Color same as facial skin, both are symmetric and evenly aligned to the head and auricle of the ear aligns with aligned to the corner of the eye. Can react to sounds or noises, normal voice tone audible, able to hear snapping fingers on both ears. P: No tenderness, no lesions and masses 21
6. Nose and Sinuses I: upon assessment the nose is symmetrical and able to sniff through each nostril, no discharges or nasal flaring, same color of the face, no lesions and deformities P: No tenderness and masses felt over bony prominence above each eye and maxillary sinuses. 7. Mouth and Pharynx I: Lips are pinkish brown in color, teeth are intact and 2 false teeth on the upper front have 32 slight yellow stained teeth. Gums are pink and tight margins to the tooth. No bulging masses. Tongue is pinkish in appearance and is in midline, moves freely up, down and sideward. Uvula hangs freely in the midline. P: The client elicits gag reflex. And tongue offers strong resistance on up, down, and side to side pressure. 8. Spine I: The patient has no bone deformities. The spine is vertically aligned Right and left clavicles and hips are at the same height. P: No masses or tenderness noted.
9. Thorax/Chest I: the posterior and anterior thorax is uniform in color. No lesions or bulging mass noted. No respiratory distress noted. Ratio of AP diameter is 1:2 Pa: No masses or tenderness are present. Has uniform body temperature. Has symmetric chest expansion. Pe: normal resonance sounds is elicited upon percussion of the thorax/chest. A: Lung sounds are clear to auscultation bilaterally. No abnormal breath sounds was heard.
11.Breast and Axilla refused
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12.Abdomen I: Presence of striae and small healed on the skin of the abdominal area. Inverted umbilicus, color is symmetric to the upper extremitites and face. A: Bowel sounds heard
13.Extremities I: Varicosities are present in both legs, scars are present on arms and legs. P: Has equal pulsations in both sides of lower and upper extremities
14.Genitals refused
15.Rectum and Anus - refused . 16.Neurologic Exam Patient was conscious, oriented, coherent and cooperative. He was able to identify objects with open and closed eyes. He can also answer questions appropriately and he was oriented.
Lucila S. Atienza Age: 47 y/o Weight: 141 lbs Height: 54
1. Skin I: The client has an evenly fair skin tone, wrinkles around the eyes and moles scattered on facial skin and on upper and lower extremities and only small scars are present on extremities. Skin is intact, and no reddened areas. Calluses are present on the sole. Has 3 large scars from 3 cesarean delivery. P: There are no masses palpated. Skin is smooth, temperature is warm and clammy and skin is dry but has good mobility and turgor.
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2. Nails I: Nails are clean, thick, and slightly pink in color, convex curvature, nails are filed; tissue surrounding the nails is intact with beaus line. P: Nails are hard and immobile. Capillary refill is present at 2 sec, smooth texture.
3. Head, Face and Neck I: Head and neck is symmetrically aligned, head is normocephalic, held still and upright. Neck has slight cervical curvature, good flexion without bulging mass. Symmetric facial movements, Hair is short and black in color, thick and evenly distributed, no presence of flakes. Facial wrinkles are prominent. P: No lumps or masses, no inflammation of lymph node in the face, there is presence of pulsations on temporal artery.
4. Eyes I: Eyebrows are black in color and symmetrically aligned, no discharges, pupils are equally round and reactive to light and accommodation. There is no discoloration of the eye, sclera appears white, and eyes are at the level of the ears, can follow the six ocular movements. The vision of client is 120/120 she. P: Absence of masses and tenderness and discharges on inner and outer cantus upon palpation
5. Ears I: Color same as facial skin, both are symmetric and evenly aligned to the head and auricle of the ear aligns with aligned to the corner of the eye. Can react to sounds or noises, normal voice tone audible, able to hear snapping fingers on both ears. P: No tenderness, no lesions and masses
6. Nose and Sinuses I: upon assessment the nose is symmetrical and able to sniff through each nostril, no discharges or nasal flaring, same color of the face, no lesions and deformities P: No tenderness and masses felt over bony prominence above each eye and maxillary sinuses.
7. Mouth and Pharynx
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I: Lips are pinkish brown in color, all teeth are intact slightly yellow stained with pasta at left lower molar. Gums are pink and tight. No bulging masses. Tongue is pinkish in appearance and is in midline, moves freely up, down and sideward. Uvula hangs freely in the midline. Hard palate is pale with transverse rugae. P: The client elicits gag reflex. And tongue offers strong resistance on up, down, and side to side tongue pressure.
8. Spine I: The patient has a straight spinal cord, without any deformities. The spine is vertically aligned right and left clavicles and hips are at the same height and moves symmetrically. P: No masses or tenderness noted.
9. Thorax/Chest I: the posterior and anterior thorax is uniform in color. No lesions or bulging mass noted. No respiratory distress noted. Ratio of AP diameter is 1:2. Pa: No masses or tenderness are present. Has uniform body temperature. Has symmetric chest expansion. Pe: normal resonance sounds is elicited upon percussion of the thorax/chest. A: Lung sounds are clear to auscultation bilaterally. No abnormal breath sounds was heard.
11.Breast and Axilla -refused
12.Abdomen I: Presence of striae and large scars due to past CS deliveries on the skin of the abdominal area. Inverted umbilicus, color is symmetric to the upper extremities and face. A: present bowel sounds Pe: 25
Pa: abdomen is soft and with doughy texture, warm to touch, no masses present. Fundus is firm, at the midline and tenderness is present when palpated. No pain is elicited.
13.Extremities I: Varicosities are present in both legs and feet and back of the hands; scars are present on arms and legs. P: Has equal pulsations in both sides of lower and upper extremities
14.Genitals refused
15.Rectum and Anus refused
16.Neurologic Exam Patient was conscious, oriented, and coherent. She was aware on what is happening around her. She was actively voluntarily cooperative. She was able to identify objects with open and closed eyes. She can also answer questions appropriately and she was oriented.
Hannah Grace S. Atienza Age: 15y/o Weight: 110 lbs Height: 56
1. Skin I: Colors is light brown and uniform. P: The texture is smooth, even and smooth. Normal skin turgor. Warm to touch. 2. Nails I: Nailbeds are pink in color.Convex and curvature P: Normal capillary refill. 3. Head, Face and Neck
26
I: The patients head is symmetrical to the body. The size, shape and symmetry of skull is normal. The color of the skin is the same with the rest of the body. Theres no distention of jugular vein. P: The carotid artery is easily palpable and theres no enlarged lymph nodes and any tenderness. Theres no bruit sounds heard while auscultation .
4. Eyes I: Pupils are equally round, reactive to light and accommodation.It has full ocular visions and peripheral visions. The eyebrows have equal hair distribution and eyelashes are cured outward. The eyelids are color light brown. P: No abnormal findings 5. Ears I: The ears are symmetric and proportional to the head, even in color and consisitent with the rest of the skin. It is aligned with the eyebrows. P: Normal pinna recoil and no abnormal findings 6. Nose and Sinuses I: Color is consistent with the rest of the skin. The client can tell the smell od=f an object being presented. P: No abnormal findings
7. Mouth and Pharynx I: She has dry and pinkish brown colored lips. The tongue is moist. Gums are pink and smooth. Tonsils are small, pink and symmetric in shape P: No abnormal findings 8. Spine I: The spine is centrally placed no curvature. P: No masses or tenderness noted.
9. Thorax/Chest I: Chest is symmetric and color is consistent with the rest of the skin.It has equal anterior and posterior excursion Pa: It has equal anterior and posterior excursion Pe:. A: No abnormal breath sounds
27
10.Cardiovascular and Peripheral Vascular/Heart I: A: No bruit was noted. No extra heart sounds noted. P: The pulmonic and aortic pulsations is easily palpable.. Peripheral pulses are equal (radial, brachia, carotid, popliteal). 11.Breast and Axilla -refused
12.Abdomen I: The patients abdomen has the same skin color with the rest of the body. Pe: Pa: No masses and tenderness.
13.Extremities I: The patients muscles, bones and joints are bilaterally symmetrical to left and right side of body, scar present on left index finger P: Theres no presence of edema, swelling, pain and tenderness
14.Genitals refused
15.Rectum and Anus - refused . 16.Neurologic Exam Patients is awake and alert. She is able to express self through speaking and gestures. Muscles and bones are bilaterally symmetrical to left and right side of the body. Movement of arms and legs are both in normal power and coordinated with all senses
Jay Marvin S. Atienza Age: 14y/o 1. Skin I: Colors is fair and uniform. P: The texture is smooth, it is also even and soft. Skin turgor and mobility goes back after 2-3 seconds. The skin is also warm and dry. Weight: 115lbs Height: 57
2. Nails
28
I: Nailbeds are pink in color.Convex and curvature P: Normal capillary refill. 3. Head, Face and Neck I: The patients head is symmetrical to the body. The size, shape and symmetry of skull is normal. The color of the skin is the same with the rest of the body. Theres no distention of jugular vein. P: The carotid artery is easily palpable and theres no enlarged lymph nodes and any tenderness. Theres no bruit sounds heard while auscultation .
4. Eyes I: The clients eye lashes is curled outward while the eyebrows have equal hair distribution. His conjunctiva is pink in color and the sclera is white and clear. Pupils are equally round, reactive to light and accommodation. The pupil response properly. P: Absence of masses and tenderness and discharges on inner and outer cantus upon palpation
5. Ears I: The patients ears are symmetric to each other just above the level of the eye. The color of the skin is the same as the color of the face P: Normal pinna recoil and no abnormal findings
6. Nose and Sinuses I: The patients nose has the same color with the rest of the face. No discharges seen, and has no pain and edema in maxillary and frontal sinuses Color is consistent with the rest of the skin. The client can tell the smell of an object being presented. P: No tenderness and masses felt over bony prominence above each eye and maxillary sinuses.
7. Mouth and Pharynx I: Lips are pinkish in color. Gums are pink and tight. No bulging masses. Tongue is moist, moves freely up, down and sideward. Tonsils are small, pink and symmetric in shape P: No abnormal findings
8. Spine I: The spine is centrally placed no curvature. 29
P: No masses or tenderness noted.
9. Thorax/Chest I: Chest is symmetric and color is consistent with the rest of the skin.It has equal anterior and posterior excursion Pa: It has equal anterior and posterior excursion Pe:. A: No abnormal breath sounds
10.Cardiovascular and Peripheral Vascular/Heart I: A: No bruit was noted. No extra heart sounds noted. P: The pulmonic and aortic pulsations is easily palpable.. Peripheral pulses are equal (radial, brachia, carotid, popliteal).
11.Breast and Axilla
12.Abdomen I: The patients abdomen has the same skin color with the rest of the body. Pe: Pa: No masses and tenderness.
13.Extremities I: The patients muscles, bones and joints are bilaterally symmetrical to left and right side of body P: Theres no presence of edema, swelling, pain and tenderness
14.Genitals refused
15.Rectum and Anus - refused . 16.Neurologic Exam The patient is conscious and able to answer questions immediately. Movements are well coordinated with the rest of the body parts. 30
John Oliver S. Atienza Age: 13 y/o Weight: 103 lbs Height: 54
1. Skin I : Color is light brown. Its texture is even, smooth, and intact. P : Skin temperature is warm. Good skin turgor. 2. Nails I :The nails are colored pink in nail beds & convex. Upon assessment, it is 160 between the nail and base. P : It has a smooth texture and capillary refill is 1-2 seconds.
3. Head, Face and Neck I :Head is normocephalic while the color is consistent with rest of the skin. It is symmetrical to the body. Eyes, nose, ears and mouth are symmetrical to each other. P : No other abnormal observations 4. Eyes I : The eyes are parallel to each other.Pupils are equally round, reactive to light and accommodation. It has good ocular visions and peripheral visions while the eyebrows have equal hair distribution and eyelashes are curled outward. The eyelashes are color black. The conjunctiva is pinkish in color. P : No other abnormal observations 5. Ears I: The ears are symmetric and proportional to the head, smooth, even in color and consistent with the rest of the skin. Auricles are normally level to each other and smooth in texture. Good hearing acuity. P : Has good pinna recoil and it can hear whispered voice from 1-2 feet away from the patient. 6. Nose and Sinuses I - Nose is symmetrical to the face and has neither underlying deviations nor nasal discharge or flaring. Color is consistent with the rest of the skin; the client can also identify the smell of an object being presented such as perfume and alcohol. P No other abnormal observations
7. Mouth and Pharynx
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I- Lips are soft, moist, and pink. The tongue is located in the midline and it moves freely from side to side and up and down. Gums are pink and smooth. The tonsils are bilateral, small, pink and symmetric in shape. Uvula is at the center. P No other abnormal observations
8. Spine I: The spine is centrally placed no curvature. P: No masses or tenderness noted.
9. Thorax/Chest I :Chest is symmetric and color is consistent with the rest of the skin. Pa : It has equal anterior and posterior thorax excursion. A :Normal Breath Sounds
10.Cardiovascular and Peripheral Vascular/Heart I : No visible palpitations A :No S3 or S4 sounds. Pa : There is palpable pulsation on aortic and pulmonic and at Point of Maximal impulse. Peripheral pulses are bilaterally equal (radial, brachia, carotid, popliteal).
11.Breast and Axilla
12.Abdomen I : Abdomen color is consistent with the rest of the skin Umbilicus is centrally located. A :No abnormal sounds Pe : Pa : No masses and tenderness
13.Extremities I :Muscles and bones are bilaterally symmetrical to left and right side of body. The patient can perform active range of motion. P : No other abnormal observations
32
14.Genitals refused
15.Rectum and Anus - refused . 16.Neurologic Exam Patient is awake and able to cooperate with us during the interview. Coordinated body movements.
VIII.
Typology of Nursing Problems
Second Level Assessment Cues/Data Family Nursing Plan
Hindi kami kumakain ng gulay. Ayaw kasi ng mga bata. as stated Herminia.
A. Faulty eating habits Health Threat 1. Inability to recognize the presence of the condition due to attitude in life which hinders acceptance of a problem 2. Inability to make decisions with respect to taking appropriate action due to: a. Conflicting opinions among family members regarding action to take b. Negative attitude towards the health condition. 3. Inability to provide adequate nursing care to the sick, disabled, dependent or at-risk member of the family due to inadequate
33
knowledge about development and care. Mrs. Green verbalized Hindi kami nag-papatingin agad sa doctor. Sa albularyo kami nagpapatingin. When Hannah Grace and John Oliver had fever 2 months ago, they call their neighborhood albularyo for help. They only consult the doctor in cases where in sickness becomes severe.
child
B. Inappropriate Health Care Health Deficit 1. Inability to recognize the presence of the condition or problem due to philosophy in life which hinders acceptance of a problem. 2. Inability to make decisions with respect to taking appropriate action due to: a. Failure to comprehend the nature of the problem. b. Negative attitude towards the health condition. c. Misconceptions about proposed course of action. 3. Inability to provide adequate nursing care to the sick, disabled, dependent or at-risk member of the family due to philosophy in life which hinders caring for the sick, disabled, dependent, at-risk member. 4. Failure to utilize community resources for health care due to negative philosophy in life which hinders effective or maximum utilization of community resources for health care.
Lucila, started having hypertension, September last year. She was given prescription by her physician and has been taking her Diovan (Valsartan) medications for hypertension 80mg once a day, every day for lifetime, since then as maintenance. Nakakadagdag sa gastos yung gamot ni Lucila. As stated by the client.
C. Hypertension Health Deficit 1. Inability to recognize the presence of the problem due to denial about its existence as a result of fear of consequences of diagnosis of problem, specifically cost implications. 2. Inability to make decisions with respect to taking appropriate health actions due to: a. Failure to comprehend the nature of the problem. b. Inaccessibility of appropriate resources for care, specifically cost constraints. 3. Inability to provide adequate nursing care to the sick, disabled,
34
dependent or vulnerable/at-risk family member due to: a. Inadequate knowledge and skill in carrying out the necessary care. b. Inadequate family resources for care, specifically absence of responsible member and financial constraints.
IX.
Problem Scoring
A. Faulty eating habits Criteria Computation 1. Nature of the problem 2/3 x 1
Actual Score 0.67
Justification The problem is a health threat since it may affect the familys health. The problem is easily modifiable and the resources are available. The problem can be prevented temporarily but it affects the whole community. The family recognizes as a problem but does need immediate action.
2. Modifiabil ity of the Problem
2/2 x 2
3. Preventiv e Potential
3/3 x 1
4. Salience of the Problem
2/2 x 1
Total Score
4.67
B. Inappropriate Health Care Criteria 1. Nature of the problem Computation 3/3 x 1 Actual Score 1 Justification The problem is a health deficit because they call the albularyo instead of seeing the doctor. The problem is easily modifiable and the resources are
1. Modifiability of the problem
2/2 x 2
35
available. 2. Preventive Potential 3/3 x 1 1 The problem is high prevention because the health center is available and accessible to them. It is perceived as a condition needing change since it makes them well without doctors diagnosis.
1/2 x 1
0.5
TOTAL SCORE:
4.5
C. Hypertension Criteria 1. Nature of the problem
Computation 3/3 x 1
Actual Score 1
Justification The problem is a health deficit since it is a lifetime illness and can be hereditary or due to lifestyle. The problem is easily modifiable and the resources are available in the health center. The problem is high prevention because the health center is available and accessible to them. The family recognized as a problem. It consulted to the health personnel and needs immediate action.
2. Modifiabil ity of the Problem
2/2 x 2
3. Preventiv e Potential
3/3 X 1
2/2 x 1
Total Score X. Priority Setting RANK 1 RANK 2 Hypertension
5 4.67
Faulty Eating Habits 36
RANK 3
Inappropriate Health Care
4.5
37
XI.
Family Nursing Care Plan Intervention Plan
Health Problem
Family Nursing Problems
Goal of Care
Objectives of care
Nursing Interventions
Method of Nurse-family contact
Resources Required
4. Hypertension
Inability to recognize the presence of the problem due to denial about its existence as a result of fear of consequences of diagnosis of problem, specifically cost implications. 5. Inability to make decisions with respect to taking appropriate health actions due to: a. Failure to comprehend the nature of the problem. b. Inaccessibility of appropriate resources for care, specifically cost constraints. 6. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk family member due to: a. Inadequate knowledge and skill in carrying out the necessary care. b. Inadequate family resources for care, specifically absence of responsible member and financial constraints.
After nursing intervention, the family will be able to have adequate knowledge in hypertension treatments, nature, causes, effects, and management.
After nursing intervention, the family will be able to: a. b. Relieve symptoms Comply with the medications prescribed by the doctor.
1. Discuss: a. Nature and causes of hypertension. b. Signs and symptoms of hypertension. c. Possible effects of hypertension. d. Benefits of the treatment. e. Side and Adverse effect of the medications. f. It will take 3-6 weeks for the full therapeutic effect of the drug.
Home Visit and Clinic Visit
Material Resources: Visual Aids on teaching principles of afterdeath call.
Human Resources: Time and effort of the nurse and the family.
Financial Resources: Expenses for teaching aids, food, and transportation of the nurse.
2.
Ask the client to: a. Check blood pressure and cardiac rate regularly. b. Decrease potassium intake. c. Continue medication even if feeling well. d. Take the medication same time each day.
38
Intervention Plan Health Problem Family Nursing Problems Goal of Care Objectives of care Nursing Interventions Method of Nurse-family contact Resources Required
1.
Inability
to
recognize
the
After
nursing
39
Faulty Eating Habits
presence of the condition due to attitude in life which hinders acceptance of a problem.
2. Inability to make decisions with respect to taking appropriate action due to: a. b. Conflicting opinions among family members regarding action to take Negative attitude towards the health condition.
After nursing intervention, the family will be able to understand the importance of balanced diet.
intervention, the family will be able to: a. Understand the importance of vegetables in the body. Eat vegetables regularly.
1. Discuss: a. b. Food pyramid Importance balance diet
Home Visit and Clinic Visit of
Material Resources: Visual Aids on teaching principles of after-death call.
b.
2. Ask the family to: a. Increase vegetables intake b. Exercise regularly Human Resources: Time and effort of the nurse and the family.
3.
Inability to provide adequate nursing care to the sick, disabled, dependent or at-risk member of the family due to inadequate knowledge about child development and care.
3. Devise a food plan that specifies total daily calories (1600 kcal/day) and includes all food groups, with three meals plus a light evening snack.
Intervention Plan Health Problem Family Nursing Problems Goal of Care Objectives of care Nursing Interventions Method of Nurse-family contact Resources Required
40
Inappropriate Health Care
1.
Inability to recognize the presence of the condition or problem due to philosophy in life which hinders acceptance of a problem.
2.
Inability to make decisions with respect to taking appropriate action due to: a. Failure to comprehend the nature of the problem. b. Negative towards the condition. attitude health
After nursing intervention, the family will be able to acknowledge the importance of regular check up with health care providers.
After nursing intervention, the family will be able to: a. b. Visit the health care providers for regular check up. Appreciate the health center within their community.
Discuss: a. b. Importance of regular check up. Benefits and programs offered by the health facilities within the community.
Home Visit and Clinic Visit
Material Resources: Visual Aids on teaching principles of after-death call.
Human Resources: Time and effort of the nurse and the family.
c. Misconceptions about proposed course of action.
3.
Inability to provide adequate nursing care to the sick, disabled, dependent or at-risk member of the family due to philosophy in life which hinders caring for the sick, disabled, dependent, at-risk member.
4.
Failure to utilize community resources for health care due to negative philosophy in life which hinders effective or maximum utilization of community resources for health care.
41
XII.
Action Plans
HYPERTENSION Time frame Problem Goals/Objective s Implementation Focus of Responsibility Resources Evaluation
2 weeks
Risk to develop severe To maintain Conduct health hypertension normal blood teaching about pressure hypertension treatments, nature, causes, effects, To monitor and management. blood pressure and cardiac rate regularly
Affected family member
BP Apparatus After two weeks and stethoscope of health education and implementation, the client will be able to be compliant to the medications
To educate family members about hypertension
42
FAULTY EATING HABITS
Time frame
Problem
Goals/Objective s
Implementation
Focus of Responsibility
Resources
Evaluation
2 weeks
Readiness for enhanced To follow nutrition appropriate standard for intake according to the food pyramid
Conduct health teaching about importance of balance diet, and food pyramid.
Children
Visual aids or pictures of food pyramid, malnutrition, and obesity.
After two weeks of health education and implementation, the family eats balance diet meals.
Conduct cooking To be free from sessions with the malnutrition or mother to obesity implement the intake of vegetables within the dishes that children will like.
Real vegetables
43
INAPPROPRIATE HEALTH CARE Time frame Problem Goals/Objective s Implementation Focus of Responsibility Resources Evaluation
2 weeks
Health seeking behavior
To express desire to change specific lifestyle patterns to maintain optimal health
Conduct health teaching about importance of regular check up and benefits given by the health center.
The whole family
Time and money After two weeks for of health transportation education and implementation, the family visits the health center for regular check ups.
To seek community resources with desired change
Have the family to tour to the health facilities within the community.
44
XIII.
Evaluation Criteria Mark if observed YES NO Remarks
1. The family was able to be compliant with their medications. 2. The family was able to take balance diet meals. 3. The family was able to recognize the health center and its offered programs. 4. The family practices regular check-ups.
45
XIV.
Recommendation Our group came up with the following recommendations to help the family cope up with the existing health problems, promoting proper nutrition, and maximizing the benefits of health facilities within the community: 1. Assess their preparedness and capabilities to learn additional
knowledge about health promotion and health lifestyle of the family. 2. Educate the family about the benefits and programs offered by the health facilities within the community. 3. Regular consultation and monitoring of the family members health status promotes wellness. 4. Compliance with the medications and proper treatment helps the family maintain healthy lifestyle.
46
List of Appendices Appendix A I. Family Functional Health Patterns Assessment A. Health Perception-Health Management Pattern 1. History a. How has familys general health been (in the last few years)? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ b. Colds in the past year? Absence from work/school due to health reasons? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ c. Most important thing you do to keep healthy? Do you think these make a difference to health? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ Members use of cigarettes, alcohol, drugs? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ d. Immunizations? Health care provider? Frequency of checkups? Accidents (home, work, school, driving)? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ e. In the past, has it been easy to fins ways to follow suggestions of doctors, nurses, social workers? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ f. Are there things important in the familys health that I could help with? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ 2. Examination a. General appearance of family members and home. 47
___________________________________________________________________ ___________________________________________________________________ ________________________________________________ b. If appropriate: Storage of medicines, location of cribs, playpens, stove, scattered rugs, presence of hazards etc. ___________________________________________________________________ ___________________________________________________________________ ________________________________________________
B. Nutritional-Metabolic Health Pattern 1. History a. Typical family meal pattern/food intake? Make a 24 hours meal pattern table.
b. Typical family fluid intake. (Describe). Supplements: types available (fruit juices, carbonated beverages, coffee, etc.)? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ c. Does family have good appetite? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ d. Anyone on the family with dental problems? How often does the family visit the dentist? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ e. Any skin problems/ healing problems in the family? ___________________________________________________________________ ___________________________________________________________________ ________________________________________________ 2. Examination If opportunity available: Describe refrigerator contents, meal contents and preparation, etc. _________________________________________________________________ _________________________________________________________________ ______________________________________________
C. Elimination Pattern 1. History
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a. Family members use of laxatives or any other aids in elimination? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ b. Problems in waste / garbage disposal? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ c. Any pet animals at home? How are wastes disposed? (indoor/ outdoor) ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ d. If indicated: Any problems with flies, roaches, rodents in your house? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 2. Examination If opportunity available: examine toilet facilities, garbage and pet waste disposal; Indicators of risk for flies, roaches, rodents
D. Activity-Exercise Pattern 1. History a. In general, do family get a lot/ little exercise? Type? Frequency? __________________________________________________________________ __________________________________________________________________ ________________________________________________
b. Are there any family leisure activities? Active/ Passive? __________________________________________________________________ __________________________________________________________________ ________________________________________________ c. Are there problems in shopping (transportation), cooking, keeping up the house, budgeting for food. Clothes, housekeeping, house cross? __________________________________________________________________ __________________________________________________________________ ________________________________________________ 2. Examination Describe pattern of general home maintenance, Personal maintenance.
49
_________________________________________________________________ _________________________________________________________________ ______________________________________________
E. Sleep-Rest Pattern 1. History a. Generally family members seem to be well rested and ready for school /work? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ b. Is there sufficient space? Is it quiet or noisy? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ c. Does the family find time to relax? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 2. Examination If appropriate: Observe sleeping space and arrangements. _________________________________________________________________ _________________________________________________________________ ______________________________________________
F. Cognitive-Perception Pattern 1. History a. Is there any member of the family with visual or hearing problem? How was it managed? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ b. Any big decisions family has to make? How was it made? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 2. Examination a. If indicated: Language/ Dialect spoken at home? __________________________________________________________________ __________________________________________________________________ ________________________________________________ b. Grasp of ideas and questions (abstract/concrete)? __________________________________________________________________ 50
__________________________________________________________________ ________________________________________________ c. Vocabulary Level __________________________________________________________________ __________________________________________________________________ ________________________________________________
G. Self Perception-Self Concept Pattern 1. History a. Most of the time , do the family members feel food/ not so good about themselves as a family __________________________________________________________________ __________________________________________________________________ ________________________________________________ b. General mood of family? Happy? Anxious? Depressed? What affects family mood? __________________________________________________________________ __________________________________________________________________ ________________________________________________
H. Roles-Relationship Pattern 1. History a. Name of family (or household) members? Indicate age and family structure (nuclear/extended). Draw a family tree or diagram
Name
Relationship to the head of the family
Age
Sex
Educational Attainment
b. Any family problems that is difficult to handle? Child rearing? If appropriate: Spouse/Parents (should be included if children are interviewed) or children ever get rough with you? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________
Family Assessment c. Relationship good/not so good among family members? Sibling? Support each other? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 51
d. If appropriate: Is family income sufficient for needs? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ e. Does the family feel apart of (or isolated from) neighbors or community? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 2. Examination a. Describe interaction among family members (if present). ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ b. Observe family leadership roles. ___________________________________________________________________ ___________________________________________________________________ ______________________________________________
I.
Sexuality-Reproductive Pattern 1. History a. If appropriate (sexual partner within household or situation): Sexual relationships satisfying? Any problem or changes? __________________________________________________________________ __________________________________________________________________ ________________________________________________ b. Use of family planning methods? Problems? __________________________________________________________________ __________________________________________________________________ ________________________________________________ 2. Examination: None
J.
Coping-Stress Tolerance Pattern 1. History a. Any big changes within the family in the last few years? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ b. Family tensed or relaxed most of the time? When tense, what helps? Use of medicines, drugs, alcohol to decrease tension? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 52
c. When family problems arise, how is it being handled? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ d. Most of the time, is this way successful? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 2. Examination: None
K. Values-Beliefs Pattern 1. History a. Generally, does the family get what it wants from life? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ b. Important goals for the future? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ c. Any rules in the family that everyone believes important? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ d. Is religion important in the family? Does this help when difficulties aries? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ 2. Examination: None
II.
FAMILY STRENGTH AND WEAKNESSES A. Identify two family strengths and why do you say so? How can this be mobilized to solve other family concerns/problems? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________ B. Identify two family weaknesses and why do you say so How can this be strengthened to help develop the family? ___________________________________________________________________ ___________________________________________________________________ ______________________________________________
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III.
PERCEPTION ON MY FAMILYS LEVEL OF FUNCTIONING: Instruction: For each statement listed below, indicate your answer by placing a check ( / ) on the corresponding columns marked Almost always, Some of the Time or Hardly ever. Then total your score for each of the five statements.
STATEMENTS
ALMOS T ALWAY S 2PTS
SOME OF THE TIME 1PT
HARDL Y EVER 0PT
1. I am satisfied with the help that I receive from my family when something is troubling me 2. I am satisfied with the way my family discusses topics of common interest and shares problems solving with me. 3. I find that my family accepts my wishes to take on new activities or make changes in my lifestyle. 4. I am satisfied with the way my family expresses affection and responds to my feelings of anger, sorrow and love. 5. I am satisfied with the amount of time my family and I spend together. TOTAL SCORE: 10 points Appendix B Scale for Ranking Health Conditions and Problems According to Priorities Criteria 1. Nature of the condition or problem presented Wellness State Health Deficit Health Threat Foreseeable Crisis 3 3 2 1 Scale 1 Weight
2. Modifiability of the condition of problem Easily Modifiable Partially Modifiable Not Modifiable 2 1 0 Scale 2
3. Preventive Potential Scale High Low 54 3 2
Moderate
4. Salience Scale A condition or problem needing immediate 2 1 1 0
attention A condition or problem not needing immediate attention Not perceived as a problem or condition needing change
55
Appendix C Manila Doctors College College of Nursing COMMUNITY HEALTH SURVEY TOOL Control No: Head of the Family (HF) (Kinikilalang puno ng pamilya): I. DEMOGRAPHIC INDICES A. Family Information Complete Address (tirahan): Extended Length of Residency (tagal ng paninirahan sa lugar): sa nasabing bahay): Ethnic Background (etnikong grupo na kinabibilangan): ( ) Matriarchal Primary Dialect Spoken (pangunahing salitang ginagamit): Egalitarian Place of Origin (rehiyong pinanggalingan): No . Name of Family Members (pangalan ng miyembro ng pamilya) Sex (kasaria n) Age (Edad ) Birth Date (araw ng kapanganakan) Month/Day/Year Date:
Type of Family (uri ng pamilya): ( ) Nuclear( ) No. of Families in the House (bilang ng pamilya Type of Family according to authority: ( ) Patriarchal ( )
Birth Place (lugar ng kapanganakan )
Civil Status (Estadon g Sibil)
Religion (relihiyon)
Relationship to HF (relasyon sa puno ng pamilya)
56
Ethnic Background: Igorot, Negrito, Kalinga, Mangyan, Maranaw, Manobo, Badjao, Matigsalug, Tasaday, Tausug, etc. Civil Status: S (single) M (married) W (widowed) Sep (separated) CL (common law) Relationship to HF: Wife (W) Husband (H) Son (S) Daughter (D) Mother (M) Father (F) Grandfather (GF) Grandmother (GM) Sister (Sis) Brother (Bro) Uncle (Un) Auntie (Au) Others (specify) B. OCCUPATION (15y/o and above but may include working individual below 15) Name of Family Members (pangalan ng miyembro ng pamilya) Age (eda d) Occupation Unemploy ed Employed Privat e Governme nt SelfEmploy ed Nature of Occupation Place of Work Estimated Monthly Income
C. EDUCATION (7 y/o and above) Name

Ag e No Formal Educatio n
Elementary Level
Out of Scho ol Still Studyin g Undergradua te Graduat e Out of School
High School Level

Still Studyin g Undergradua te Graduat e Out of Scho ol
College Level
Still Studyin g Undergradua te Graduat e
Others (Please Specify)
57
Out of school: if a person whose age is proper for an educational level, but nit currently enrolled in the same level. Undergraduate: a person who did not finish an educational level and his/her age is no longer appropriate to the same level. Age Brackets Per Level Elementary 7-12 y/o, High School 13-17 y/o, College 18-23y/o. 1.) Source of income Primary Source: Other sources of income or livelihood (iba pang pinagkukuhaan ng kabuhayan) You can check more than one. ( ) Sari-sari store ( ) Livestock ( ) Craft making ( )Public utility ( ) Others, pls. specify: 4.) First 5 priorities for expenditure. Rank 1 to 5, 1 as the highest and 5 as the least priority. Food (pagkain) Health (kalusugan) ( ) Farming ( )Fishing Clothing (damit) tubig, etc) Others, pls. specify: 5.) Land and House ownership a.) Land ownership (pagmamay-ari ng lupang tinitirahan) ( ) Owned ( ) Rented ( ) Rent to own ( ) Rent Free ( ) Others, pls. specify: b.) House ownership (pagmamay-ari ng bahay na tinitirahan) ( ) Owned ( ) Rented ( ) Rent to own ( ) Rent Free ( ) Others, pls. specify: 6.) Type of materials used for building the house (yari ng bahay) ( ) Light ( ) Concrete ( ) Mixed 7.) House Ventilation ( ) Well ventilated ( ) Fair 58 8.) Source of Light ( ) Electricity ( ) Others, pls. specify: ( ) Poorly ventilated ( ) Candle House rental (upa sa bahay) Education (edukasyon) Housebills (bayad sa kuryente,
2.) Average family income (buwanang kita ng pamilya) Income P 1,000 and below P 1,001 5,000 P 5,001 10,000 P 10,001 15,000 P 15,001 20,000 P 20,001 25,000 P 25,001 30,000 P 30,001 35,000 P 35,001 and Above 3.) Monthly family expenditure (buwanang gastusin ng pamilya) Expenditure P 1,000 and below
( ) Kerosene
3. Garbage a. Waste Segregation ( ) Yes ( ) No ( ) Sometimes b. Container used for garbage collection (pinaglalagyan ng iniipong basura) ( ) none ( ) Garbage bag ( ) Sack ( ) Trash can/pail) II. ( ) others, pls. specify: c. Condition of garbage container? (kalagayan ng lalagyan ng basura) A. WATER SUPPLY ( ) Covered ( ) Uncovered 1. Source of drinking water (pinagmumulan ng inuming tubig) d. Types of disposal ( ) collected ( ) open dumping ( ) burning ( ) Level I- Point source (without distribution system- protected ( ) composting ( ) throw in river/canals well, developed spring) ( ) others, pls. specify: ( ) Level II- Faucet system (piped and communal faucet) ( ) Level III- Individual household connection C. ANIMALS AND PESTS ( ) Commercially prepared a. Domestic animals ( ) Others, pls. specify: Kind (uri ng Numb Vaccination Status alagang er With W/o Chained Astray Either 2. Storage of drinking water (paraan ng pag-iimbak) hayop) (bilang (meron (wala) / Caged/ ( ) Covered ( ) Uncovered ) ) Penned Dogs 3. Method used in water treatment (paraang ginagamit upang mapanatiling malinis ang inuming tubig) Cats ( ) None ( ) Boiling ( ) Sedimentation ( ) Chlorination Others, pls. ( ) Filtration ( ) Processed (multi- stages) Specify: ( ) others, pls. specify: b. Presence of vectors, rodents and other pests B. WASTE DIPOSAL ( ) mosquitoes ( ) roaches ( ) termites ( ) flies ( ) 1.) Excreta rodents a. Type of toilet (uri ng palikuran) ( ) others, pls. specify: ( ) No toilet ( ) Open pit privy ( ) Closed/ c. Ways to control Covered pit privy Breeding place of: Ways to control Effective ( ) Water-sealed ( ) Flush ( ) others, pls. specify: Yes No Mosquitoes b. Ownership of toilet (pagmamay-ari ng palikuran) Roaches Termites 59 Flies Rodents Others (specify):
P 1,001 5,000 P 5,001 10,000 P 10,001 15,000 P 15,001 20,000 P 20,001 25,000 P 25,001 30,000 P 30,001 35,000 P 35,001 and Above ENVIRONMENTAL INDICES
( ) Private (sariling palikuran) ( ) Public (gamit pambayan ( ) Shared (may ibang pamilyang gumagamit) ( ) N/A(no toilet) 2.) Sewerage a. Sewerage system ( ) Blind drainage ( ) Open drainage ( ) none b. Condition of sewerage (kalagayan ng tubig) ( ) Free-flowing ( ) Stagnant ( ) N/A (blind drainage) 2.) Maternal Mortality III. HEALTH INDICES (Related to pregnancy, labor, delivery Puerperium) A. Morbidity (past 6mos.) Illness Acute lower RTI andPneumonia Acute Diarrhea Influenza Hypertension TB Respiratory Parasitism Chickenpox Diseases of the Heart Malaria Dengue Fever UTI Scabies DM Others, pls. specify: B. Mortality (past 5 years) 1.)Infant Mortality (0-1 year) Illness Neonatal sepsis Age Sex Treatment Wit Without h Cause of Death Complications Hypertension Hemorrhage Pregnancy with abortive outcome Others, pls. specify: 3.) Other Mortality Cause of Death Heart Disease Vascular System Diseases Malignant Neoplasm(Ca) Pneumonia Tuberculosis, all forms Chronic lower respiratory diseases Diabetes Mellitus Acute Peptic Ulcer Others, pls. Specify: 60 Age Sex Interventions With Without Age Intervention With Without
Age in month s
Treatment With Withou
t Pneumonia Congenital malformations of the heart Disorders related to short gestation and low birth weight Intrauterine hypoxia and birth asphyxia Diarrhea Others, pls. specify: C. For women of reproductive age (15-45 y/o) 1.)Previous pregnancy (Last 3 pregnancies, if applicable) No. With iron supplemen t Yes No If no, why? TT immunizatio n Yes No If, no why? Prenatal check up of at least 3x Yes No If no, why?
1st 2nd 3rd 2.)Previous deliveries (Last 3 deliveries, if applicable) No . Docto r P G Nurse P G Midwif e P G Traditional Birth Attendant Others, specify Reason for choosing the person to handle delivery Post Partum visits Yes No Why?
1st 2nd 3r d Legend:
P-Private
G-Government
61
3.)Present Pregnancy Name Obstetric Score G P T P A L Legend: G-Gravida D. For Children 1) Immunizatio (0-8years) Nam e Birth date BCG 1 OPV 2 DPT 2 HEPA B 1 2 MEASLE S 3 STATUS (0-1) NOT FIC FIC STATUS 1 YEAR Complet e Incomplete P-Parity (T-full term delivery; P-preterm delivery; A-abortion/miscarriage; L-living) LMP AOG EDD/ EDC Prenatal Checkup 1st 2n d 3rd Tetanus Toxoid Reason for absence or Incomplete TT immunization With iron supplem ent Yes No If no, why?
2.) Nam e a ge
Feeding(0-2 years) Exclusiv es BF until 6 mos. Complementa Reasons for not BF until ry 6 mos. BF until 6 mos & 1 day-2yrs Age of weanin g Bottle Feeding Formula othe Milk rs Other food given aside from milk
62
Yes
No
Yes
No
3.)Nutritional Status (0-72 mos.) Name Birthday Age in months Date of weighing weight in kilogram Nutritional Status( N,A, B)
Nutritional Status: E.
N: Normal
A: Above Normal
B:Below Normal
For Married Couples Of Reproductive Age 1) Practice Family Planning (FP) ( ) Yes ( ) No ( ) Sometimes 2) If yes, for how long? 3) If no, why? 4) If sometimes, reason for not consistently using FP 5) Family Planning Methods Natural Awar e Not aware Utilize d Artificial Aware Not aware Utilize d Permanen t aware Not aware Utilize d Willingness to learn more about FP methods Yes No What topic
Basal Body Temp
Condom IUD 63
Vasectom y Tubal Ligation
Calendar Cervical mucous Lactationa l Amenorrh ea Others,
Injectible hormonal contraceptives Pills
Others,
Others,
F. Other Practices Related to Health 1) Food a) Food Frequently eaten ( Pagkaing madalas kinakain) ( )Fish ( )Vegetable ( )Pork ( )Beef ( )junk food ( )canned or processed food Others, pls. specify: b) Usual food preparation (pinakamadals na paraan ng pagluto) ( )Boiled ( )Fried ( )Broiled ( )Steamed ( )Raw ( )Others, pls. specify:
64
2) Smoker/s Alcoholic drinker/Prohibited drug user a) Prohibited drug user (Kapamilya na gumagamit ng pinagbabawal na gamot) ( )Yes ( )No b) Smoker/s(kapamilya na naninigarilyo) ( )Yes ( )No c) Alcoholic Drinker (kapamilya na umiinum ng alak) ( )Yes ( )No
65

Family Nursing Care Plan & Community DX

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Family Nursing Care Plan & Community DX

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A Family Case Study of the A.

Presented to the Faculty Of Manila Doctors College, College of Nursing

Buzon, Myra Katrina R. Caberte, Iris D. Jinno, Chieri D.

X. XI. XII. XIII. XIV.

Appendices 53 Appendix A Appendix B Appendix C I. Introduction

BARANGAY LAS PIAS

TALON DOS CITY

11.Breast and Axilla - refused

Dante D. Atienza Jr. Age: 38 y/o Weight: 170lbs Height:56

11.Breast and Axilla refused

Lucila S. Atienza Age: 47 y/o Weight: 141 lbs Height: 54

7. Mouth and Pharynx

11.Breast and Axilla -refused

15.Rectum and Anus refused

Hannah Grace S. Atienza Age: 15y/o Weight: 110 lbs Height: 56

8. Spine I: The spine is centrally placed no curvature. 29

P: No masses or tenderness noted.

11.Breast and Axilla

John Oliver S. Atienza Age: 13 y/o Weight: 103 lbs Height: 54

7. Mouth and Pharynx

8. Spine I: The spine is centrally placed no curvature. P: No masses or tenderness noted.

11.Breast and Axilla

Typology of Nursing Problems

Second Level Assessment Cues/Data Family Nursing Plan

A. Faulty eating habits Criteria Computation 1. Nature of the problem 2/3 x 1

Actual Score 0.67

2. Modifiabil ity of the Problem

4. Salience of the Problem

1. Modifiability of the problem

3. Salience of the Problem

C. Hypertension Criteria 1. Nature of the problem

2. Modifiabil ity of the Problem

4. Salience of the Problem

Total Score X. Priority Setting RANK 1 RANK 2 Hypertension

Faulty Eating Habits 36

Inappropriate Health Care

Family Nursing Care Plan Intervention Plan

Family Nursing Problems

Method of Nurse-family contact

Home Visit and Clinic Visit

Material Resources: Visual Aids on teaching principles of afterdeath call.

Faulty Eating Habits

1. Discuss: a. b. Food pyramid Importance balance diet

Home Visit and Clinic Visit of

Material Resources: Visual Aids on teaching principles of after-death call.

Inappropriate Health Care

Home Visit and Clinic Visit

Material Resources: Visual Aids on teaching principles of after-death call.

c. Misconceptions about proposed course of action.

Affected family member

To educate family members about hypertension

FAULTY EATING HABITS

Visual aids or pictures of food pyramid, malnutrition, and obesity.

Health seeking behavior

To express desire to change specific lifestyle patterns to maintain optimal health

The whole family

To seek community resources with desired change

Evaluation Criteria Mark if observed YES NO Remarks

C. Elimination Pattern 1. History

_________________________________________________________________ _________________________________________________________________ ______________________________________________

Relationship to the head of the family

ALMOS T ALWAY S 2PTS

_________________________________ _ ______________