NATIONAL INSTITUTE OF NURSING

EDUCATION, PGIMER

Family care study

Submitted to: Submitted by:

Dr. Sushma Sarbjeet Kaur
Lecturer, NINE M.Sc (N) 1st year
PGIMER NINE,PGIMER
 IDENTIFICATION DATA OF THE FAMILY:
Head of the family: Avtar Singh

Address: house no 43, milk colony, dhanas

Religion: Sikh

Marital status: Married

Type of family: Joint

Number of family members: 9

House: Pucca

Ventilation: well

Occupation of HOD: Carpenter

Total family income: Rs. 45,000/- per month.

Per capita monthly income: Rs. 5833/-

Socioeconomic status: Average

Mother tongue: Punjabi

FAMILY CHARACTERISTICS:

Sl. Name of Relation Age/ Mar Educationa Occupati Dietary Remarks

no. the family with head Sex ital l status on habits
memeber of the stat
family us
1. Avtar Self 60 M Class VIII Carpenter Non Healthy, goes
Singh y/Male Vegetaria For work, so health
n Assessment not done
2. Kamaljeet Wife 57y/Fe M Illiterate Housewif Vegetaria Unhealthy, had CVA
Kaur male e n attack
3. Gurwinder son 34y/ M Matric Carpenter Non Unhealthy goes
Singh male Vegetaria For work, so health
n assessment not done
4. Manjeet Daughter 32y/ M Matric Housewif Vegetaria Healthy
Kaur in law Female e n
5. Satnam Grandson 5y/male U Nursery Student Non Goes to
Singh Vegetaria School,so health
n assessment not done
6. Aviraj Grandson 2y/male U - ---- Breast Healthy
feeding
7. Bal;jinder Son 31y/ M Matric Carpenter Non-veg Lives in dubai
Singh Male
8. Amandeep Daughter 29y/ M Graduation Housewif Vegetaria healthy
Kaur in law female e n
9. Agamjot Grandson 1.2y/ U --- --- Non healthy
Singh male Vegetaria
n
Family Structure

Type of family: Joint

No of familymembers: 9

Family genogram

Avtar Singh 60 Y Kamaljeet Kaur 57Y

Manjeet Kaur Gurwinder Singh Baljinder Singh Amandeep Kaur

32Y 34 Y 31Y 29Y

Agamjot Singh 1.2Y

Satnam Singh Aviraj singh

5y 2y
 Relative PGIMER
Temple s

Governme worksho
nt school p

Family Friends and

anganwadi
neighnbour

Civil
dispensary
prayas

Market

Bank
COLLEGE /ATM

Environment

Type of the house: Pucca

Ventilation: well

Number of rooms: 4

Kitchen: Separate Kitchen

Water supply: Tap

Latrine: Sanitary latrine

Electricity: Yes

Drainage Closed
Type of fuel used: LPG

Animal kept: No

Disposal of refuse: Hygienic

Pets & rodents: no

Other pets: No

Social cultural History: Family belong to Sikh community .They are following their rituals.

ASSESSMENT OF FAMILY MEMBERS

Nameof Kamaljeet Kaur Manjeet Aviraj Amande Agamjot

family Kaur ep Kaur Singh
members
Identification
Data
Age/Sex 57Y/F 32Y/F 2Y/M 29Y/F 1.2Y/M
BMI 21 29 18.5 22.31 18.26
Nutritional no overwei HC=4 no HC= 46
deficiency ght 8cm cm
Yes/no MAC= MAC=
16 cm 15cm
no no
H/O past Chief complaints: Inability to Nothing Nothin Nothing Nothing
Illness speak, inability to walk, Right side significa g significa significan
H/O present paralysis *10 yrs nt signifi nt t
illness Personal/ social history:- She is cant
Chief bedridden, not able to perform
complaints activities of daily living, family
members help her to take bathe,
eating meals, passing urine and
stool
Present health history: She was
apparently well 10 yrs ago, when
she was having a hypertensive
episode and then paralysis of right
side of body. She was taken to sec
16 hospital from there she was
referred to PGIMER chandigarh. In
PGI she was diagnosed with CVA,
got some treatment not known to
relatives but her symptoms didn’t
 improved. She was kept on
medicine for 9 yrs , last yr she gave
up taking any medicine due to no
improvement in symptoms.
Personal Personal Hygiene maintained by Hygiene Hygie Hygiene Hygiene
history daughter in laws. Bedridden,can use maintain ne maintain maintaine
only left limbs, right limb paralysis. ed, mainta ed, d by
Asks for food by making some No drug ined No drug mother,
noises, not able to talk, but abuse, by abuse, No drug
understand what is Sleep mother Sleep abuse,
communicatedby others. Pass urine rest , rest Sleep rest
self by picking up pot herself, stool normal No normal normal
assisted by other family members drug
Not taking any abusive substances abuse,
Sleep/rest normal Sleep
rest
normal
General Physical Examination ( Head to toe assessment)
Vital signs: T 37C HR – 80 b/min R – 20 T=37, T=37, T=37, T=37,
HR=78 HR=88 HR=72 HR=98
b/min BP- 140/80mm/Hg R=22 R=32 R=22 R=36
: BP=130/ Consci BP=120/
70 ous , 70
General Sensorium: Conscious , unable to Conscio oriente Conscio Conscio
appearance: speek, make some voices us , d us , us ,
oriented oriented oriented
Normal
Posture Normal Normal Normal Normal
Could not be assessed as bed ridden Normal no Normal Normal
Gait
Could not be assessed as bed ridden cyanosi
s,pallor
Skin : no cyanosis, pallor no Nails: no no
Skin
Nails: clean , trimmed, CRT cyanosis clean , cyanosis cyanosis
Nails normal, ,pallor trimme ,pallor ,pallor
Nails: d, CRT Nails: Nails:
CRT
clean , normal clean , clean ,
trimmed trimmed trimmed,
CRT , CRT CRT
normal normal normal

Hair Normal Normal Normal Normal Normal

Colour Grey Black Black Black Black
Distribution Normal Normal Normal Normal Normal
Dandruff No No No No No
pediculosis No No No No No
HEAD Normal Normal Normal Normal
Shape Normal Clean Clean Clean Clean
Scalp Clean No No No No
Injury No injury injury injury injury injury
Infections No infections No No No No
infection infectio infection infection
ns
Eyes: normal sclera, no discharge, no Normal Normal Normal Normal
Sclera redness, pallor conjunctiva
Discharge vision: impaired,
Redness
Visual acuity

Ear
Otalgia Normal
Otorrhea Hearing could not be assessed Normal Normal Normal Normal
Hearing loss
Tinnitus
vertigo
Oral mucosa: healthy no sore healthy healthy healthy healthy
healthy no no sore no sore no sore no sore
sore
NECK
Swelling Normal Normal Normal Normal Normal
Lymphnodes
symmetr symmet symmetr symmetr
symmetrical, bilateral movement,
Chest: ical, rical, ical, ical,
B/L air entry equal
shape bilateral bilatera bilateral bilateral
Movement moveme l moveme moveme
Lungsounds nt, B/L movem nt, B/L nt, B/L
air entry ent, air entry air entry
equal B/L air equal equal
Function entry Function Function
al equal al al
normal Functio normal normal
Abdomen : Round, nal Round, Round,
Round, Soft and non- distended
Shape Soft and normal Soft and Soft and
No scar,normal bowel sounds
Scar non- Round, non- non-
Bowel sounds distende Soft distende distende
d and d d
No non- No No
scar,nor distend scar,nor scar,nor
mal ed mal mal
bowel No bowel bowel
sounds scar,nor sounds sounds
mal
bowel
 sounds
Limbs: structure normal. Left side Normal Normal Normal Normal
tremor functional, right side paralysis
Clubbing
ROM
exercises

SYASTEMWISE ASSESSMENT
Nervous Coscious, aphonia, Inability to Conscio Consci Conscio Conscio
system: speak, inability to walk, Right side us,orient ous,orie us,orient us,orient
sensorium paralysis not able to perform ed nted ed ed
Consciousnes activities of daily living
s Bedridden,can use only left limbs,
Dizziness right limb paralysis. Asks for food
Weekness by making some noises, not able to
Headache talk, but understand what is
communicatedby others. No
seizures no headache

Respiratory Bilaterally symmetrical movement Normal Normal Normal Normal

System No cough, normal lung sounds lung lung lung lung
sounds sounds sounds sounds

Gastrointestin Bowel sounds normal & no other Bowel Bowel Bowel Bowel
al system: disease, no nausea, vomiting, sounds sounds sounds sounds
accepting orally normal normal normal normal
& no & no & no & no
other other other other
disease disease disease disease
Integumentar Skin intact. Skin Skin Skin Skin
y system: Not cyanosed and flushed intact. intact. intact. intact.
No diabetic foot Not Not Not Not
cyanose cyanose cyanose cyanose
d and d and d and d and
flushed flushed flushed flushed
No No No No
diabetic diabetic diabetic diabetic
foot foot foot foot
Urinary No dysuria/ burning micturation , Normal Normal Normal Normal
system: take bedpan herself to pass urine, micturat mictura micturat micturati
for passing stool assistance given by ion tion ion on
family members
DISEASE CONDITION

Kamaljeet Kaur

Chief complaints: Inability to speak, inability to walk, Right side paralysis *10 yrs

Personal/ social history:- She is bedridden, not able to perform activities of daily living, family
members help her to take bathe, eating meals, passing urine and stool

Present health history: She was apparently well 10 yrs ago, when she was having a
hypertensive episode and then paralysis of right side of body. She was taken to sec 16 hospital
from there she was referred to PGIMER chandigarh. In PGI she was diagnosed with CVA, got
some treatment not known to relatives but her symptoms didn’t improved. She was kept on
medicine for 9 yrs , last yr she gave up taking any medicine due to no improvement in
symptoms.

MEDICATION

T. Telma H (80/12.5) BD
T. MinipressXL 5mg BD
T. Amlong10 mg BD
T. Atenolol 50mg OD
T. Rosulip 20mg HS
Nature of medical aid utilized

Government hospital (PGI), Dhanas Health and wellness centre

Family planning: No of eligible

Name of eligible couple
Characterisrtics
Family planning status Yes or
No, if yes then specify
Significant history
Anenatal
Intranatal
Postnatal
Gurwinder singh and Manjeet
Kaur
Using condom often and
ejaculation withdrawl method
no
Nothing significant
Nothing significant
Nothing significant
Baljinder singh and amandeep
Kaur
Use condom,baljinder singh is
staying in Dubai,comes
ocassionaly
No
Nothing significant
Nothing significant
Nothing significant
 MTP/ ABORTION nil nil
BIRTH Normal normal
Maternal assistanc ; Doctor/ Health worker Health worker
Registerered nurse/ health
worler/ TBA DAY
LANGUAEG PROGRESS: normal normal
NORMAL/ PROLONGED/
PRETERM
TYPE OF DELIVERY: VAGINAL/ Vaginal aginal
INSTRUMENTAL /
CAESSAREAN
NEONATAL HISTORY: Nothing significant Nothing significant
TIME OF INITIATION OF Within 30 min of delivery Within 30 min of delivery
BREAST FEEDING
COLOSTRUM FEEDING yes yes

HEALTH CARE GROUP

3 children immunized uptodate

Immunization card is present

GERIATRIC GROUP(>60y)

Name Avtar singh

Psychosocial issues No memory loss, no depression
Living in joint family
No feeling of loneliness, goes to work as
carpenter
In home spend most of time with
grandchildren
Activities of daily living Independently perform all activites of
dailyliving
Goes for work daily

NEEDS IDENTIFIED IN FAMILY

Needs identified
Sl.n Needs Nursing Goal Care Implementati Evaluation
o identified diagnosis planned on

1. Mrs. Impaired To help To give 1.Family was Risk of

 Kamaljeet is physical Mrs. health demonstrated complicatio
bedridden mobility Kamaljeet education to about range of ns related to
related to improved improve motion
hemiparesis, mobility mobility and exercisesand Immobility
loss of and prevention also taught was reduced
balance and prevention of about its as family
coordination of complicatio importance. was
and brain complicato ns 2. 2 hourly
injury ns related posture change involved in
to was advised. doing ROM
immobility 3.Optium useof exercises.
left limbs was
advised

BMI of
2. Manjeet Altered 1.She was
Mrs.
Kaur was 29 nutrition advised to Manjeet
which comes pattern more To bring decrease started
in than body the BMI of To help hercalorie morning
overweight requirement Mrs Mrs. intake.
walk and
as evidenced manjeet manjeet in 2.A diet plan
by BMI 29 Kaur in planning her was given improved
normal diet . She was her dietary
range and advised to intake
to motivate consume fat
her to free diet, to
reduceweig decrease oil
ht intake, avoid
junk food and
to increase
intake of
vegetables and
fruits
3.She was
advised to do
walk daily and
also to join
yoga in
healthand
wellness centre
4Adult women
assessment
was done
3 Mrs. Noncomplian To motivate To Family is Mrs Manjeet
Kamaljeet ce with family for encourage asked about promised to go
stopped treatment regular to follow up what for regular
taking regimen follow up regular makesthem r follow up and
medicine related to of treatment treatment not to follow to go for
poor of Mrs and the treatment regular check
motivation Kamaljeet checkups then they upof Mrs.
Kaur replied that Kamaljeet
there is no
improvement
in her . they
were
encouraged to
take medicine
for Bp,
regularly to
prevent further
complications
4. Agamjot and Risk of home To prevent To educated 1.mothers were Mothers were
aviraj are accidents home mothers advised to keep aware of the
very secondary to accidents about medicine box risk associated
naughty. developmenta prevention away from the .
They keep on l age of home reach of
exploring accidents children
everything 2. motherswere
advised to keep
an eye over
children while
they were
playing
3. they were
advised not to
put any
harmful
substance into
eatable boxes.
4. to keep
cylinder closed
after cooking

5. Eligible Knowledge Family 1. To Assess Women was They gained

couple are deficiet planning the not having the the knowledge
not using any related to methods knowledge adequate regarding the
effective family will be related to knowledge various family
family planning adopted family about the planning
 planning,eth methods planning family methods
od methods planning
2.To Advise metods
the mother They were
to adopt the advised for Cu-
methods ; T as a spacing
spacing and method
Cu- T She was taught
3.Explain about the
the various various
methods and methods and
advantages the advantages
and and
disadvantag disadvantages
es of various of various
methods methods

Health education:

 Family is advised to go for regular check ups of Mrs. Kamaljeet

 Mrs Manjeet advised to go for regular morning walk and to do active and passive
exercises
 Mrs Manjeet is encouraged to follow advised diet pattren
• They were educated about various family planning methods