INITIAL DATABASE

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 INITIAL DATA BASE

Our duty in the community started last September 29, 2008 and ended on September 30, 2008.

Our clinical instructor in the area, Mrs. oriented us on what will be our assignments and routines in our

two days stay. The group was divided by pair and was instructed to choose a client for family assessment.

This family will be their chosen subject for study.

MQP, a client during that time, who happens to have rashes all over his body, which our

instructress identified to be measles, was our subject of study. According to the mother, the child had a

fever for three days before those rashes appear.

Given a subject, me and my partner formulated plans and designated task to done individually. We

ask permission to our client to be able to visit her at home. Upon the approval of our request we set a

date of visit. The next day, equipped with the necessary tools, we proceeded in their home for our home

visit.
 A.FAMILY STRUCTURE AND DYNAMICS
No. Name of Sex Birthday Age Height
family member (mm/dd/yy)

1 DDP M 12-07-78 29 y/o 5’ 10’’

2 NP F 05-11-80 28 y/o 5’ 2’’

3 MQP M 03-13-2008 6 ½ mos. 22 inches

Relationship to family
Weight Civil Status Religion Educational Attainment Occupation head

69.41kg M R/C CG GRCO Head of the family

54.98kg M R/C CUG Housewife Wife

7kg C R/C N/A N/A Sibling

 Family’s head DDP is 29 years old, born on December 7, 1978, 5’10’’ in height and 153 lbs. in weight.

He is a GRCO graduate, presently working in CC in Boni Avenue. His wife NP is 28 years old, born on May

11, 1980, 5’2’’ in height and weighs 119 lbs. She was an undergraduate of the course Bachelor of Science in

Business Administration. Presently, she was a plain housewife to DDP and a mother to their child. NP

was born in the Northern part of Samar while her husband was from the Western part of it. Their three

years of marriage was blessed with a healthy baby boy named MQP. He is 61/2 mos.old, 22 inches long

and weighs 15.43 lbs. All family members are Roman Catholic. To show their dedication they never fail to

go to church every Sunday to give thanks and praise for all the blessings God has given them.

Their family is nuclear in structure. According to them they owned the house but not the land, for

it is owned by the government. Common languages spoken were Waray and Tagalog. In times of conflicts

and problems they always depend on each other in solving it. For them they can face any kind of

hardships and problems as long as they are together.

B. SOCIO-ECONOMIC STATUS
 Monthly Income: P10, 000-P15, 000
Weekly Budget: P2, 500

Amount Expenditure
P1500 Foods( Groceries)
P500 Bills: Electricity and water
P250 Transportation (Father)
P250 Savings
TOTAL: P2,500

Prioritization of Need

Rank Priorities
1 Food
2 Bills
3 Transportation

Majority of the family’s budget is allocated to their food needs. Second to this is their budget to

their billings like electricity and water. Based from the table above you can observe that they give
importance to their savings. This is for the preparation of their child’s future. When it comes to their

clothing you can observe it has not been indicated above for they seldom spend money in clothing.

Financial difficulties of the family are solved by borrowing money from friends and relatives, to be

returned after the head of the family received his salary.

C.ENVIRONMENT
Home:
Ownership of the House Owned
Construction Materials Used Mixed
Space adequacy Adequate
Lighting Facility Electricity
Lighting Adequacy Adequate
Ventilation Adequate
Water Supply Level III (nawasa)
Drinking Water Nawasa
Food Storage Covered

Waste Disposal:
Garbage Container Covered
Method of Disposal Garbage Collection
 Toilet Facility Level II (with poso negro not connected to
sewerage)
Drainage System:
Type of Drainage Open Drainage
Domestic Animals, Insects, Breeding Sites:
Pets/Animals None
Pests/Insects Rodents, Cockroaches, Mosquitoes, Flies
Way of Eradication Trapping, Using Insecticides

FLOOR PLAN MEASUREMENT

ROOM
7
SALA KIT CHEN CR
 7
7

10

B.HEALTH STATUS

GEONOGRAM OF PALIMA FAMILY

RP LP ES YS

Hypertension, None
Diabetes
DD P NP
 MQP

PHYSICAL ASSESSMENT

Name of Client: DDP

Age: 29 years old

MEASUREMENTS
 RESULT NORMAL VALUES ANALYSIS
A medium frame man
Height 5’ 10’’ with a height of 5’10’’ Normal
should have a weight
Weight 153 lbs (69.41kg) range of 151-163 lbs.

VITAL SIGNS
Temperature 36.5 degree celcius 36-37 degree celcius Normal
Pulse Rate 63 60-100 bpm Normal
Respiratory Rate 20 16-20 bpm Normal
Blood Pressure 110/80 120/80 Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

ASESSED

Skull Symmetry Symmetry Normal

Scalp Without flakes Without flakes
Hair Resilient hair Resilient hair
Face Symmetry Symmetry Normal and healthy
Eyebrows Hair equal, intact Hair equal, intact
Eyelashes Intact, with curl Intact, with curl
Eyelids Aligned Aligned
Lower palpebral Pinkish Pinkish
(conjunctiva)
Sclera White and clear White and clear
Cornea Transparent, shiny Transparent, shiny
Pupils Black, equal, round Black, equal, round
Iris Symmetry Symmetry

Eye movement Coordinated Coordinated Normal and healthy

Visual fields Can see object in peripheral Can see object in peripheral
Visual acuity 20/20 vision 20/20 vision
Ear canal Uniform in color Uniform in color

Hearing acuity Normal voice can respond Normal voice can respond Normal and healthy
Internal nares Symmetry Symmetry
Septum Symmetry Symmetry
Lips Pinkish Pinkish
Gums Pinkish Pinkish

Teeth 32, smooth, shiny smooth, shiny Normal and healthy

Tongue Smooth Smooth
Frenulum Smooth Smooth
Cheeks, buccal mucosa Uniform in color Uniform in color
Palate Soft and glistering Soft and glistering
Uvula Light pink Light pink

Tonsils Pink and smooth Pink and smooth Normal and healthy
Voice Can be heard Can be heard
Muscular strength Equal strength Equal strength
Areola Round or oval Round or oval

Nipples Round and equal Round and equal Normal and healthy
Abdomen Unblemished skin, uniform in Unblemished skin, uniform in
color color
Name of Client: NP
Age: 28 years old

MEASUREMENTS
RESULT NORMAL VALUES ANALYSIS
A small frame man with
Height 5’ 2’’ a height of 5’2’’ should Normal
have a weight range of
Weight 119 lbs. (54.98 kg) 115-130 lbs.
VITAL SIGNS

Temperature 37 degree celcius 36-37 degree celcius Normal

Pulse Rate 70 60-100 bpm Normal
Respiratory Rate 19 16-20 bpm Normal
Blood Pressure 100/80 120/80 Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

ASESSED
Skull Symmetry Symmetry Normal
Scalp Without flakes Without flakes
Hair Resilient hair Resilient hair

Face Symmetry Symmetry Normal and healthy

Eyebrows Hair equal, intact Hair equal, intact
Eyelashes Intact, with curl Intact, with curl
Eyelids Aligned Aligned
Lower palpebral Pinkish Pinkish
(conjunctiva)
Sclera White and clear White and clear
Cornea Transparent, shiny Transparent, shiny
Pupils Black, equal, round Black, equal, round
Iris Symmetry Symmetry

Eye movement Coordinated Coordinated Normal and healthy

Visual fields Can see object in peripheral Can see object in peripheral
Visual acuity 20/20 vision 20/20 vision
Ear canal Uniform in color Uniform in color

Hearing acuity Normal voice can respond Normal voice can respond Normal and healthy
Internal nares Symmetry Symmetry
Septum Symmetry Symmetry
Lips Pinkish Pinkish
Gums Pinkish Pinkish

Teeth 32, smooth, shiny smooth, shiny Normal and healthy

Tongue Smooth Smooth
Frenulum Smooth Smooth
Cheeks, buccal mucosa Uniform in color Uniform in color
Palate Soft and glistering Soft and glistering
Uvula Light pink Light pink

Tonsils Pink and smooth Pink and smooth Normal and healthy
Voice Can be heard Can be heard
Muscular strength Equal strength Equal strength
Areola Round or oval Round or oval

Nipples Round and equal Round and equal Normal and healthy
Abdomen Unblemished skin, uniform in Unblemished skin, uniform in
color color

Name of Client: MQP

Age: 6 ½ mos. old
MEASUREMENTS
RESULT NORMAL VALUES ANALYSIS

Height 22 inches An average weight of a 6 Normal

months old infant is
Weight 15.43 lbs (7 kg)
16.53 lbs.

VITAL SIGNS

Temperature 37.2 degree celcius 37.2 degree celcius Normal

Pulse Rate 113 bpm 120-140 bpm Normal

Respiratory Rate 48bpm 30-50 bpm Normal

HEAD TO TOE ASSESSMENT

 AREAS TO BE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
ASESSED

Skull Symmetry Symmetry Normal

Scalp Without flakes Without flakes
Hair Resilient hair Resilient hair

Face Symmetry Symmetry Normal and healthy

Eyebrows Hair equal, intact Hair equal, intact
Eyelashes Intact, with curl Intact, with curl
Eyelids Aligned Aligned
Lower palpebral Pinkish Pinkish
(conjunctiva)
Sclera White and clear White and clear
Cornea Transparent, shiny Transparent, shiny
Pupils Black, equal, round Black, equal, round
Iris Symmetry Symmetry

Eye movement Coordinated Coordinated Normal and healthy

Visual fields Can see object in peripheral Can see object in peripheral
Visual acuity 20/20 vision 20/20 vision
Ear canal Uniform in color Uniform in color

Hearing acuity Normal voice can respond Normal voice can respond Normal and healthy
Internal nares Symmetry Symmetry
Septum Symmetry Symmetry
Lips Pinkish Pinkish
Gums Pinkish Pinkish

Teeth 32, smooth, shiny smooth, shiny Normal and healthy

Tongue Smooth Smooth
Frenulum Smooth Smooth
Cheeks, buccal mucosa Uniform in color Uniform in color
Palate Soft and glistering Soft and glistering
Uvula Light pink Light pink

Tonsils Pink and smooth Pink and smooth Normal and healthy
Voice Can be heard Can be heard
Muscular strength Equal strength Equal strength
Areola Round or oval Round or oval

Nipples Round and equal Round and equal Normal and healthy
Abdomen Unblemished skin, uniform in Unblemished skin, uniform in
color color

ABNORMAL FINDING:
 Skin Smooth and unblemished Rashes all over the body Measles is an infection
characterized by fever
rashes and symptoms
referable to upper
respiratory tract, the
eruption is preceded
about 2 days coryza,
during which stage
grayish peck (Koplik
Spots) may be found
on the inner surface of
the cheeks. A
morbilliform rash
appears on the 3rd or
4rth day affecting the
face, body and
extremities.
( Public Health
Nursing pp. 267)

Nutritional Status
 Name of Family Height Weight BMI Interpretation
Member
DDP 5’ 10’’ 153lbs 22 Normal
NP 5’ 2’’ 119lbs 22 Normal
MQP 22 inches 15.43 lbs 23 Normal

All the family members have normal total body mass index because the ratio was 18.5-24.9.

Exercise Pattern

Name of Family Member Hours of Exercise Times per Week Normal

DDP 30 minutes 7 times a week 30 minutes/day
NP 30 minutes 7 times a week 30 minutes/day
MQP N/A N/A n/a

The father, DDP was not able to practice it everyday because of work. His wife on the other has a daily
routine exercise in a form of dancing. Their child on the other hand was still too young to participate in
the activity.

C.Values, Belief and Practices

Just like typical Filipinos they grow up to an environment wherein respect was being emphasized.
The kind of environment they want their child to have and grow-up with. They do not want him to be
stubborn or disrespectful in front of people older than him. They want him to believe and have faith in
God just like them. For them what they plant to their child is what they will also earn in the future.

II. ORGANIZATIONAL DATA

Cues Normal Standards Based on Reference

Subjective:
“Nilagnat siya ng tatlong araw A healthy child must be free from diseases or illnesses like
bagolumabas yang mga pula-pula niya sa fever cough and colds, rashes and the like.
katawan.”

Subjective:
“Ang daming ipis dito pag umaga, yung A healthy home must be free from rodents and pest, it is clean,
pag binuksan mu yung ilaw, kanya well ventilate and free from threats.
kanyang takbo na sila. Minsan din
malangaw at may magnilan-ngilang daga
na naghaharutan sa may kisame.”
 Subjective:
“Nakakatakot lang ditto yung bukas na A healthy home must be free from rodents and pest, it is clean,
kanal dyan sa may labas. Lalo kapag well ventilate and free from threats.
umuulan at bumabaha, baka kasi di
mapansin malusbot dun”

III. CLUSTERED DATA

Cues/Data Family Health Care Plan

6 ½ mos old male infant with cough and rashes A. Measles and as a Health Deficit
all over his body. 1. Inability to provide adequate nursing care to the dependent
member with measles and cough due to:
“Nilagnat siya ng tatlong araw bagolumabas • Lack of knowledge on the nature and management of the
yang mga pula-pula niya sa katawan.”
“Ang daming ipis dito pag umaga, yung pag
binuksan mu yung ilaw, kanya kanyang takbo
na sila. Minsan din malangaw at may
magnilan-ngilang daga na naghaharutan sa
may kisame.”
“Nakakatakot lang ditto yung bukas na kanal
dyan sa may labas. Lalo kapag umuulan at
bumabaha, baka kasi di mapansin malusbot
dun”
health condition.
B. Presence of Vectors and Rodents as Health Threat
1. Inability to recognize the health threat due to lack of
knowledge about the condition.
2. Inability to make decisions with regards to the management of
the condition due to the failure on identifying what measures
are appropriate.
3. Inability to provide home conducive to health maintenance
and personal development due to ignorance in preventive
measures.
C.Open Drainage as Health Threat
1. Inability to make decisions with respect to taking appropriate
health actions due to lack of knowledge about alternative
solutions.
IV. PRIORITIZATION OF THE PROBLEM

1. Measles with cough

 CRITERIA COMPUTATION SCORE JUSTIFICATION

Nature of the problem 3/3 x 1 1 It is a health deficit that requires immediate

intervention.
Modifiability of the 2/2 x 1 1
problem Resources needed are available.

With the compliance in the given instructions of

Preventive potential 3/3 x 2 2 appropriate health providers, disease will be
manageable.

The family considers this as a problem that needs

Salience 2/2 x 1 1 immediate attention.
TOTAL 5

2. Presence of Vectors and Rodents

 CRITERIA COMPUTATION SCORE JUSTIFICATION

Nature of the problem 2/3 x 1 0.7 It is a health threat that needs an immediate
attention.
Modifiability of the ½x2 1
problem The family has the necessary resources but does not
utilize them properly.

Preventive potential 2/3 x 1 0.7 The susceptibility in acquiring other infections can be
prevented if the problem will be solved.

The problem was recognized by the family but they do

Salience 1/2 x 1 0.5 not think it needs an immediate attention.

TOTAL 2.9

3. Open Drainage
 CRITERIA COMPUTATION SCORE JUSTIFICATION

Nature of the problem 2/3 x 1 0.7 It is a health threat for it could damage the health of
the family.
Modifiability of the ½x2 1
problem It is partially modifiable for the family alone can’t
solve the issue, referral to higher officials were still
needed.
Preventive potential 2/3 x 1 0.7
Solving the problem lessen the risk of the family on
acquiring infections brought about by an unpleasant
environment
Salience 1/2 x 1 0.5
The family recognizes the problem but does not think
it needs an immediate action.

TOTAL 2.9

PROBLEM PRIORITIZATION
 Family Problems According to Priority

1 Measles and cough 5

2 Presence of Rodents and Vectors 2.9

3 Open Drainage 2.9

V. FAMILY HEALTH CARE PLAN

 INTERVENTION PLAN
HEALTH FAMILY GOAL OF OBJECTIVES OF METHOD OF
PROBLEM NURSIN CARE CARE NURSING RESARCHER- RESOURCES REQUIRED
G INTERVENTION FAMILY
CONTACT

Measles and Inability to After nursing After nursing 1. Establish rapport. Home Visit Material Resources:
cough manage intervention, intervention, the 2. Prepare the necessary Visual Aids on Measles and cough.
the the family family: equipments needed.
condition must be 3. Inform the family about Human Resources:
due to the equipped with -will be able the visit. Time and effort of both the
lack of the necessary identify the cause 4. Health education about researchers and the family.
knowledge knowledge and effect of the the diseases and its
regarding they need in disease. management. Financial Resources:
its dealing with Money for the researchers’
manageme the situation. -Know the transportation and food (if
nt. appropriate necessary).
intervention to
make.

FAMILY HEALTHCARE TEACHING PLAN

NURSING INTERVENTION METHOD OF RESOURCES REQUIRED
RESARCHER-FAMILY
CONTACT

1. Analyze with the family the Home Visit Material Resources:

problems measles and cough. Visual Aids on Measles a cough.

2. Discuss with the family the Human Resources:

appropriate courses of action. Time and effort of both the researchers and the family.

3. Enumerate to the family the Financial Resources:

danger signs they need to watch Money for the researchers’ transportation and food (if necessary).
out for namely:
 inability of the infant to
drink or breastfeed
 vomits everything
 convulsions
 abnormally sleepy or
difficulty to awaken

What to teach…
What is measles?
Measles is one of the most contagious viral diseases. It is caused by paramyxo virus and is the most unpleasant and the
most dangerous of the children's diseases that result in a rash. This is due to the complications of the disease.

How is measles transmitted?

• Droplets transfer the infections. Although the sick person may be in isolation, the disease may still spread from
room to room.

• Anybody who has not already had measles can be infected.

• Infants up to four months of age will not be infected if their mother has had measles herself because they will be
protected by her antibodies.

• The incubation period - the time between infection and the outbreak of the condition - is usually one to two weeks.

• Patients are infectious from four days before the onset of the rash until five days after it appears.

What are the symptoms of measles?

After about 14 days the following symptoms start showing:

• A fever at about 39ºC.

• A cold.

• Coughing, possibly with a barking cough.

• Sore throat - the lymph nodes in the throat may swell.

• Reddish eyes.

• Sensitivity to light.

• Grayish spots, the size of grains of sand may appear in the mucous membrane of the mouth just around the molar
teeth. These are called Koplik's spots and can be seen before the rash appears.
 • After three to four days the temperature may fall, although it can run high again when the rash appears.

• The rash usually begins around the ears and spreads to the body and the legs within a day or two.

• At first the spots are very small - a couple of millimeters - but they double in size quickly and begin to join together.

• The spots are a clear red color.

• The temperature, which may run as high as 40ºC, may stay that high for a couple of days. Then it disappears
together with the rash, which may leave some brown spots.

• After a week the child will be fit again.

How are measles treated?

The treatment is to stay in bed in a cool room without any bright lights. Medicines for coughing and reducing the
temperature should only be given after consulting a GP.

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