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Bulacan State University College of Nursing City of Malolos FAMILY SERVICE AND PROGRESS RECORD Client: Carmen Reyes

Address: 603 San Isidro, Hagonoy, Bulacan


FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/RELATIONAL PATTERN MEMBERS OF HOUSEHOLD LIVING WITH FAMILY MEMBERS NOT CURRENTLY LIVING WITH FAMILY

SOCIAL, ECONOMIC/CULTURAL CHARACTERISTICS

HOME AND ENVIRONMENT

The client Carmen Reyes, 28 y/o, a G2P1 is living with his husband Eric Reyes, her in-laws Sergio and Magdalena Reyes, and her nephew Gedion Reyes. Eric was considered as the head of their family. Her husband is 34 y/o, her father-in-law is 72 y/o, mother-in-law 74 y/o and her nephews age is 1 y/o. Magdalena and Sergio are also married. Their birth dates: Carmen: Oct. 1983 Eric: Mar. 1977 Magdalena: Oct. 1938 Sergio: Aug. 1940 Gedion: Aug. 2010

The clients family has two different religions. Carmen, Eric and Gedion are Roman Catholics, while Sergio and Magdalena are Pentecostals. Although they have different religions, this does not make any conflicts between them, they just dont talk about their religious beliefs when they are together. Carmen is a college graduate, took up Bachelor of Science in Tourism Management. Eric is an under graduate in Nautical while Sergio and Magdalena are Elementary under grads. Their Family is a native of San

The clients family owns their house, which is made in mixed materials. It has 4 bedrooms available for sleeping and has an adequate space and ventilation. Sanitary condition is fine. They also own a waterline from the local water district. The water from the faucet is not potable thats why they often buy mineral water. They store their foods in a refrigerator, sometimes; they just cover their left viands and reheat it for the next meal. They use gas stove for cooking, sanitary condition is good. For the waste disposal, they

The family is considered as extended and patriarchal because Eric serves as the head of the family, considering also that the income of the family comes from the store business which he manages. Whenever problems occur within their family, they see to it that everyone is part of the discussion because for them thats what families are for. According to her, there are no significant conflicts between them and as I can see, they talk to each other well.

Isidro, Hagonoy, Bulacan. None of the family members has job or work but they have a sari-sari store as the source of their income. The Monthly family income is between 5001 to 10,000 Php, and according to the client, it is also the range of their family expenditures. The priorities and expenditures are as follows: 1. Food 2. Utilities 3. Clothing 4. Health 5. Recreation 6. Savings 7. Education As for the financial aspect, Eric and Carmen decide on how to manage their income. Cultural Orientation of the family, they believe that illness is caused by physiologic factors, punishment by God and supernatural phenomenon. They also believe that health can be restored by God and supernatural powers, like hilot. But they seek health personnel whenever there are health problems in the family.

place their garbage in a plastic bag and they practice proper segregation for compliance and environmental benefits. They have their own toilet facility, with water flush. Location of water source is less than 20 feet. They also have septic tank. They practice cleaning the yard everyday as control or preventive measure from vector diseases. There are present breeding sites like the bird cages especially birds waste. Theres also exposed canals at the sides of their house. The family has harmonious relationship with the neighborhood. BHC is available for the community. The have their own tricycle for their transportation and the use cellular phones for communication.

Sometimes they practice local cultural practices about health manners. They also actively join fiestas and local cultural practices.

B. HEALTH STATUS
HISTORY OF PRESENT/CURRENT OR SIGNIFICANT PAST ILLNESS NUTRITIONAL ASSESSMENT DEVELOPMENTAL ASSESSMENT RISK FACTOR ASSESSMENT PHYSICAL ASSESSMENT RESULT OF LAB/DIAGNOSTIC AND OTHER SCREENING PROCEDURES

The client is now on her 25th week of gestation and she feels sleepy often and also her appetite increases. Sometimes, she feels pain in the abdomen.

According to her, when shes on her first weeks of pregnancy, her appetite started to increase and also she feels thirsty all the time. Because of that, she increased her meal and also eats miryendas and has siestas. The client usually eats mixed prepared foods (usually fish and vegetables), its what she prefers. Meat is her second choice of food. She prefers mixed foods because she thinks it is balanced and healthy. She

Psychosocial: Generativity vs. Stagnation -In this stage shows the clients desire to have a good future for her family and develop her child for the better. Psychosexual: Genital Stage -The client is now on her second

According to Initial Physical the client her Assessment: As reported by my partner mother has asthma and Breast size: they have Unequal; shape: history of symmentrical hypertension. Nipples: On the side of everted her husband, Color: Dark they also have with increased history of vein hypertension Abdomen: The client presence of also doesnt linea Nigra and have any some striaes regular Fundic height exercise, she 28 cms watch TV

Pregnancy Test Kit: Positive HbSAG: Negative for Hepa B CBC UTZ: Cephalic, Baby boy Urinalysis

doesnt prefer meat pregnancy. because she thinks it is unhealthy, and also they Cognitive: cant afford to buy meat Formal products often. Operational Stage She eats mixed foods everyday and meat once a -The client has week. They prepare their her own family, meal at home, they dont and was able to buy cooked foods outside think abstractly (carenderia, restaurants) and logically to be able to The client eats canned and support them. fried foods very seldom. They only drink Moral: carbonated beverages occasionally. Conventional stage The client also drinks 6-8 -The client glasses of water a day knows what is Carmen is currently taking right from wrong her meds daily before bed that shows an as prescribed by the effective moral physician: reasoning. - Multivitamnis+ Minerals (Usantal) - FeSO4 + Folic Acid + Vitamin B Complex + Ascorbic + Nicotinamide (Terraferron) Her medicines help her to maintain her recommended daily allowance for nutrition,

programs while taking care of their store.

OB history: Menarche: 14 y/o EDC: May 4, 2012 AOG: 25 weeks 3/7 days LMP: Aug. 28, 2011 Trimester: 2nd trimester G2P1 F0P1AL

but for calcium, she doesnt take much milk or other dairy products. The clients weight is 139 pounds and height is 53. Her BMI is 26.71 which is slightly above the normal range of 19.0-26.0

C. VALUE, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION


BELIEF/PRACTICES

IMMUNIZATION STATUS ANTENATAL LIFESTYLE PRACTICES REGISTRATION/ FAMILY PLANNING The family believes No Tetanus Toxoid She started her The client does not that the person must yet prenatal check up on have regular exercise rd be consulted at times her 3 month of routine. For her, doing of illness is the doctor. pregnancy. Until now, household chores and They only go to the shes having her taking care for their hospital if the illness is checkup once a month. store is her exercise. severe. For common The client is an She eats 3 times a day coughs, colds and acceptor of family regularly and with 5-8 fever, they self planning, this is for glasses of water for medicate only. They their future and for her drinks. buy medications as good health of the She also eats her prescribed by the family (natural family mirendas like, physician but they also planning) mangoes(sweet) and consider those over bread. the counter The client usually medications. The also sleeps 10 pm-6 am. use herbals, like oregano for coughs.

AWARENESS OF COMMUNITY/DOH HEALTH PROGRAMS The family is aware of the barangay health center in San Isidro. Gedion, a one year old child, comes to BHC regularly for his check-up and immunization.

II. HEALTH CONDITION AND PROBLEM SHEET HEALTH CONDITIONS FAMILY NURSING SUPPORTING AND PROBLEMS PROBLEMS DATA/CUES Potential for enhanced capability for health lifestyle: Exercise and physical activity Poor home condition as for polluted water supply Inability to recognize the presence of the condition due to lack of knowledge about its benefits Failure to utilize community resources for health care due to unavailability of required services Inability to recognize the presence of the condition due to low salience for the problem Exercise is not important for them IDENTIFIED Feb 22, 2012

DATE RESOLVED

ACTION/S TAKEN, RESPONSES AND EVALUATION OF OUTCOMES

Water not potable and has low pressure

Feb 22, 2012

Unhealthful lifestyle and personal habits/practices specifically inadequate exercise

Exercise is not important for them

Feb 22, 2012

III. FAMILY NURSING CARE PLAN


HEALTH CONDITION

FAMILY NURSING PROBLEMS

OBJECTIVES OF NURSING CARE

PLAN OF INTERVENTION

EVALUATION PLAN

EVALUATION CRITERIA

METHODS

TOOLS