INTRODUCTION

Community health nursing is one of the two major fields of nursing in the Philippines; the other is hospital nursing. Community health nursing primarily works on the promotion and preservation of the health of the population. The nature of practice is comprehensive, general, continual and not episodic. Its basic knowledge and skills are anchored on nursing theories and important concepts form the science of public health. There are different levels of clientele in community health nursing: the individual, family, population group and community.

Infant and childhood mortality are sensitive indicators of inequity and poverty. Children who are most commonly and severely ill, malnourished and most likely to die of their illness are those of the most vulnerable and underprivileged populations of low-income countries. Every day, millions of parents seek health care for their sick children, taking them to hospitals, health centers, and the like. These factors along with limited supplies and equipment, combined with an irregular flow of patients make providing quality care to sick children a serious challenge. Experience and evidence show that improvements in child health are not necessarily dependent on the use of sophisticated and expensive technologies but rather on effective strategies that are based on a holistic approach which are available to the majority of those in need, and which take into account the capacity and structure of health systems as well as traditions and beliefs in the community. WHO and UNICEF have addressed this challenge by developing a strategy called the Integrated Management of Childhood Illness (IMCI). IMCI is a strategy developed by the World Health Organization's Division of Child Health and Development and UNICEF. It has been introduced to address morbidity and mortality in children under five years. The strategy focuses on the child as a whole, rather than on a single disease or condition. IMCI is a strategy that integrates all available measures for disease prevention and health problems during childhood, for their early detection and effective treatment, and for promoting healthy habits within the family and community. IMCI offers the knowledge and abilities to sequentially evaluate and integrate the status of child health and, in this way, detect the diseases or problems frequently affecting it according to the epidemiological patterns of the respective location. A comprehensive examination for general danger signs and major symptoms of diseases is done for all sick children. The combination of individual clinical signs leads to a classification rather than a diagnosis. The procedures use a limited no. of

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essential drugs. Encouragement of the active participation of caretakes is done. Counseling of caretakers is also done. Based on this evaluation, IMCI gives clear instructions on disease classification and problems, establishing the treatment that should be administered for each one. The strategy also provides instructions on how to control the progress of treatment, in order to identify the need for applying prevention measures as well as how to inform and educate parents on disease prevention and child health promotion. On this basis, IMCI is currently regarded as the most efficient strategy for reducing the burden of disease and disability among the population in this age group. Its main goal is to contribute to a healthy growth and development during the first five years of life.

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OBJECTIVES

General objective: By the end of our 4-week IMCI rotation, we will be able to come up with an all-inclusive mini family case study which aims to present adequate information regarding the general wellbeing of our selected family. Our target is to have an acquisition of new knowledge and enhancement of skills in the application of the community health nursing concepts and principles reflected on our act of service to our client family.

In specific, we aim to: select a family that has the qualifications to be subject for this case study; establish rapport with the family to initiate cooperation in line with the trusting nurseclient relationship throughout the process; gather data regarding the familys over-all status to compose the initial data base for a more systematized presentation of our chosen family through interviews and observations using the family assessment guide; Conduct an IMCI check-up if one of the children has 1 or more of the major symptoms and if he/she is an infant or 5 years and less. Assess the familys coping mechanisms in response to different situations to provide a basis for estimating the nursing needs of our selected family through the family coping index; identify existing and potential problems of the family in their environment, safety, personal hygiene, finances, resources, social relationships, or spirituality; Prioritize the recognized crises to determine what should be considered first and what problems doesnt need immediate solutions; Devise appropriate nursing interventions in order to meet the needs of the family through nursing care plans; Implement the proposed nursing care plans that will solve the familys existing problems, if not, prevent potential problems to occur or to improve the familys way of living; Evaluate the implemented plans whether there was an improvement or otherwise; FAMILY CASE STUDY | 3

Provide health teachings to the family regarding health, its maintenance and promotion towards wellness. Determine the implication of this case study to nursing education, research and practice.

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INITIAL DATA BASE A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS DEMOGRAPHIC DATA Demographic Data Demography encompasses the study of the size, structure and distribution of populations, and spatial or temporal changes in them in response to birth, migration, aging and death. On November 12, 2012, we, the BSN-2A Group 1 subgroup 2 conducted an interview on the Encarquez Family, an extended family which is composed of 5 families with a total of 50 members. They are currently residing at Barangay 21C Blk-85 Piapi Boulevard, Davao City. They have been living on the community for forty-six years. The house was originally owned by their grandmother but since the latter was dead, they claim the house as their own. The parents are Roman Catholic and pure Dabawenyos.

FAMILY MEMBERS CHART FAMILY MEMBERS FAMILY MEMBERS

NO
.

RELATION TO HEAD

AGE

SEX

CIVIL STATUS

EDUCAT -IONAL ATTAINMENT

OCCUPATION
TYPE OF WORK PLACE

NAME

Romeo Encarguez

-------

35

Married

Grade 3

Garbage Collector Anywhe re

Melinda Encarguez

Wife

31

Married

Grade 6

N/A

N/A

Mary Frances Encarguez

Daughter

14

Single

Grade 6

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Christian Encarguez

Son

13

Single

Grade 5 *

Rommel Encarguez

Son

12

Single

Grade 3 *

Chris Mae Anne Encarguez

Daughter

10

Single

Grade 1 *

Justine Encarguez

Son

Single

Raymond Encarguez

Son

Single

Raymart Encarguez

Son

Single

10

Reggie Encarguez

Son

Single

Mr. Romeo Encarguez is 35 years old. He has no stable job because he was not able to finish his studies. He is working as a garbage collector in CENRO. He drinks alcohol almost every day and no one can ever stop him even his daughter. His wife left them 2 years ago due to some family problems. He doesnt cook or prepare food for the children, only his daughter, Mary Frances. Mary Frances is 14 years old. She only graduated grade 6 and was forced to stop because she is the only one to take care of her siblings because their mother left them in such a young age. She sacrifices herself for her younger siblings because their father doesnt care to his children. She is fully in-charge of whatever necessary things for her siblings such as water and food supply. Christian, Rommel and Chris Mae Anne are fortunate enough to avail the program offered by the government. The government take full responsibility of their basic needs and currently living in the place where the government supports like bahay pasilungan, Don Bosco and etc.

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Unfortunately, Justine together with the triplets, Raymond, Raymart and Reggie doesnt go to school due to financial problems. For the meantime, theyre just enjoying being a kid of their time.

PLACE OF RESIDENCE Encarguezs family is residing at their own house at Brgy.21C Blk-85 Piapi Boulevard Davao City.

TYPE OF FAMILY STRUCTURE The Encarguez family is under the Extended family. 5 families are living there, compose of their 4 aunties family and them. All in all, they are composed of 20 adults and 30 children. In their family, it only consist of 6 members including the father since the 3 children lives in the charity.

ACTIVITIES OF DAILY LIVING Body Mass Index calculation and corresponding calculation

Family Member Romeo

Weight (kg) 53 kg

Heigh t (m) 1.6 m

BMI

Malnourished <16

Underweight 16-19

Normal 20-25

Overweight 26-30

20. 55

Melinda Mary Frances Christian Rommel

N/A 36 kg

N/A 1.5 m 15. 95

N/A N/A

N/A N/A

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Chris Mae N/A Ann Justine 11 kg

N/A

1m

11. 09

Raymond

8.5 kg

0.9 m

10. 33

Reymart Reggie

8 kg 8 kg

0.9 m 0.9m

9.7 9.7

Activities of daily living are the tasks of everyday life. These activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet and the like. Instrumental activities of daily living are activities related to independent living and include preparing meals, managing money, or doing housework.

Eating Pattern Our body needs energy to get through the day and this energy comes from food. It is important to eat regular meals to ensure your body gets the energy it needs to perform. Good nutrition and a balanced diet helps one grow up healthy. To improve and correct nutrition, one can basically assess from the eating pattern of the Encarguez family. The table presents the respective Body Mass Index of each family member with its respective classifying range and interpretation, except with the mother (Melinda) and three other siblings, which are Chris Mae Ann, Rommel and Christian because we did not have the chance to see them. The Body Mass Index was computed by dividing the weight of the individual (in kilograms) by the square of the height (in meters). Based from the calculations Mary Frances, Justine and the three triplets were classified under malnourished, only Romeo was classified normal. The factors that can affect the siblings malnutrition are starvation, lack of vitamins and their hyperactivity that is common in children at their age. The family eats two to three times a day. They dont have snacks in between meals because they cant afford to buy some. They dont follow the proper timing in mealtime. Take for example the time they consume their breakfast. They usually eat it for 10 am. They also call it FAMILY CASE STUDY | 8

brunch because that meal consists of their breakfast and lunch. They prefer cooking their own food rather than buying some in the carinderia because its costly. They eat the meal right away because they dont have a refrigerator in storing their food. They make use of kalan and uling in preparing their food because it is less expensive. They usually prepare food viands like soup with accompanying meat and leafy vegetables like kangkong and beans and fried foods. They seldom buy chicken and pork meat because the price is considerably more expensive. The Encarguez family usually take their breakfast at 9:30 am. Lunch is usually served 1 or 2 pm, sometimes they eat none during this time and dinner is taken by 8 pm. Mary Frances feeds his younger siblings and usually they do not wait for their father anymore so they eat their meals ahead of him. The table below shows the 24 hour dietary recall of the family as mentioned by Mary Francess our informant.

Eating pattern 24-Hour Dietary Recall Meal Breakfast Lunch Dinner November 11, 2012 Rice and kangkong Egg and rice Pansit canton and rice

As what we can see in the table above, the meals taken by the family as of breakfast are rice and kangkong. They ate egg and rice during lunchtime. For their supper, they ate instant noodles and rice.

Leisure Time Activities Since Mary Frances is the one who take good care of her siblings, they bond with each other through playing around in the gym or playing with their cousins who also live there. They also watch television at their neighbours. Mary Francess also chats with her friends just around FAMILY CASE STUDY | 9

the corner. The father doesnt play or interact with his children because he spends more time with his drinking buddies. They dont have any educational activities that are good with the children the fact that his father only finished studying until elementary and also their sister, Mary Frances who are also graduated in elementary only. They dont go to church every Sunday. Their activities of daily living are always the same, no changes. FAMILY CHARACTERISTICS General Family Relationship/Dynamics In every family unit, it is an unavoidable fact wherein conflicts would arise between family members. However, even if there are conflicts between each member of their family, they are still determined to resolve these conflicts. According to Ms. Mary Frances, being hardheaded of of her siblings is the usual cause of the familys conflict

CRITERIA Observable conflicts between family members

STATUS Present

ADDITIONAL INFORMATION Alcohol drinking and smoking by the father, he forgot to take care of his children and pass all the responsibilities to his eldest child, he have a conflict with his sister-in-law or their aunt, who helps also to take care of the children, because of this. Financial matter is also a problem since only the father, a garbage collector and their aunt, a nonpermanent worker, works for their living that is why sometimes, problems on budgeting is difficult since they have many members to feed and their budget is inadequate. Mrs. Mary Lingganon, their aunt, mentioned that each members talk FAMILY CASE STUDY | 10

Characteristics of communication

Informal

to each other everytime problems occur. She talks to the member everytime there are issues to tackle and in one-on-one talk to solve the issue right away to avoid more complications. Here are times that some of the problems like quarrels are not being talked and they just leave it and there will come a day that the problem will just forgotten and it just gone and back to normal. According to their sister,Mary Interaction patterns among members Communication Present Frances, they do interact with one another since they are seeing each other everyday and their house is not that big for them to miss each other. They talked everyday especially the kids, they play with one another although there are times that they quarrel which is normal, still they make peace afterwards.

Every family experiences some level of family conflict. The disagreements are a normal part of any relationship. They happen when people have different needs, wants or beliefs. However, if these conflicts go unresolved, they can begin to harm relationships in the home. According to Ms. Mary Frances, they also had incidents of verbal arguments and so far had not encountered a fight with that lead to physical assault.

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B.SOCIOECONOMIC STATUS & CULTURAL CHARACTERISTICS SOCIOECONOMIC STATUS Family Income and Educational Attainment Family Members Educational Attainment Employment Status Occupation Net Income Other Sources of Income Romeo Encarguez Melinda Encarguez Mary Frances Encarguez Christian Encarguez Rommel Encarguez Chris Mae Anne Encarguez Justine Encarguez TRIPLETS None Unemployed N/A N/A N/A None Unemployed N/A N/A N/A Grade 1 Unemployed N/A N/A N/A Grade 3 Unemployed N/A N/A N/A Grade 5 Unemployed N/A N/A N/A Grade 6 Unemployed N/A N/A N/A Grade 6 Grade 3 Stable Employment Unemployed Garbage Collector N/A N/A N/A 25 pesos/day N/A

The undeniable aspect common in the community we worked with is indeed poverty. Poverty can be manifested clearly with the type of housing facilities, and other indicators. Common reasons why people are left jobless is their lack of education. Most of the people havent finished their schooling and so, they become jobless leaving the basic needs of the family unattended.In the case of the Encarquez Family, the sole provider of the family is Mrs. Romeo Encarquez, who is working 20 days a month and receives his salary of 25php/ day. The family depends on his earnings from the work and sometimes in their aunts earning from FAMILY CASE STUDY | 12

assisting the missionaries feeding the oppressed. But her job is not permanent. Mr. Encarguez is working at the Government as a Garbage Collector. He is working 8hrs a day from 6pm-2am, 5 days a week. He is earning 25php/ day amounting to 500php a month, this money provides for 6 persons including the expenses for water which is 7 pesos per drum, gas for their light because they are just using lampara to aid their eyes during night, food and other miscellaneous. Melinda Encarguez, the mother, left her family 2 years ago due some family problem. She left all her children in the shoulders of her husband. Mr. Encarguez is a member of the newly indorsed program of Phil Health at their barangay. He can receive 500 pesos a month per child in the family intended solely for the health of his children until 2016. Aside from this, they are no longer a member of any organization/program. Whenever they are sick they just avail the Free Health services that is given at the Piapi Health center in Boulevard or get free medicines whenever there are oppurtunities at the Miniforest health center..

Family Expenses EXPENSES Rice AMOUNT 30 pesos

*viand depends on the food preference for the day* Gulay/ Pansit canton/ itlog 15 pesos

Water

7 pesos

Sometimes, if their father doesnt have money or wasted by his vices such as smoking and drinking alcohol, they have nothing to eat. Or sometimes, their aunt shares a some food for the children.

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CULTURAL CHARACTERISTICS Ethnic Background and Religious Affiliation FAMILY MEMBER Romeo Encarquez Melinda Encarquez Mary Frances Christian Rommel Chris Mae Anne Justine Triplets ETHNICITY DABAWENYO DABAWENYO DABAWENYO DABAWENYO DABAWENYO DABAWENYO DABAWENYO DABAWENYO DABAWENYO RELIGION ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC ROMAN CATHOLIC

Mr. Romeo Encarguezs father and mother are originally from Davao City. Mr. Camoro and his siblings were raised in Davao City also. Mrs. Melinda Encarguez together with her siblings came also from Davao. The children of the couple are pure Dabawenyo since both of them came originally form Davao City. All of them are Roman Catholic in religion .The family does not go to the mass every Sunday because of lack of interest Significant Others Mary Frances had mentioned that there is any significant other who helps in the family, and that is her aunt Mary. The children who are not living in the house usually visits during vacations.

Relationship of the Family to the Larger Community According to Mrs. Mary Lingganon, there was a minor conflict before between to their neighborhood because of the canal infront of their house. But later on, they were able to talk about it and reconcile. Since then, whenever they have misunderstandings, they extend their patients and try to settle it on a nice and peaceful way. FAMILY CASE STUDY | 14

FAMILY DEVELOPMENTAL TASK Family with Teen-agers and Young Adults is the fifth stage of developmental task wherein they should maintain open communication among parents and children and supports ethical and moral values within the family, balancing freedoms and responsibilities for teenagers, releasing adults with appropriate rituals and assistance, strengthening marital relationships and maintaining supportive home base In the case of our client, they cannot meet those goals since they dont a good foundation within their family. Two years ago, their mother left them due to unknown reason and their father dont have the time to communicate properly with them because if he is not working , he keeps on drinking alcohol together with their neighbours.

ENVIRONMENT FACTORS Home and Environment Encarguez family has been a resident of Barangay 21C- Blk. 85 Piapi Boulevard for 46 years. Their house is situated in a congested squatter area. The way leading to their house is wet and slippery due to the water overflowing from the canal. The available facilities in the community are Barangay Hall, chapel and health center. Some people in the community have their own electrical and mechanical appliances like television, radio and cable wires. Most of the people there dont have cellphones. Jeep, tricycle, single motorcycle are the main transportation and pedicab on the sides of the road. Their house in mainly made up with cement and wooden materials for their wall and floor. They have a multipurpose house that serves as living room, dinning room and bedroom for the 50 of them. With regards to the structure of the house, the lower part of the house has a ceiling made up of 4x4 wood while the upper part has none. They have medium-sized rooms but its not suitable for accommodating 10 persons. Their pillows and bed has a covering and a blanket on top. They have a rack for their eating utensils but it is not neat and organized and a cabinet wherein their clothes are placed and kept. They have a small mirror in two rooms and use a lamp for their lighting. They dont have an electric fan instead they use the conventional fan that is made up of coconut leaves. There are also some nails coming out of the wooden walls. The FAMILY CASE STUDY | 15

house was untidy because of the kids playing and there wasnt enough storage for their belongings; the environment was very dirty because there were trashes scattered all over the interior and exterior part of the house. Pertaining to the drainage system they have poor drainage system. The plates are left beside the floor with a basin filled with water, after washing they throw the water outside of their house; they also wash the clothes outside. They rely on buying their water supply from their neighbor about 10 meters away from the house for only 7 pesos per drum. The water they store is placed on a drum and left uncovered. They dont have a budget for solane or burner; instead they use cheaper cooking materials such as kalan and charcoal. They have two pet cats and different sorts of pests and insects infiltrates the house like cockroaches, mosquitoes, houseflies and rats which can cause leptospirosis, dengue, polio and etc.

Ventilation in the house There is only one door for entrance which is made up of wood and they have one big window that is located upstairs on the triplets room. All their windows are not screened nor draped with curtains. Mary Francess said it gets hot during the night because all the ten of them are compressing due to small sleeping space. With regards to this, we have computed the ventilation of their house.

To determine whether the house has good ventilation, we first compute for the total floor area: TFA =LxW = 2 m x 2.5 m = 5 m2 Since they have 2 floors, we multiplied the floor area of the first floor by 2 to get the total floor area of their house: = 5 m2 x 2 TFA

= 10 m2

Then, we get the total window opening of the house through the following:

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16

Window:

WO = L x W (no. of windows) = 1.24 m x 2.5 m = 6.2 m2 x 1 windows WO = 6.2 m2

Door:

DO = L x W = 1.77 m x 0.875 m DO = 1.549 m2

Total window opening: WO + DO TWO = 6.2 m2 + 1.549m2 = 7.749 m2 After which, we solve for the ventilation: Ventilation = Total Window Opening / Total Floor Area x 100 = 7.749 m2 / 10 m2 x 100 = 77.49% As we interpreted, the Encarguez family has good ventilation because ventilation above 20% is considered good.

To compute for the overcrowding, we have to identify the Total Floor Area and the number of household members. In their case, they have TFA of 10 m2 and there are10 members of the household composed of 3 adults and 7 children. To compute for the total space requirement of the family, we have: TSR = (3 x 2.25 m2) + (7 x 1.26 m2)

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= 6.75 m2 + 8.82 m2 = 15.57 m2 There is overcrowding since the TFA is lesser than the TSR. The total floor area is lesser than their total space requirement, therefore there is overcrowding.

Housing The family owns the house. The construction material used is mixed and is a two-story type building. The walls in the room are made up of plywood and some are cemented. There are five rooms for each of the family to sleep. They sleep either on the floor with a mat and some in the chair. The room serves both their sleeping and eating area. Their primary source of light during the evening is a lamp located on the corner of the house. The house is very dirty and disorganized. Garbage, wastages, unwashed clothes and dishes and empty bottles are seen inside the house.

Adequacy of Living Space The house is inadequate for their living space due to its size and the number of person living. The entire family consists of 50 members. During our interview, Mary Francess said that they sleep with 8-10 other family members. They have problems sleeping at night because of the space and how they position themselves in order to have a good rest. Their sleeping area serves as eating, playing and dressing area.

TFA

=LxW = 2 m x 2.5 m = 5 m2

Since they have 2 floors, we multiplied the floor area of the first floor by 2 to get the total floor area of their house: = 5 m2 x 2 TFA

= 10 m2
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To compute for the overcrowding, we have to identify the Total Floor Area and the number of household members. In their case, they have TFA of 10 m2 and there are10 members of the household composed of 3 adults and 7 children. To compute for the total space requirement of the family, we have: TSR = (3 x 2.25 m2) + (7 x 1.26 m2) = 6.75 m2 + 8.82 m2 = 15.57 m2 There is overcrowding since the TFA is lesser than the TSR. The total floor area is lesser than their total space requirement, therefore there is overcrowding

Sleeping arrangement Each of the members sleeps with their own family on five different rooms. The triplets sleep upstairs with seven other family members, which is their siblings, parents and cousins. They sleep on the floor laid with two mats and pillows. The triplets usually sleep together with their sister and father on their sides while their cousins sleep in another corner of the room together with their cousins.

Adequacy of the furniture There wasnt much of furniture inside the house. The only furniture they have is a bed, cabinet, chair and a table. They do not own any electrical appliances the fact that they dont have electricity. They use pot and charcoal to cook their foods. They do not store their foods properly instead leave it aside with no covers.

Presence of insects and rodents Since both the exterior and interior part of the house is filled with waste and garbages, their house is teeming with different types of illness causing pests like mosquitoes, houseflies, cockroaches and rats which can cause life threatening diseases like cholera and leptospirosis. FAMILY CASE STUDY | 19

Flies and other insect infested their left eating utensils that brings bacteria that cause a disease. There was a mini canal outside their house, it was not flowing or draining properly because garbage were blocking its passageways. Stagnant water plus the used bottles containing water makes a good habitat for mosquitoes to thrive in. The family is unaware of the dangers it may cause to their health. Presence of accident hazards There are a lot of hazardous things found inside and outside their house. One of which are broken glass bottles, the children usually tends to walk barefoot. Their slippers are either rugged or lost a pair of it. They play and run a lot with no slippers on, the old ones are aware the dangers of it but forget to remind the child to always wear one for their protection. We also noticed that the entire foundation of the house is not stable, when the children plays upstairs, that part of the room somewhat moves and the flooring was not intact as well. The stairs also pose a great harm, Mary Francess once told us that one of their cousins fall from it because it has no side rails. But today, they have one fixed on the side for support, but for us it is still not stable enough to prevent someone from falling.

Food storage and cooking facilities Leftover foods are usually uncovered and if it spoils, they wrap it inside a plastic bag then dispose on the garbage sack. They cook their foods on kalan and charcoal, usually they only eat rice with salt and other flavoring, and sometimes they consume ready to eat foods. They dont have refrigerator to preserve or store their food. They mostly eat all their dishes and if possible there are no food leftovers.

Water supply The familys primary source of water is being bought from their neighbor for only seven pesos. It contains one drum full of water. They use it for bathing, drinking, flushing the toilet, laundry and dishwashing. They could consume 4-5 drums per day. They spend 28-35 pesos for their water bill everyday. The water container has no cover and is stored on a multi-purpose room. FAMILY CASE STUDY | Presence of insects and rodents 20

Kitchen Our client has only one kitchen. It is located inside the house. Since they have no electrical appliances for cooking, they use conventional methods of preparing their food like the use of charcoal and kalan. They have two areas for cooking; the other one is located outside and is only used for minor cooking such as boiling noodles and water. Their eating utensils are not washed right away after consuming their food instead they soak it on a small basin filled with water to mollify the hardened food stains.

Toilet facility They have a comfort room before but through the years, the septic tank became full so they transferred it to another area inside the house. This time, it doesnt have any walls or doors but it has a toilet bowl. They use a pail of water to flush their stools. All five families share the same toilet bowl for their personal necessities. The toilet bowl is very foul in odor and flies hover around it.

Domestic Animal The family owns two cats. The felines usually stay inside the house and sleeps on one bed of the family. The fur of these animals irritates the lungs when inhaled and triggers asthma attacks.

Garbage/Refusal disposal Harley (cousin of the triplets) took charge in throwing the garbage usually early in the morning. All of their waste is accumulated into one garbage bin without separating the biodegradable, non-biodegradable and recyclable materials. When we asked the family about proper segregation, they have the knowledge about it but they do not apply it for themselves. They use plastic bag to wrap their garbage before disposing it to the bin. Inside their house are accumulated wastes. From broken glass bottles, used napkins and other dirty items. Their FAMILY CASE STUDY | Presence of insects and rodents 21

improper waste disposal can lead to other problems like presence of breeding sites that bring diseases or source of health complication.

Drainage system The kind of drainage system of the family is an open drainage. Water flows into a small canal located in front of the house. The surrounding area of the canal is wet and muddy because water overflows on it. Sometimes when they finish doing the laundry, the used water overflows on the canals lining. The most suitable place for microorganisms to thrive are these kind of conditions. We also noticed that some of the children specifically the triplets walk barefoot and this would make these harmful microorganisms to stick on their feet.

Kind of Neighborhood The whole neighborhood is in a slum and congested area. The houses are built closely together and it was overcrowded and mostly inhabited by poor people. According to Mary Francess, they have a harmonious relationship with their neighbors and did not have any major fights or conflicts with each other.

Social and Health Facilities available The family can identify all nearby facilities within their area. They know about the services rendered by the Piapi Health center like free immunization and health supplements, prayer venues such as chapel for Roman Catholics but the family doesnt attend any prayer meetings during Saturdays. The family used other health facilities such as Mini Forest when they suspected Mary Francess to have Kochs disease and decided to take the Direct Sputum Smear Microscopy and has shown a negative result.

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22

Communication and Transportation Facilities Since the family does not have any private-use vehicle, they use public transportation such as pedicab, single motorcycle and jeep. They usually prefer walking when their place of destination is near and in order for them to save money. They dont have problems regarding their transportation since they mostly go to nearby places like sari-sari stores, eatery and the Piapi Gymnasium. The only member of the family to have a communication device is Harley. He uses his cellular phone for calling, texting and listening to the radio.

Health and Health practices The triplets had no serious illnesses before except for the common colds, fever and cough. On 2008, Raymond, Reggie and Raymart were diagnosed with diarrhea before in Southern Philippines Medical Center and were confined for two days. After discharge, the siblings were sent home and were advised by the doctor to continue home treatment and health teachings like increase fluid intake. Their older brother Justine didnt have any hospitalizations or was diagnosed with any time of major illnesses. On 2009, Mary Francess was referred by the Piapi Health Center to Mini Forest when she was suspected to have the signs and symptoms of Tuberculosis, she was then advised to take the Direct Sputum Smear Microscopy and shown a negative result. Moreover, we found out that it was a result of her chain-smoking 2 years before. At present, she stopped smoking for good. On the same year, heir father was once hospitalized for bacterial infection in the gastrointestinal tract and was vomiting for three days. He was confined for one month and seven days at SPMC. Mr. Romeo also shared that he could consume 2-4 cigarette packs per day. He often smokes and drinks alcohol. Melinda had left the house for 2 years now due to an unknown reason but according to Mr. Romeo his wife was in a state of mental disorder. He stated that usahay di nako siya masabtan kay magusabusab iyang batasan ug kalit pa jud masuko sa amoa maskiy walay rason. Naa pay kaisa na niingon siya na magpakamatay daw siya. Mrs. Melinda followed her schedule on prenatal check up in the Piapi Health Center and has four live children with no abortion. She stopped breastfeeding the triplets on the age of 1 and continue on with formula feeding for another year. Since Mrs. Melinda isnt leaving anymore with the family, Mary Francess took the role of their mother. She manages their home and takes the responsibility for the familys health. When one of the family members is sick, shes the one who decides whether to relieve it with some drugs or to consult a physician or any health worker if the ailment becomes severe. FAMILY CASE STUDY | Presence of insects and rodents 23

Diabetes, asthma and hypertension are the only hereditary diseases present in the family. Mary Francess told us that they avoid taking up medicines when they experience illnesses. For instance, when the triplets is having cough and cold, the only intervention they do is apply a menthol liniment on the upper chest of the siblings and drink lots of water to relieve and alleviate the severity of the sickness. Mary Francess, Justine and the triplets are fully immunized children. They received all the immunizations at Piapi Health Center. Date Immunization 1st dose BCG DPT OPV Hepa B Measles Vit.A 09-06-08 10-15-08 10-15-08 10-15-08 06-03-09 10-12-08 10-12-08 10-15-08 12-10-08 12-10-08 12-10-08 2nd dose 3rd dose Booster

During the times when they experience deviations in their health condition, they just medicate themselves like taking over the counter drugs like Paracetamol (Bioflu and Biogesic) for fever and Neozep for colds. For consultations, they go to Tambayan and Don Bosco Health Center for free check up.

Rest, Sleep and Exercise For their sleeping routine, they use their multi purpose room upstairs to sleep. Mary Francess also said that the triplets sometimes have problems and disturbances during sleep. It is due to the inadequacy of space and the hot temperature because they only use fans. The triplets have an adequate time span of rest about 10-11 hours daily except for Mary Francess FAMILY CASE STUDY | Presence of insects and rodents 24

and their father. She usually sleeps 11 pm after watching teleseryes from their neighbors television and wakes up early in the morning mostly 5 am to prepare the familys breakfast. The triplets usually sleep at the same time together with their cousins Harley, Robert and Thomas at 8-9 pm and rises 6 in the morning and lastly, Mr. Romeo who usually retires 10 pm after his drinking and smoking session with his buddies then wakes up at around 6 am. He doesnt have a regular sleeping pattern and inadequate sleeping hours. Raymart, Raymond and Reggie usually stay at home when they have nothing to do. But when they have the time they play with their neighbors. They have adequate exercise because they move around constantly. Mary Francess chats with her neighbors during spare time or either watch television. In the morning, she strolls around the area. It is her only way of exercising because she usually stays at their house. Their father doesnt have an adequate exercise because he either smokes or drinks when he gets bored in the house. He watches basketball games in the Piapi gymnasium but he isnt interested in playing the game because he has a low stamina.

Relaxation and Stress Management Activities The family doesnt have the proper coping mechanism. Mary Francess once told us that if she ever encounters a problem, she usually smoke in order to relieve tension and stress. She doesnt ask for advice or guidance from her parents since her father is always out drinking and smoking and her mother is not in the house anymore. She couldnt approach her aunts or uncles because they are too busy minding their own family, rather she goes to her barkadas and then they do all sorts of stuff just to divert her attention or leave her problems behind. Since she has stopped with her vices two years from now, the only way she could manage her problem is to just keep it to herself. When she likes to rest or relax, she either sleeps or plays with her younger siblings. The father of the family, Mr. Romeo, doesnt cope well when faced with stress. Drinking alcohol and smoking are the relaxing things he prefers to do to loosen up and relieve his tensions. Mary Francess told us that their father doesnt bond with them always. He is too busy minding others rather than his own family.

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IMCI NARRATIVE

Last November 5, 2012 at 8 am, we assessed the child named Reymart Encarguez, 50 months of age. He lives at Barangay 21-C Piapi Boulevard, Davao City. He weighs 8 kilogram and his temperature is 36.6 degrees Celsius. We asked the sister whats the childs problem, she said he has fever last night but doesnt know what was the temperature. The child is able to drink water. He doesnt vomits everything he eats. He have no convulsions and hes not abnormally sleepy or difficult to awaken. The child doesnt have cough or difficult to breath. His respiration is 38 breaths per minute. He doesnt have any chest indrawing, stridor or wheeze. He doesnt have diarrhea. The child has fever last night only, blood smear is not done. He doesnt have any signs for measles. With all this data, we classified it as Fever Malaria Unlikely. He doesnt have the signs of Dengue Hemorrhagic Fever. We assess his ears, there are no ear problems present to the patient. Next is, we check for Malnutrition, the child doesnt have severe wasting. His MUAC is 15.5 cm. There is no edema present on both feet. We determine his weight for age, and it is not normal. We classified it as Very Low Weight. So, our patient is malnourished. The child completed all his immunizations as we checked his record in the health center. We checked his Vitamin A supplementation, our patient doesnt receive vitamin A for the past 6 months. The child also doesnt received albendazole/mebendazole for deworming. The child was breasfed before by his mother only for 2 weeks before their mother left since he was an infant. The child eats rice, drinks water and coffee. He ates 3 times a day, but sometimes twice only if they have no money at all. He uses spoon, plate and glass for eating, but sometimes, he uses his hands only. His sister feeds him every meal or sometimes, he can feed his self also. During illness, the child doesnt changed his feeding.

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PHYSICAL ASSESSMENT GENERAL SURVEY I. The patient is ectomorph. He stands 91.5 cm, weighs 8 kg. and has BMI of 9.7 . He has a normal posture and gait. He walks with alternating arms swaying. He is alert when we receive him but he is not so attentive and does not answer our questions. He has poor hygiene. He is not oriented to time, place and person while we ask the patient. His vital signs for temperature was 36.6 degrees Celsius, pulse rate is 123 bpm, heart rate is 125, Respiration rate is 38 bpm and his blood pressure was 90/60 . II. SKIN

He has a poor complexion of skin. And it wasnt smooth but he has a good skin turgor. When we pinched his skin, the skin comes back to its original position by 0.2sec. His skin temperature is warm or normal. His skin moisture was dry. There were lesions noted at the left side of an eyebrow and no edema noted. There was no ulceration noted and his nail was dirty and untrimmed. His capillary refill is normal by 1 sec. III. HEAD

The skull is symmetrical. There were no dandruff, lesion and lice noted on the scalp. Normal distribution of hair noted and the patient has fine hair. The face has symmetrical movements such as chewing, smiling, and frowning. And there is no edema and masses noted. The muscle strength of the jaw of the patient is normal. And its measurement is 91.5 cm. IV. EYES

The eyebrows are aligned and have a symmetrical movement. Eyelids it is symmetrical to each other. The eyelashes curled outward. Lacrimal ducts are normal and no swelling noted. The cornea/lens is clear. The conjunctiva is pinkish. The reaction of the pupil to light is brisk and reaction to accommodation is uniform. The extra ocular movement is normal. Eyes converge uniformly. Visual acuity of the patient is normal. He cant count his fingers that we ask to do it because he doesnt know how to count, but he can see the light perception and hand movements.

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V.

EARS The pinna is symmetrical. Foul smell and discharge not noted. The hearing acuity is normal,

he can hear sounds on both ears. VI. NOSE The nasolabial fold is symmetrical. The septum is found at midline. The mucosa is pinkish. Discharges at the nose are not noted. Both nostrils are patent. There is no tenderness noses noted in the sinuses. VII. MOUTH

Lips are symmetrical and pinkish but dry. The tongue is found at the midline. Incomplete teeth noted and have 6 teeth with cavities. There is tartar present on teeth. The gums, mucosa, and palette are pinkish in colour. The tongue is whitish. There is no bleeding, tenderness, and lesions noted. VIII. PHARYNX

The uvula is found at the midline. The mucosa is pinkish; no swelling and ulceration noted. Tonsils are not inflamed. Gag-reflex is evident.

IX.

NECK

Trachea is found at the midline. The lymph nodes are not palpable. The thyroid is palpable when the client swallows and bruit sounds are not noted. Range of motion is normal. Jugular vein distention is not visible. Muscle strength is normal. X. THORAX

Thorax is symmetrical. Spinal alignment is normal, no tenderness, bulges and lesions noted. The breathing is effortless. Chest skin turgor is good. Respiratory excursion and tactile fremitus are symmetrical. Upon percussion of the chest, the sound produced is resonant. When we assess his chest, there is no chest indrawing, wheezing or stridor heard. Its measurement is 50.5 cm.

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XI.

HEART

His heart beats normally. There is no unsual sounds heard while assessing. XII. BREAST

The breasts are symmetrical. No edema and tenderness noted.

XIII.

ABDOMEN

The waist line measures 46 cm. Upon auscultation, the bowel sound is normoactive and bruit sound is not noted. The bladder is nonpalpable. There is no pain on his stomach when we assess him.

XIV.

GENITO-URINARY

When we assess his genito-urinary, it is all normal. There are no lesions or discharges noted. The client verbalizes that there is no pain when urinating.

XV.

Musculoskeletal system The patient has ectomorph body structure. As we measure the muscle for its size with tape measurement, the height is 91.5 cm, the head circumference is 47cm, the chest circumference is 50.5 cm , waist is 46 cm., and mid upper arm measures 16cm. And it is symmetrical to each other. Muscle tendon, contractures and muscle tonicity are not noted. The muscle strength of the patient on the left side can be graded by 5 because it has an active movement against full resistance. And the other side is can be graded by 5 because it has an active movement against full resistance. As we checked the strength of the sternocleidomastoid, trapezius, biceps, triceps and hip muscles. The patient can resist the force when we exert a force, and it appears to be satisfactory.

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XVI.

Bones The skeleton structure of the client is normal. Edema and tenderness are not noted.

XVII.

Joints

The joints are symmetrical to each other. Tenderness, swelling, crepitation of joints are not noted. Smoothness of movement is noted as we assess the joint range of motion on both arms.

XVIII.

Neurological assessment

The client is well oriented place and person by tactful questioning. The level of consciousness of the patient (RLS/GCS) is 15/1 Eye motor is4; verbal response is 5and the motor function is 6 - alert. XIX. Cranial Nerves In assessing the CN 1 (olfactory): The client can determine the different scents such as unpleasant odor and pleasant odor with eyes closed. In CN 2(optic): for this assessment we have no opportunity because the child cannot read. For CN 3(oculomotor),4(trochlear),6(abducens): the patient has a normal ocular movements and both pupils is equally round and reactive to light and accommodation. In CN 5(trigeminal): When touching the cornea lightly with wisp of cotton, it elicits blink reflex and eyelids blink bilaterally. In CN 7(facial): the patient was able to smile, frown, shows teeth. Facial movements is symmetrical. In CN 8(acoustic): the patient was able to hear spoken words. In assessing the CN 9(glossopharyngeal) and 10(vagus): the movement of the uvula is at the center and when the client says ah there is a symmetrical raise of soft palate and uvula. Gag reflex is present the tongue blade touches the back of the tongue soft palate. The is no opportunity to assess the identification taste because the client not cooperative. In CN 11(spinal accessory): when applying force on the patients shoulder, the patient can resist the force and there is symmetrical, strong contraction of trapezius muscle. There is a strong FAMILY CASE STUDY | Presence of insects and rodents 30

contraction of sternocleidomastoid muscle when we ask the patient to turn his head side to side against the force of the hand. In CN 12(hypoglossal nerve): the patient was able to protrude his tongue and move it to each side against tongue blade. There is symmetrical tongue with smooth outward movement with bilateral strength.

Reflex XX. Biceps reflex: the biceps contracts 2+(normal) for both sides. And for Triceps reflex: the elbow extends of 2+(normal) for both sides. For brachioradialis reflex: the elbow flexes with pronation of forearm, 2+(normal) for both sides. For patellar reflex: the extension of the knee is +2(normal) for both sides. Achilles reflex: the plantar flexion of foot is 2+ for both sides.

Motor function (GROSS MOTOR AND BALANCE TEST) XXI. The patient was able to walk with steady gait with apposite arm swing. In assessing the Rombergs test, we have no opportunity because the child is crying and appears to be not cooperative.. The patient was not able to perform heel-toe and toe or heel walking because the child is not cooperative. (FINE MOTOR TEST FOR UPPER EXTREMITIES) XXII. FINGER TO NOSE TEST: The client was able to abduct and extend the arms at shoulder height and touch the nose alternately with one index finger and then the other. XXIII. ALTERNATING SUPINATION AND PRONATION OF HANDS AND KNEES: the client was not able to pat both knees with palms of both hands and then the back of the hands alternately and increasing rate because the child is not cooperative. XXIV. FINGER TO NOSE AND TO THE NURSES FINGER: the client was able to touch the nose and then nurses index finger at about 35cm at increasing rate. XXV. FINGERS TO FINGERS: the client was not able to bring the fingers together at the midline with open eyes first and then closed first slowly and then rapidly with spread arms broadly at shoulder height because the client is not cooperative.

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XXVI.

FINGERS TO THUMB: the client was able to touch each finger of one hand to the thumb of the same hand. (FINE MOTOR TEST FOR LOWER EXTREMETIES)

XXVII.

HEEL DOWN OPPOSITE SHIN: there is no opportunity to perform this assessment because the client is not cooperative. TOE OR BALL OF FOOT TO THE NURSES FINGER: the patient was able to touch the nurse finger with the use of the large toe of each foot. (LIGHT-TOUCH SENSATION)

XXVIII.

XXIX.

The client was able to identify sensation symmetrically with eyes closed. The client was able to feel light-touch sensation to these specific areas: forehead, cheek, hand, lower arm, abdomen, foot, and lower leg. (PAIN SENSATION) For this assessment, we dont have the opportunity because the client doesnt know how to say if dull or sharp. TEMPEARATURE SENSATION: the client was not able to identify hot and cold water with eyes closed.

XXX.

XXXI.

XXXII.

KINESTHETIC SENSATION: with eyes closed, the client was able to identify correctly the direction of the body part is moved.

(TACTILE SENSATION) XXXIII. ONE-AND-TWO POINT DESCRIMINATION: with eyes closed, the patient was able to identify the two points correctly on forearm at 35mm apart, back of 50 to 90mm apart and fingertips at 3 to 6mm apart. XXXIV. STEREOGNOSIS: the patient was able to identify the correct familiar object such as coins, keys and paper clips when placing it in the patients palms with eyes closed. XXXV. EXTINCTION PHENOMENON: the patient was able to feel stimulation in two symmetrical areas of the body, such as the thighs, the cheeks, or the hands with eyes closed.

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FAMILY COPING INDEX

Categories Rate I. Physical independence 5

Admission Justification We had this rating just by observing that the family is able and each member of the family can do the daily activities of daily living such walking, eating, playing and fetching water except for the triplets and Justine since they cannot carry drum of water. And also, there is no bedridden in the family. Rate 5

Discharge Justification We still gave them this rating because we dont see any changes that happened regarding to their ADL. And there is no member of the family who became disable for them not to do such things such as their daily routines.

II. Therapeutic independence

The family goes to the health center when they got sick but only if the illness is severe now. The family carries out some but not all the treatments. They often self-medicate when they are sick. They apply efficascent oil if they dont feel well, and they do water therapy.

The family still selfmedicate but they promised us that they will go to the health center immediately if they feel unusual to their bodies especially the kids.

III. Knowledge of condition

We rated it by 3 since the family particularly

After some teachings and sharing our knowledge of 33

FAMILY CASE STUDY | Presence of insects and rodents

the sister stated that she knows her siblings conditions by stating that her siblings is malnourished but they cannot do anything about it due to poverty. IV. Application of principles of personal hygiene 1 As we have observed to our client they dont have proper hygiene. They usually take a bath during afternoon and they dont brush their teeth. They also walk bare-footed. With these observations, we can say that they werent properly taken care of. V. Attitude towards health care 3 The family sees health care as important. They take advices from health care professionals and seek help from health centers. They accept treatments warm heartedly but they cannot follow it at all times because of poverty. They also go to quack doctors if they dont feel well. 3 3

such illness, we are able to see and assess that Mary Frances was able to learn something out from it but they are not applying the health teachings that we have rendered to them. Through our health teaching and interventions, we can say that they have improved during our exposure in the community. They now take a bath early morning, wear slippers which we have provided for them.

After our interventions and health teachings, the familys attitude towards health care is still the same.

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VI .Emotional competence

At the time of our assessment, we have observed that the family is not emotionally stable. They look sad and longing for the love and care of the mother.

The emotional state of the triplets has improved since the first time we assessed them. On the day we left on their house, we observe that we have created a bond between them. Although we still felt that theyre longing for the love of a mother.

VII .Family living patterns

The parents of the triplets are separated due to some family problems. Their mother has left them for 2 years already. It is really visible that the triplets are sad and longing for a mother love and care.

We did not feel the willingness of the family to change or improve their living patterns. After all the interventions and health teachings, we did not see any change in their practices.

VIII .Physical environment

We can say that the physical environment where the family lives is not suitable for living. Their living space is not adequate, their surroundings are very dirty and there are accident hazards all over the place. Their cooking area is outside their house, which is near to breeding sites

The physical environment of the family has improved but only for a day after our intervention. They were not able to maintain the cleanliness and apply our health teachings.

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of mosquitoes. IX. Use of community resources 3 The family is aware of the facilities in their community and uses some of it but not all. They attend feeding sessions and they go to the health center if they have severe illnesses. 3 Even though we have rendered a lot of health teachings and advices, the family is still the same. They are hardheaded and that we are not sure if they will follow our advices.

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PRIORITIZATION OF FAMILY PROBLEM UNHEALTHY LIFESTYLE AND PERSONAL HABITS/PRACTICES SPECIFICALLY SMOKING CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit COMPUTATION 2/3x 1 ACTUAL SCORE 0.66 JUSTIFICATION The problem is considered as health threat since the father of the triplets and most of the people in their house may be considered as chain smokers. Their aunt is also positive for TB but is receiving treatment. Their older sister almost had TB if she did not stop smoking. The problem is partially modifiable because it is hard for a smoker to stop smoking. Minimizing sticks per day may be a good strategy. Willingness of the patient is also a factor, the father and other members of the family should have the willingness to change for the betterment of themselves and the other members of the family. Health teachings on the effect of smoking. The preventive potential of the problem is low since smoking has been the habit of the father for a long time already and we dont see the willing ness of the father to stop his smoking. The family does not see smoking as a problem because they are already used to it. They have been smoking for a long time already and see it as a normal thing to do.

MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable

1/2x 2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

1/3 x 1

0.33

0/2 x 1

1.99

FAMILY CASE STUDY | Presence of insects and rodents

37

INADEQUATE FOOD INTAKE BOTH IN QUALITY AND QUANTITY CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION The problem is considered as a health threat since it is conducive to diseases. They do not get the proper nutrients they need from what they eat which may cause the weakening of their immune system. The problem is partially modifiable since the willingness and dedication of the family is needed. We may also conduct feeding activities for them, specifically the triplets during our exposure. But we cannot feed them forever; the family should work hard to provide for their needs. The preventive potential of the problem is low since they do not have enough resources to buy food, but we have observed that they still have the guts to buy cigarettes even though they dont have anything to eat. The family sees their eating habits as a problem which needs immediate attention. The family does not eat on time and is not able to provide the proper food and the proper amount on time.

1/2 x 2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High

1/3 x 1

0.33

SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

2/2 x 1

2.99

FAMILY CASE STUDY | Presence of insects and rodents

38

HOME AND ENVIRONMENT: INADEQUATE LIVING SPACE CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit COMPUTATION 2/3x 1 ACTUAL SCORE 0.66 JUSTIFICATION We rate this problem as health threat because we observed that their house is lacking on space, the possibility of spreading airborne diseases is high and may be a threat for the health of the family. In addition to this, accidents may also potentiate because of the small range of living space where the members of the family could move. It is partially modifiable since it requires reconstruction increasing a living space may require a lot of financial resources from the family and the family doesn't prioritize this. Hopefully, the knowledge we share to them may decrease the susceptibility of the family to some diseases. Preventive potential is moderate since the client knows ways on how to prevent widespread of diseases like covering their mouth whenever they cough or sneeze. The family sees this as a problem needing immediate action since they have lack of space in the room where they sleep and that it is hard for them since 10 members of the family sleeps together.

MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable

1/2x 2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

2/3 x 1

0.66

2/2 x 1

3.32

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ACCIDENT HAZARD: FALLS CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION The problem is a health threat since it may lead to accidents. Their stairs is not safe to use since it does not have a strong support and does not have railings.

x2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High

2/3 x 1

0.66

SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

0/2 x 1

It is partially modifiable because it is hard to reconstruct the house, sufficient money and manpower is also required in this kind of plan. We student nurses shared some tips on how to minimize the risk or the actual problem that may affect the health and safety of the family. The preventive potential of the problem is moderate since there are ways to prevent accidents through safety precautions and renovation of the stairs. It is only moderately preventable because the willingness of the family is a factor. The family does not perceive this as a problem since they are already used to it and does have any intention in changing/renovating their stairs.

2.32

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HEALTH PROBLEM: FIRE HAZARD CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION This problem is a health threat that possess to a strong risk to fire incidents since their house is made of light materials such as wood/ Also their neighbourhood is congested. The houses nearby are made up of wood and fire could cause a major destruction if improper handling of candles and other fire-causing materials is observed. The problem is partially modifiable because the house of the family is made of flammable materials (i.e. wood) and that they use lamps and candles at night since they do not have electricity. The preventive potential is moderate since they have lack of resources. The interior of their house is not properly arranged and it is messy. The family perceives fire hazard as a problem that needs immediate attention because they have almost lost their house due to fire. They are afraid that it will happen again.

MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable

x2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

2/3 x 1

0.66

2/2 x 1

3.32

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HEALTH PROBLEM: PRESENCE OF BREEDING SITES CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION Insects, rats and pests in the environment could inflict a lot of diseases especially to the family members living in a malaria risk area. They could acquire airborne and vector acquired diseases, such as malaria and dengue which could possibly contribute to their illness condition. This is a health threat that may cause diseases to the client and her family since there is presence of rats, mosquitoes, and rodents that can cause rabies, dengue, and food contamination. The family can modify the condition easily through applying measures of eradicating vectors of diseases that can be taught by the nurse. Their willingness to cooperate, learn and acquire knowledge about the diseases that they may get through this can possibly help in this kind of problem. Simple cleaning and maintaining good environment can be a good strategy in eradicating those pests that can affect the health of the client. The preventive potential is moderate since the family has no experience in pests and mosquito related illnesses and had also not used spray insecticides yet. The availability of resources could also be a factor since they have financial constraints, the materials needed like insecticides and mosquito repellent materials 42

MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable

2/2 x 2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High

2/3 x 1

0.66

FAMILY CASE STUDY | Presence of insects and rodents

SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

x1

0.5

cannot be easily provided yet, frequent cleaning is really the best way to prevent the problem to worsen which is affordable and easy to do. The family perceives the presence of breeding sites as a problem not needing immediate attention. They are aware that those breeding sites may cause diseases but they are not doing anything to clean/prevent it.

3.82

Health Problem: Lack of Proper Toilet Facility CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION The problem is a health threat since their toilet is located near their entrance and they only use a small piece of plywood to cover it. It is totally unhygienic and they may get diseases from it. It is partially modifiable because it needs to be planned and requires money. Moreover the need of manpower is greatly needed in order to build a Comfort Room in their house. The preventive potential is low because they still need to renovate it, but that is not their priority because they do not have enough money.

x2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High

1/3 x 1

0.33

FAMILY CASE STUDY | Presence of insects and rodents

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SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

0/2 x 1

The family does not perceive it as a problem because they are already used to it. It has been part of their day-to-day life and they do not care about it anymore.

1.99

INAPPROPRIATE ROLE ASSUMPTION CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable COMPUTATION 1/3 x 1 ACTUAL SCORE 0.33 JUSTIFICATION The problem is a foreseeable crisis because taking care of children is a major responsibility of the mother and father and not of the sister.

0/2 x 2

The problem is not modifiable since their mother has already left them and that they do not have contact with their mother due to family problems.

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High

1/3 x 1

0.33

Its preventive potential is low since even though it is hard for their older sister to take the responsibility of being the mother for the triplets, she doesnt really have a choice since their mother is not around.

FAMILY CASE STUDY | Presence of insects and rodents

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SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

x1

0.5

They see it as a problem but does not need immediate action because they know that the possibility of the mother to come back is low.

1.16

UNHEALTHFUL LIFESTYLE: POOR PERSONAL HYGIENE CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION It is a health threat since poor personal hygiene would result to dysfunctions of some body parts if these will not be taken good care of. Also, prolonged negligence in taking care of ones self might result to severe complications. The modifiability of the problem is high. The willingness of the family is change and improves their personal hygiene. They just need to have motivation and health teachings. It is on moderate preventive potential because of the interventions implemented by the student nurses were giving health teachings on the important things to remember in proper hygiene and the importance of it. Members of the family especially the children are willing to participate in conducting the intervention. However, it cant be assured 45

MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable

2/2 x 2

PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High

2/3 x 1

0.66

FAMILY CASE STUDY | Presence of insects and rodents

SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention

2/2 x 1

that those actions done will be maintained. The family sees the problem as a problem the needs immediate attention. The triplets really need a mother figure, someone that will care for them and just be there to guide them through their growth.

4.32

IMPROPER WASTE DISPOSAL CRITERIA NATURE OF THE PROBLEM (1) 1- Foreseeable crisis/ stress point 2- Health threat 3- Wellness state/ health deficit MODIFIABILITY OF THE PROBLEM (2) 0- Not modifiable 1- Partially modifiable 2- Easily modifiable PREVENTIVE POTENTIAL (1) 1- Low 2- Moderate 3- High COMPUTATION 2/3 x 1 ACTUAL SCORE 0.66 JUSTIFICATION It is a health threat since there would be unexpected consequences of this problem. It may cause illnesses to the family which will give them more stress.

2/2 x 2

It is easily modifiable since there is a high chance to improve the waste disposal management of the family.

2/3 x 1

0.66

it is moderately preventive since the student nurses were able to give interventions like giving information about proper garbage disposal and effects of improper disposal of wastes. The family helped in implementing this proper disposal of garbage and able to segregate each type of waste. However, it cant be assured that the family can maintain the proper ways in garbage 46

FAMILY CASE STUDY | Presence of insects and rodents

disposal. SALIENCE (1) 0- Not perceived as a problem 1- A problem not needing immediate attention 2- A problem needing immediate attention 0/2 x 1 0 The family does not see this as a problem because they are already used to not segregating their garbage.

3.32

Results PROBLEMS UNHEALTHFUL LIFESTYLE: POOR PERSONAL HYGIENE HEALTH PROBLEM: PRESENCE OF BREEDING SITES IMPROPER WASTE DISPOSAL HOME AND ENVIRONMENT: INADEQUATE LIVING SPACE HEALTH PROBLEM: FIRE HAZARD INADEQUATE FOOD INTAKE BOTH IN QUALITY AND QUANTITY ACCIDENT HAZARD: FALLS UNHEALTHY LIFESTYLE AND PERSONAL HABITS/PRACTICES SPECIFICALLY SMOKING Health Problem: Lack of Proper Toilet Facility INAPPROPRIATE ROLE ASSUMPTION RESULTS 4.32 3.82 3.32 3.32 3.32 2.99 2.32 1.99

1.99 1.16

FAMILY CASE STUDY | Presence of insects and rodents

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