Eto Na FNCP

CITY OF OLONGAPO GORDON COLLEGE COLLEGE OF NURSING
FAMILY NURSING CASE PRESENTATION
Submitted by: Aldana, Olivia A. Bolagao, John Casper B. Caseja, Easter Joyce A. Lucena, Jayvee C. Macadaan, Bernadette E. Puruganan, Maria Agatha Rae C.
Submitted to: Mr. Bryan Dimen, RN
Date: August 17, 2011
I.
INTRODUCTION
Family is a group of persons united by ties of marriage, blood, birth or adoption, and it is composed of two or more people who are emotionally involved with each other and live in a close geographical proximity. (Friedman, 1981)
Family is the basic unit of society, a primary entity of health care or institution responsible for the physical, emotional and social support of its members. The family is the unit of care in Community Health Nursing because it is considered as the natural and fundamental unit of society. As a group it generates, prevents, tolerates and corrects health problems within its membership. The family is the most frequent focus of health decisions and actions in personal care. It is an effective and available channel for much of the community health nursing efforts. It also provides a crucial environmental force; the family through its interaction within the larger social system validates and influences health efforts. The family is said to be the foundation of the individual s personality development. The individual s personality depends on how their family molds them to be a better person. A parent tends to be the first teachers of their children. They play an important role in their child s physical, emotional, social and spiritual development. They should set as a good example for their children. Since communities is made up of families, as future community health nurses we would be the front liners in the community. We must familiarize ourselves to the need of our clients. One of the four clienteles would be the family. Student nurses must be able to identify problems that exist within the family and must be able to prioritize problems according to the family needs. We conducted a family interview to gather information that would serve as a baseline data.
BRIEF FAMILY HISTORY
The Family X who is a cohabitated family resides in a small makeshift house in PAG-ASA, Olongapo City for about 10 yrs. Mr. X and Mrs. X have 3 children, 2 boys and a girl. Their religion is catholic. Mr. X who is 33 years old originated from Bataan, he was born on March 11, 1978. He was an -
elementary Undergraduate and grade two is his highest educational attainment. Mr. X is self-employed; he uses his own side car to collect garbage from baranggayPag-Asa, Sta. Rita to Kalaklan. Mrs. X is 24 years old and was born on June 14, 1987. She was an Elementary Undergraduate and grade three is her highest educational attainment. Mrs. X is self-employed, and works as a barker for jeepneys. She relies on the tip given to her by the jeepney drivers so she does not have regular earnings. The family X is in the Family with School Aged children according to Duvall s development/ task of the family where their eldest child is 6 years of age until the child turns 13 years of age .Their eldest son is 8 years old and was born on March 3, 2003. He is currently a grade three student in Kalalake Elementary School. Their second son who is 7 years old was born on August 14, 2004. He is currently a grade 1 student in Kalalake Elementary School Mr. and Mrs. X s youngest child is a 3 year old girl. It is in the year 2001 when Mr. X transfer from Bataan to Olongapo City together with his parent s to seek for a job. In that same year, Mr. X and Ms. X met and decided to build a family.
IMPORTANCE OF STUDY
y y y y
This study will help family X identifies what problem has the highest priority to be solved first. This study will make their consciousness active on the importance of health. This study will help to prevent further unexpected illness. This study will help to promote proper hygiene in their daily living.
OBJECTIVES
To know the health status of the family, their cultural practices, their habits, and how they prevent and treat disease.
y y y
To help the family realize that they are the one who is responsible for their health. To introduce to the family the importance of health promotion and disease prevention. To be able to prioritize problems of the family and to identify the nature modifiability, preventive potential and salience of these problems.
To make an appropriate family nursing care plan that would suit to the identified problems.
II.
FAMILY STRUCTURE AND CHARACTERISTICS
A. GENERAL FAMILY STRUCTURE NAME RELATION TO SEX THE HEAD OF THE FAMILY Mr. X Head of the family Mrs. X Live-in partner JR RJ Angel Son Son Daughter M M F 8 7 3 3/21/2003 8/14/2004 5/6/2008 Grade 3 Grade 1 N/A F 24 6/14/1987 Grade 3 M 33 3/11/1978 AGE BIRTHDATE HIGHEST EDUCATIONAL ATTAINMENT Grade 2 Elementary undergraduate Elementary undergraduate Student Student N/A N/A N/A N/A Catholic Catholic Catholic Barker Catholic Scavenger Catholic EDUCATIONAL STATUS OCCUPATION RELIGION
Family X is a co-habitating family consisted of a father and a mother who are not married and their three children living together in one house. The family is matrilineal because members of the family affiliates with a group of people related to them through their mother. The two boys who are already going to school live with their maternal grandmother on weekdays and stay with their parents on weekends. In terms of residence, the family is patrilocal since the house that they live in is located in the lot which belonged to the family of their father. In decision making, although the father says he is the one who decides for the family it was evident that he is a submissive partner when his partner called him and told him to cook their food.
Interpretation:
Family X is a cohabitation family because the father and the mother are not married, lives together and has three children. The family is matrilineal because their two sons affiliate with a group of people, specifically their grandparents related to them through their mother. In terms of residence, the family is patrilocal since the place that their house is located used to be the property of the father s family. In terms of decision making, the family is egalitarian because even though Mr. X says that he is
the one who is in charge, it was obvious that he listens to what his wife tells him. Family X is in the stage of Family with School Age Child/Children because their eldest and middle children are already going to school.
Analysis:
Cohabitation families are composed of heterosexual couples and perhaps children, who live together but remain unmarried (Pillitteri,A., 2009). A family is matrilineal according to descent when members of the family affiliate with a group of people related to them through their mother. It is said that a family is patrilocal according to residence if they live near the domicile of the parents of the husband. According to authority, a family is egalitarian when husband and wife exercise a more or less amount of authority, father and mother decides. Important nursing concerns during this family with a school age child stage are monitoring children s health in terms of immunization, dental care, and health care assessments; monitoring child safety related to home or automobile accidents; and encouraging a meaningful school experience that will make learning a lifetime concern (Pillitteri,A., 2009).
GENOGRAM
MR. X (33)
MRS X (24)
(24)
JR (8)
RJ (6)
ANGEL
(3)
A.GENERAL FAMILY RELATIONSHIP
Family X has a united but conflicted relationship, they live in one house but when the mother talks to the father she always shouts and curses him. It is the father who takes care of their youngest and when she d make noises while the mother is sleeping she d shout at the child. While we were on the process of information gathering, the mother is out playing coins with other kids and we had no choice but to get most of the information from the father and their two boys.
Interpretation:
This kind of relationship that the husband and wife has and how the wife treats everybody in the family may have a negative impact on the children especially the youngest one who stays with them the most. Analysis:
Shared household work and decision with spouse can strengthen the family s capacity to improve the well-being of the members (Reyala, 2000).
B. DIETARY HABIT BREAKFAST THURSDAY Pancit bought from local vendor FRIDAY fried rice, egg, dried fish Mr. X SATURDAY Sopas local vendor LUNCH DINNER
fried rice and giniling rice and vegetables (pakbet) Mr. X rice and fried fish Mr. X rice and smoked fish Mr. X local vendor rice and fried fish Mr. X rice and smoked fish Mr. X
Family X usually consumes 2 kilos of rice each day and buys ulam or viands from their local vendor or carinderia or buys fish from the market and he fries it. According to Mr. X he eats approximately 4 cups of rice, his wife 2 cups and the 3 kids 1 cup each, the rest he feeds to their dog. What they ate at lunch would almost always be what they would eat for dinner. And they would drink
water after meals, 2 glasses each for him and his wife, 1 glass each for the children who sometimes would not empty the glass.
Interpretation:
They consume too much carbohydrate, they do have protein in the diet in the form of fish but smoked fish contains high sodium or salt. Fruits are never in their diet and vegetables are very rare only when they would buy from the carinderia. Their dietary habit is mainly a product of Filipino culture. Filipinos do not consider it a meal if rice is not served. Plain steamed rice is the basis of the diet. Eating too much carbohydrate can lead to increased blood sugar level along with other diseases like diabetes and hypertension. While having too much salt in the diet can lead to kidney disease and hypertension as well.
Analysis:
Nutrition is what a person eats and how the body uses it. Nutrients are organic and inorganic substances found in foods that are required for body functioning. Adequate food intake consists of a balance of nutrients: water carbohydrates, proteins, fats, vitamins and minerals. Foods differ greatly in their nutritive value (the nutrient content of a specified amount of food), and no one food provides all essential nutrients (Kozier, 2008). The key word there is specified amount, anything that is over or under in terms of quantity can affect health. The desirable contribution to total energy intake should range from 55-70% carbohydrates, 20-30% fats, 10-15% protein. A balanced diet is one that contains all the nutrients and other substances found naturally in food, in proper amounts and proportions needed by the body to function well. Eating a diet that includes a wide variety of foods in the right amount chosen from different food groups helps individuals to meet the Recommended Dietary Allowance (Reyala, 2000).
III. SOCIO ECONOMIC
A. MONTHLY INCOME
Mr. X earns from 100-250 pesos per day from scavenging in places near their house to as far as Sta. Rita and Kalaklan and it is mostly 100 pesos than higher. His wife sometimes works as a barker for jeepneys and rely on the drivers tip so she does not have a steady income. However, Mr. X told us that his wife is a member of the 4Ps or the Pantawid Pamilyang Pilipino Program wherein the government provides conditional cash grants to extremely poor households to improve their health, nutrition and education particularly of children aged 0-14. They get about 1,400 pesos a month from the 4Ps. The education of their two sons is free and what they need for school is being shouldered by their grandparents. Mr. X s income is just enough for their food and water and they have no chance of saving anything for the rainy days or if one of the family members get sick.
Interpretation:
Family X s total monthly income is approximately 4,400 pesos divided among 5 members of the family it is only 880 pesos for each person. It would be really hard for Mr. X to save up for the rainy days and probably save up for their plan of transferring to a bigger house because his only source of income is through scavenging. He couldn t find a job that he could earn higher because of his educational attainment. It is fortunate however that the grandparents of their kids are willing to help them by keeping the boys with them and giving them things that their father could not give like clothing and things for school.
Analysis:
For 2007, Filipino families consisting of five members should be earning a combined monthly income of 6,195 pesos in order to meet their most basic food and non-food needs for this year, according to National Statistics Coordination Board. This data is four years ago and prices are still getting higher. So it is safe to say from this data alone that Family X is below the poverty line.
IV.FAMILY HEALTH STATUS
A.HEALTH HISTORY
Mr. X stated that in the past 6 months, the head of the family or the father had encountered illness like mumps. Mr. X went to the health center to consult for his illness. Barangay health officials advise him to use gumamela flower and he did not take any kind of medication. Mr. X also stated that during their childhood, they experienced illnesses like mumps, chicken pox, and measles.
B.FELT FAMILY NEEDS
Adequacy of Living Space
- There is inadequate living space for the family. The house is too small for them. y Sleeping Arrangement
- The family altogether sleeps in a small area. The house is consisted of one bed and there are 5 family members. y Adequacy of furniture
- They donot have enough furniture in their house. They only have kerosene and 1 bed. y Presence of Insects and Rodents
- Their house is open and has no door. Their dog freely goes in and out of their house and the place is full of garbage so it is expected that there are many insects and rodents living all over the area. y Presence of Accident Hazards
- They live near the river so they are prone to accident hazards like drowning. The place where they live is full of garbage and at risk in having diarrhea, typhoid fever and pulmonary tract infection (PTI). y Food Storage and Cooking Facilities
- They do not have proper food storage in their house and they do not have enough cooking facilities in their area. They often buy their foods and drinks in a sari-sari store and at risk for hepatitis. y Water Supply
- They do not have water supply and they only buy their own drinks in plastic containers. y Toilet Facility
- They do not have their own toilet. They throw their waste excretions to the river. y Garbage Disposal
- The family has no proper container for garbage waste. They just put it in plastic cellophane where flies and rodents are present.
C.HEALTH BELIEFS (PRACTICES)
The family X does have health practices. They take a bath twice a day. Perform hand washing before and after eating but they do not know the proper way. They brush their teeth twice a day and comb their hair after they take a bath. They change their underwear after they take a bath. According to Mr. X, their only exercise is bicycling when he goes to work, his wife doing the laundry and their kids play and they do have enough rest and sleep. Mr. X had a mumps this last 6 months and went to the health center to have a checkup. They gave him gumamela, a medicine for his mumps. They do not have a family doctor and dentist. They often consult their health problems in the health center because they have free medications and medicines but rarely go there because of inadequate source of income. He stated that his eldest son, RJ, had been hospitalized because he accidentally fractured his arm when he fell from a tree before the school started this year. They went to the health center and they placed a cast on his fractured arm. Family X drinks water after they eat and only if they are thirsty. Mr. X does not smoke but only drinks liquor when he wants to relax. His wife smokes after eating her meal. She is a member of an organization in their community but she is not that active. The client stated that all their children are fully immunized in their barangay health center. Mr. X stated that he wakes up at 5:00 in the morning to get reusable materials from trash and sell it to the junkshop. And after that he goes to the market to buy food. Then when he gets home, he will cook breakfast for his family. In the afternoon he will goto the streets to find some reusable trash to sell and when he gets home he ll cook again then eat and sleep. Mrs. X wakes up at 10:00am to eat breakfast then after that she will wash their clothes. She is unemployed so she stays at home all the time. Then sometimes she is a barker at night. Mr. X stated that his first child and the second child wake up early in the morning to go to school. His youngest child is 3 years old so she stays at home all day. The client stated that they are using family planning and they use condom to prevent Mrs. X from getting pregnant. They are aware on how to use it. He stated that they get condom from the health center and sometimes there are programs where health workers goes house to house to give
condom for free to promote family planning. The client also stated that they practice the withdrawal method when they don t have condom as contraceptive. Mr. X stated that during his free time or relaxation time, he is just sleeping and watching television from their neighborhood. Mrs. X s relaxation is just sleeping and playing Cara Cross in the street. He also stated that his stress coping activity is just drinking alcohol (EMPERADOR) whenever he wants to relax while Mrs. X smokes after eating her meal.
Interpretation:
Family X lived almost 10 years near the river. Even though they do not have enough money for living and they only enough money for their everyday living they are still happy. They live in a small house that is not conducive to live. They all sleep in a one small bed and at risk in having backpain and bad posture because of wrong sleeping position. There will be a possibility that they will be suffocated because of lack of oxygen in the sleeping quarters. They also live near the river and there is a possibility that when there is a high tide they can get communicable diseases like typhoid fever, diarrhea, dengue fever, pulmonary tract infection (PTI) and leptospirosis. They even throw their waste excretions in the river. They often buy their foods in the carinderia and the water that they always drink is placed in a plastic container and they are at risk in having hepatitis, dysentery and cancer. Rodents and vectors are always present in their surroundings because of improper garbage disposals. They only have few appliances in their house so they have no means of entertainment and relaxation. The family X takes a bath twice a day and before they eat they perform hand washing but do not know the proper way. According to Mr. X, they do not take exercise regularly and at risk in having cardiovascular disease when they get old. They often go to the health center because of free medication and medicines but rarely go there because of inadequate source of income. When his eldest son, JR, had been hospitalized due to his fractured arm when he fell from a tree they went to the health center to cast it. They should go to the hospital too to be safe if it really healed or not. Mr. X drinks liquor whenever he wants to relax and to relieve his stress. Mrs. X smokes after eating her meals. Because they have vice like drinking and smoking they are at risk in having tuberculosis and cirrhosis of the liver. They also used condom for their family planning.
Analysis: Health According to Nightingale, health is a state of being well and using every power the individual possesses to the fullest extent. (Kozier and Erb,2007) WHO (1948) a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity. . (Kozier and Erb,2007) Talcott Parsons (1951) ability to maintain normal roles. . (Kozier and Erb,2007) US President s Commission on Health Needs of the Nation Health is not a condition; it is an
adjustment. It is not a state but a process. The process adapts the individual not only to our physical but also our social environments. It emphasizes health as an adaptive process rather than a state. . (Kozier and Erb,2007) ANA (1980)- a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent possible. Health is more than a state or the absence of disease; it includes striving toward the optimal functioning. . (Kozier and Erb,2007) ANA(2004) an experience that is often expressed in terms of wellness and illness and may occur in
the presence or absence of disease or injury. . (Kozier and Erb,2007) Health status state of health of an individual at a given time. A report of health status may include
anxiety, depression or acute illness and thus describes the individual s problem in general term. Health status can also describe such specifics as pulse rate and body temperature. . (Kozier and Erb,2007) Health Beliefs concepts about health that an individual believes are true. Such beliefs may or may not be founded on fact. . (Kozier and Erb,2007) Bathing removes accumulated oil, perspiration, dead skin cells and some bacteria. It produces a sense of well-being. (Kozier and Erb,2007) Immunization in.(Reyala,2007) the process by which vaccines are introduced into the body before infection sets
III.
HOME AND ENVIRONMENT
The house of family X was demolished recently because the land that is the standpoint of their house has been repossessed by the bank, and until now they are still there but different from the usual, because now, they just occupied a small part of that land. Their house today is just a makeshift with only
one room occupied by three persons. In reality, this room is only for one person, but because of poverty and inadequate resources they do not have any choice but to live there. The light that they are using is only a candle and it is not adequate because it can cause a fire if left unattended. As we estimated the size of their house, the width is 3meters and the length is 4meters, and you can t stand there if you are 4-5ft. and above, because the roof is too low. The ventilation in their house is not adequate because it is too small and patchy, and the surroundings of their house have so much garbage, so you cannot snuffle fresh air. There are so many hazards in their house one of this is the river at the back of their house, because the head of the family or their father mentioned that his children plays on the river so therefore, the children are at risk of getting drowned. They don t have drainage, they are collecting their garbage on a plastic and place it in the trashcan 5meters away from their house to be collected by the garbage collectors every Tuesday and Friday, and they are just excreting in his mother in law s toilet near their house. The house of family X is too small for them and their surroundings are dirty because of the scattered trash. They do have vectors and rodents present in their house like cockroach, mice, and termites. They do have a pet, one dog, the breeding is a stray dog, and where kept under their house. Their dog has no vaccination. They do not have their own water supply. They only buy their drinking water from their neighbor and store it in a plastic container. Since they do not have water supply there is no distance of water source from the house. They use plastic bottle as their water storage for drinking. One gallon of water costs only two pesos. They have a container that can occupy three gallons and it cost only six pesos. They do not have a method for sanitizing water. The type of water storage for bathing/for any household chores is also a plastic container. They do not have a proper cooking facility but they have kerosene stove used for their cooking. They use pot for their food storage for cooked food. They do not have food storage for uncooked food. When Mr. X buys food he cooks it as soon as possible. They use a kerosene gas stove as their way of cooking their food. They use plastic bag or sack for their garbage, which is collected by the garbage truck every Tuesday and Friday. As we go around with our assessment we found out that their surroundings are scattered of trash. Since they do not have their own toilet facility there is no distance of septic tank from their house. There is no materials use for septic tank. And there is no condition of septic tank. They only shared toilet with their in-laws when they need it.
Interpretation:
The house of family x is not conducive to live because it is too small for 3 person and the ventilation is inadequate so communicable disease are can easily be transmitted to the other member of the family. Their house is too close to river and when there is high tide, the water from the river reaches them, so they are at risk of having Athlete s foot and the most worst is getting drowned especially for the children. Their house is surrounded with garbage and tires with water can be the reservoir of mosquitoes which can cause dengue and malaria, and the garbage that surrounds them can be the cause of Typhoid fever and diarrhea. They are buying their foods in the near carinderia even though they don t know if it is clean and safe to eat, so they are at risk to get Ascariasis which is the causative agent of Ascaris Lumbricoides. Also, they are buying their water from their neighbor not knowing when it came from, they drink and used it for washing their utensils and for bathing, so they are at risk to get diarrhea, cholera, and amoebiasis.
Analysis:
LIVING CONDITION
Poor living conditions may lead to illness, easy transmission of disease, injuries that can adversely affect the health of the people; likewise a healthy and wholesome environment promotes healthy life and absence of disease. Each family (of about 5 people) has about 10 m2 to sleep and organize their living space.(Reyala,2000)
HEALTH AND SANITATION
Environment Sanitation I still a health problem in the country. Diarrheal diseases ranked second in the leading causes of morbidity among the general population. Other sanitation related diseases are tuberculosis, intestinal parasitism, schistosomiasis, malaria, infectious hepatitis, filariasis and dengue hemorrhagic fever which are controlled and/or eradicated by health programs with environmental sanitation components but still afflicting a great number of the population..
The Department of Health through the Environmental Health Services (EHS) has authority to act on all issues and concerns in environment and health including the very comprehensive Sanitation Code of the Philippines (PD 856, 1978). However, the implementation of the environmental health programs need to be standardized and intensified coupled with police power to attain a better quality of life towards the end of century.(Reyala,2000)
WATER SUPPLY SANITATION PROGRAM
There has been a steady increase in the number of household having access to safe water supply sources. However, insufficient knowledge and inappropriate practice in the handling of water from the source to the storage point in the house could contaminate drinking water. People who get drinking water from the pipe water facilities are not exempted from diarrheal disease contraction particularly those that are served with old worn-out pipes that suck in sewage or filt through cracks and joints of the pipes. (Reyala,2000)
PROPER EXCRETA AND SEWAGE DISPOSAL PROGRAM
It is significant to note that there has been an increase in the proportion of households having sanitary toilet facilities both in the urban and rural areas but there is also an increase in the absolute number of persons, which do not have an access to sanitary toilet facilities in the sense that the mothers still allow their children to move their bowel elsewhere despite of the presence of toilets in their homes. (Reyala,2000)
FOOD SANITATION PROGRAM
The rapid change in the eating habits of the Filipinos in fast food establishments particularly those in the urban centers increases the risk of the segment of population to food-borne infection due to unsanitary handling of preparation of food. The banning of shellfish consumption during red tide period to reduce the number of persons that contract paralytic shellfish poisoning has its complexities with regards to the aggravated economic conditions of affected fisherman and shellfish vendors. (Reyala,2000)
V. FAMILY ENVIRONMENT
Since the X family lives near the river, there is a high risk that their house would be flooded whenever there is a high tide. They are also prone to dengue and malaria. They also have a noisy and not peaceful environment. The house in their neighborhood is built close to each other. Their surrounding is dirty because of the presence of scattered garbage found within their area. This garbage produces unpleasant odor that makes the surroundings prone to flies, rats and cockroaches. They do have hospital, health center and birthing home located in their community as their health facilities. They do not have a school located in their barangay but there are schools in the near barangays. Pag Asa Public Market is the center of trades in their vicinity. There are Christian churches located within their barangay but the nearest Catholic Church is situated in barangay Kalalake. Even though there are establishments that promote relaxation which are located within the vicinity of their barangay, they can t afford to go there because of financial problems. The family X do not use any means of communication facilities for they do not have any resources for it. Since Mr. X uses his bicycle with side car to collect garbage, this also serves as their means of transportation. They do not use other means of transportation except for their bicycle with side car. Mr. X had said that whenever one of the family members get sick, they go to the health center which is just a walking distance from their home to consult the community health doctor. It only means that they trust the health facilities located in their community.
Interpretation:
The family X is prone to home hazard because of the presence of river located at the back of their house. There is great chance to that they might acquire dengue and malaria for they do not have a drainage system. Living in a noisy and not peaceful environment can greatly affect the family s health. One of the major problems of the family and community is the improper garbage disposal, it can cause gastrointestinal diseases. Their communities have complete social facilities which are easily accessible. Though some facilities are not located in their barangay, like school and church some social facilities are located in the near barangay which is a walking distance they do also have a complete health facilities like hospital,
health center and birthing home. Because of the lack in income they can t afford to buy a cellphone or other device used for communication so they are not aware in their relatives residing in other province. The family trusted the health center present in their community for he verbalize pag may nagkakasakit nagpupunta agad kmi sa center, wala kasi kaming perang pampagamot.
Analysis:
Family surroundings influence the family s knowledge, attitudes, and practices (KAP) on their health especially when they are ignorant of their own health. e.g. use of regulated drugs and smoking may increase health risk. Many still adhere to superstitious beliefs in terms of health practices among the elders and tend to pass it on the next generation. Decision of other family members may prevail even against the will of the concern individual. (Reyala,2000)
VI. AWARENESS OF COMMUNITY ORAGANIZATIONS
The family X is not active in their community. They are not members of an organization in their community. Mrs. X is a member of a National Government Program called 4 P s ( Pamilyang Pilipino Pangkabuhayan Program). Mr. X is also aware of the said program. They receive a monthly amount of P 1,000 in exchange that they would send their children in School. Mr. X emphasized that their family is only active in the community festivities. Their children participate in the parlor games which is one of the programs during the barangay fiesta.
Interpretation:
The family X is not active in participating in their community organization mainly because they are busy with their jobs. Even though they are aware of the existence of an organization they can t find time to participate in the activities of the organization. It is not enough that only their child participates in their community festivities. Parents should be the role model off their child specially regarding with the socialization of the family.
VII. PRIORITIZATION OF PROBLEMS
IMPROPER GARBAGE DISPOSAL
CRITERIA
COMPUTATION
ACTUAL SCORE 0.67
JUSTIFICATION It is a health threat because improper garbage disposal can affect their health.
NATURE OF THE 2/3 X 1 PROBLEM
MODIFIABILITY
2/2 X 2
It is easily modifiable because the resources are available and
interventions are feasible.
PREVENTIVE POTENTIAL
3/3 X 1
The preventive potential is high because communicable disease transferred by insects and rodents can be prevented.
SALIENCE
0/2 X 1
The family does not perceive this as a health problem.
TOTAL SCORE
3.67
INAPPROPRIATE OR INADEQUATE HYGIENIC PRACTICES
CRITERIA
COMPUTATION
ACTUAL SCORE 0.67
JUSTIFICATION It is health threat because
unhealthy lifestyle can greatly affect the health of the family.
MODIFIABILITY
2/2 X 2
It is easily modifiable because they can practice appropriate hygienic practices if they only have eagerness to do it.
3/3 X 1
This is preventable and once they practice this properly and become their habit, it cold, can flu stop and
transmitting
infections caused by viruses and bacteria.
SALIENCE
0/2 X 1
They do not care about this problem; the most important for them is their food.
TOTAL SCORE
3.67
INADEQUATE LIVING SPACE
CRITERIA NATURE OF THE PROBLEM
COMPUTATION 2/3 X 1
ACTUAL SCORE 0.67
JUSTIFICATION It is a health threat because it makes communicable diseases easily transmitted
MODIFIABILITY
1/2 X 2
It is partially modifiable because even though they live in a makeshift house they still can widen the space from materials Mr. X can find from scrap
2/3 X 1
0.67
The problem has a moderate preventive potential because if solved, spreading of communicable diseases like Tuberculosis, Pneumonia and Dengue can be prevented within the family but still they could be infected from carriers outside their house
SALIENCE
2/2 X 1
The family is well aware of this problem that is why the two boys stay with their grandmother on weekdays
TOTAL SCORE
3.34
INABILITY TO ATTAIN PROPER NUTRITION
CRITERIA
COMPUTATION
ACTUAL SCORE 0.67
JUSTIFICATION It is health threat because it can lead to other diseases
NATURE OF THE 2/3 X 1 PROBLEM MODIFIABILITY 1/2 X 2
It is partially modifiable because the decision to change this
practice depends on the family. You don t need to be rich to buy a nutritious food.
3/3 X 1
It is highly preventable potential because if solved nutritional
problems such as malnutrition, anemia, preventive. SALIENCE 0/2 X 1 0 It is not felt need because they are used to buying cooked food. infection can be
TOTAL SCORE
2.67
LIVING TOO CLOSE TO A RIVER
CRITERIA
COMPUTATION
ACTUAL SCORE 0.67
JUSTIFICATION It is a health threat because the family is at risk in drowning whenever there is a high tide or accident near the river and they need to evacuate immediately.
MODIFIABILITY
0/2 X 2
It is not modifiable because they do not have a permanent place to live and they do not have enough money to evacuate in that place.
2/3 X 1
0.67
The preventive potential is low because accident hazard like
drowning and dengue can be prevented. SALIENCE 0/2 X 1 0 Not felt need because the family does not perceive this a health threat but as one of the basic needs of the family
TOTAL SCORE
1.34
PROBLEM IMPROPER GARBAGE DISPOSAL INAPPROPRIATE HYGIENIC PRACTICES
TOTAL SCORE 3.67 3.67
INADEQUATE LIVING SPACE INABILITY TO ATTAIN PROPER NUTRITION LIVING TOO CLOSE TO A RIVER AS A ACCIDENT HAZARD
3.34 2.67 1.34
IX.FAMILY NURSING CARE PLAN
IMPROPER GARBAGE DISPOSAL
CUES
NURSING DIAGNOSIS
GOALS
OBJECTIVES
NURSING INTERVENTION
METHODS OF NURSE FAMILY CONTACT
RESOURCES REQUIREMENTS
TIME AND DATE
EVALUATION
Subjective:
Improper
Short term:
Short term: After
-Discuss
theHome-visit
Visual needed
aidsAugust 6, 2011 to9-10am
- Minsan yunggarbage disposalAfter mga nakakalakal
proper garbage
due to inabilityconducting a 1conducting a 1disposal to the to provide ahour of healthhour of healthfamily. teaching theteaching the-Conduct health and the
discuss the topic of garbage disposal. proper
naming basurahome natatambak naenvironment lang dito verbalized the client. aswhich byconducive health maintenance Objective: and
client will beclient will beteaching isable to knowable tothe separationverbalize of garbage suchseparation as todiscuss
thepossible effect ofof improper
Time and effort of the nurse and the family.
proper garbagegarbage disposal one s health. -Identify the and in
personalbiodegradable, disposal. non
Expenses teaching and
for aids
-the garbage sdevelopment
in their house isdue to lack ofbiodegradable Long term: scattered
allskill in carryingand recyclable. After 3 days ofcausative nursing
transportation of the nurse.
over the place. out measures to
the risk factors
-even the was
thoughimprove
homeLong term:
intervention, theof
improper
garbageenvironment. collected
After 3 days offamily will be ablewaste disposal nursing to show proper-Teach the to
every Tuesday and Friday the garbage of their neighbor was
intervention, thegarbage disposalclient family will beas evidence by theseparate able to know howabsence ofgarbage
into
to maintain ascattered trash inbiodegradable, clean environmenttheir surroundings.nonand know the importance proper garbage disposal. of biodegradable, and recyclable.
dispose to their surroundings.
INAPPROPRIATE HYGENIC PRACTICES
CUES
NURSING DIAGNOSIS
GOALS
OBJECTIVES
NURSING INTERVENTI ON
METHODS OF
RESOURCES
TIME AND EVALUATION DATE
NURSE REQUIREMENTS
FAMILY CONTACT
Subjective: The
Inappropriat
Short
term Short The the base
term: -Encourage client s the client to clean the
HOME VISIT
Visual aids needed August 6, to topic discuss of the 2011 9-
client e
hygienic goal: After
verbalized
practices due
proper 10am
Naliligo kami to inability to health araw-araw at provide yungginagami t home a teaching, the
assessment
surroundings
hygiene.
after health of the house. will Time and effort of the nurse and the family. Expenses teaching and to transportation of the nurse. for aids
client will be teaching is to *this
naming environment e which
able to give be able to minimize or learn proper prevent the of
natubig yunginiinum din namin.
is importance
conducive to to health maintenance and personal personal hygiene.
their hygiene and spread able to infection.
verbalize the -instruct importance them
Objective: -the surroundings
development due to lack of
Long goal:
term of
hygienic separate to their dog in their house. *to prevent
practices series health. nursing Long term: After
knowledge of After of
of their house importance are full of of
hygiene interventions
series scabies.
garbage.
and
the client will of
nursing -teach them right
-they are not sanitation. wearing slippers the member and boy of
be able to intervention show appropriate Hygienic Practices
the client will the
be able to procedures verbalize: in hand
as 1. The ways washing. on how to *to prevent improve the spread of microorganis ms.
the family are not their wearing shirt
evidence by:
1.
Changing Hygienic Practices.
likewise their brief. -the dog is sleeping under house their and
of clothes 2. Wearing of slipper frequently. 3. Trimming of nails. 4. clean appearance. Overall
-encourage the client to give attention in their personal hygiene. *this will
sometimes they don t
care if the dog enters house. -not using of soap for their
improve their lifestyle and prevent them on
washing their
hands and the water they drinking that are is
getting
sick
especially the children.
also the water that they are using to wash their utensils and hands. their
-teach
the
client on the effects of the dirt in their health. *this will
minimize the negligence of the client.
-instruct them to wear their clothes especially they are in the place. *to them protect from dirty
dirt and in the rain.
INADEQUATE LIVING SPACE
CUES
NURSING DIAGNOSIS
GOALS
OBJECTIVES
METHODS OF NURSE FAMILY CONTACT
RESOURCES REQUIREMENTS
TIME AND DATE
EVALUATION
Subjective: Temporary lang naman yan pag nakaipon lilipat din kami as verbalize by the client.
Inability to provide a home environment which is conducive to health maintenance and personal development
Short Term: After 1 hour of health teaching, the client will be able to know the implications of having cramped space as their house on their health Long Term: After a series of nursing interventions, the family will
After 1 hour of health teaching, the client will able to verbalize the importance of having an adequate living space enough for the number of people in the same house.
Introduce self and the group
Home-visit
Human resources:
August 6, 2011 910am
Face to Face Establish rapport Time and effort of the student Provide general knowledge on how communicable diseases could be easily transmitted in a limited space (to motivate the family and create awareness) Expenses for teaching aids Suggest ways on maximizing their space such as arranging their and transportation of the nurse. Family cooperation and participation nurses and the family members
Objective: Family X lives in a makeshift house constructed from wood
due to inadequate family resources, specifically limited financial
and cartons and measures about 3 sqm
resources
display an interest in making their home more spacious as evidenced by rearrangement of their things
house (to foster selfreliance and develop initiative)
Encourage the family to push through with their plan of moving to a more spacious house as soon as possible
INABILTY TO ATTAIN PROPER NUTRITION
CUES
NURSING DIAGNOSIS
GOALS
OBJECTIVES
METHODS
RESOURCES
TIME AND EVALUATION DATE
OF NURSE REQUIREMENTS FAMILY CONTACT
SUBJECTIVE: Lagikamingna mimilinglutong
Inability
to Short goal:
term After hour
one Identify the risk
client Home Visit Visual aids needed August 6, for to topic discuss of the 2011 9-
attain proper Nutrition to
client will be malnutrition to After one able of verbalize the: Note availability and use of to assess causative factors.
proper 10am
ulam at saka due lagging tinapayungula m inability
nutrition
to hour
recognize the health
Time and effort of the nurse and the family.
naming presence of a teaching the problem due client will be 1.Importanc fear
yunlangkasiyun g
kaya to
of able to know e of proper financial the nutrition in resources their health. 2.Three food groups To conduct and Expenses for
ngbudget. as verbalized the client.
consequence
by s of diagnosis following: of problem 1.The importance of
support system.
teaching aids and transportation the nurse. CHN bag of
specifically OBJECTIVE: *The economic/
proper and able to health teaching in distinguish them. about importance proper the of
children cost with complication
Nutrition
together their
one s health.
Pictures foods
of that
mother s.
2. The three 3.
are skinny and they have a
food groups( Understandi GO, and foods) GROW GLOW ng causative of
nutrition.
belongs to the three food
small built.
Discuss three
the food
groups.
and factors food when
*They frequently tinapa which is a kind of dried fish. Weight: *Mr. X 76 Kgs. *Mrs. X 42 Kgs. *Eldest child 27 Kgs. *Middle 16.5 Kgs. *Youngest child 9.5 Kgs. child
the pyramid.
groups and the
known and food pyramid. necessary
3. Determine intervention the and cause s.
Promote adequate timely intake. and fluid
related 4. that Importance the of food
factors affects family s Nutrition pattern.
pyramid.
Emphasize importance of
5. how
Ways well-balanced to nutritious intake. Provide
purchase low
cost information regarding individual nutritional
nutritious Height: *Mr. X 168 cm *Mrs. X 148 cm. Long term: After consecutive Home Long term : foods.
needs and ways
Visit After every to meet these
*Eldest 123cm *Middle 97cm *Youngest 67cm
child
the
clients Home
visit needs clients financial
with
will be able the child to
attain will be able constraints. to: Promote proper 1. gain at exercise and
progressive weight gain.
least 2 kgs. stress reduction of weight. 2. Demonstrat Discuss ways to purchase low their methods.
e behaviors, cost alternative life style foods.
changes to regain maintain weight. Evaluate daily total food and Long term:
intake. Let the patient obtain a diary of patterns and times of
eating.
Promote pleasant, relaxing environment, including socialization when possible.
Develop consistent, realistic weight goal with client.
Weigh at regular intervals document results. and
X. BIBLIOGRAPHY
Doenges, Marilynn E., Moorhouse, Mary Frances and Murr Alice: Nurses Pocket Guide Diagnosis Prioritize Intervention and Rationales 200, 565-569. Kozier and Erb s: Fundamentals of Nursing, Eight Edition 2007,295,300,748.
Pillitteri, Adele. Maternal and Child Health Nursing 6th ed. Volume 1.Lippincott Williams & Wilkins, 2009 p. 41
Berman, Audrey; Snyder, Shirlee; Kozier, Barbara; Erb, Glenora: Kozier & Erb s Fundamentals of Nursing 8th Ed. pp. 578, 774,775, 1232
http://www.rnpedia.com/home/notes/community-health-nursing-notes/family-health-nursing http://www.fnri.dost.gov.ph/index.php?option=com_content&task=view&id=1122&Itemid=99999999 http://www.nscb.gov.ph/poverty/FAQs/default.asp
Reyala, J., Nisce Z., Martinez, F., Hizon N., Ruzol C., Dequina R., Alcantara A., Bermudez M., Estipona G: Community Health Nursing Services in the Philippines 2000, 89, 90, 91, 138.
Reyala J.,Cruz-Earnshaw, Bonito S., Sitioco, J., Serafica L., Public Health Nursing, 10th Edition2007, 142.
XI.APPENDICES / DOCUMENTATION
Amoebiasis - is an infection of the large intestine or other organ caused by the single-celled parasite Entamoeba histolytica.
Anemia - a condition in which thin the blood is deficient in RBC or Hemoglobin.
Ascariasis - is infection caused by ascaris lumbricoides, intestinal roundworm.
Athlete s Foot- also known as ringworm or tinea pedis, it is a fungal infection of the skin that causes scaling, flaking, and itch of affected areas.
Backpain - pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.
Cancer - a class of diseases in which a group of cells display uncontrolled growth, invasion that intrudes upon and destroys adjacent tissues
Cardiovascular Disease - the class of diseases that involve the heart or blood vessels (arteries and veins).
Cholera -Cholera is an infection of the small intestine that is caused by the bacterium Vibrio cholerae.
Communicable Disease to another.
an infection that is capable of being transmitted in any way from one person
Crooked Arm -It is arm set in an awkward angle.
Dengue
infectious virus disease transmitted by Aedes Aegypti mosquito. Occurring in the tropics and
some temperature areas., it produces fever, headache and fatigue, followed by severe joint pains, aching muscles, swollen glands and a rash.
Dengue-is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue viruses. It occurs in tropical and sub-tropical areas of the world.
Diarrhea abnormal frequency, urgency and looseness of stools.
Diarrhea - meaning "flowing through" is the condition of having three or more loose or liquid bowel movements per day. The loss of fluids through diarrhea can cause dehydration and electrolyte imbalances.
Dysentery
infectious disease characterized by diarrhea, bleeding and abdominal cramps. It spreads in
contaminated food and water, especially in the tropics. It can be treated with antibacterials and fluid replacements.
Fracture - injury to the bones as a result of a force being exerted against it.
Food Guide Pyramid - a graphic aid that was develop by USDA as a guide in making daily food choices.
GO FOODS- Go foods are the type of a food group that provides energy, hence the name "go". Examples of this type of food group are bread, rice cereals and other foods that primarily provides carbohydrates.
GROW FOODS- Grow foods are foods that enhances growth development. Foods like milk, yogurt,
cheese
and
other
dairy
products
are
types
of
this
food
group.
GLOW FOODS- Glow foods are foods that enhances the quality or the "Glow" of our skin. These foods are rich in Vitamin D that is important for the development of a healthy skin. Green-leafy vegetables are examples of this food group.
Hepatitis A hepatitis is a general term referring to inflammation of the liver.
Hepatic Cirrhosis
a chronic disorder of the liver characterized by inflammation of secretory cells
followed by nodular regeneration of fibrosis.
Infection - the disease process produced by microorganism.
Leptospirosis - caused by exposure to several types of the Leptospira bacteria, which can be found in fresh water that has been contaminated by animal urine. It occurs in warmer climates.
Malaria- is caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitoes. In the human body, the parasites multiply in the liver, and then infect red blood cells. Malnutrition - a disorder of nutrition; insufficient nourishment of the body cells.
Nutrition- the sum of all the interactions between an organism and the food it consumes.
Pulmonary Tract Infection - classified as an upper respiratory tract infection (URI or URTI) or a lower respiratory tract infection (LRI or LRTI).
Tuberculosis
a chronic bacterial infection that usually infects the lungs, although other organs are
sometimes involved. It is primarily an airborne disease.
Typhoid Fever
acute, sometimes epidemic communicable disease of digestive system. It is spreads in
contaminated food and water, it is characterized by bleeding from the bowel and enlargement of the spleen.
Typhoid Fever- is a bacterial disease, caused by Salmonella typhi. It is transmitted through the ingestion of food or drink contaminated by the feces or urine of infected people.
The improper disposal of garbage outside the house of the X Family
Front of the house of the X Family
The side car of Mr. X that he is using to collect garbage.
The river at the back of their house.
The students while conducting an interview.
The unsanitary Environment of the family
Their dog that lives under their house.
The water container that the family used to store their water for drinking .
Assessment for School Age 1.Physical/Biological
Name of the Client: JR Age: 7 years old Sex: Male Address: 12th St. Pag-asa, Olongapo City Educational Attainment: Grade 3 School attended: Kalalake Elementary School Religious Affiliation: Roman Catholic
A.Measurements
Area of assessment Weight Height BMI 15.2
Actual Findings 23 kgs. 123 cm
Normal Findings 21 kgs 115 cm
Interpretation/ analysis normal normal
B.Vital Signs Area of Assessment Temp PR RR Actual Findings 36.6 C 75 beats/min 20 breaths/min Normal Findings 36-37.5C 75-120 15-25 Interpretation/Analysis Normal Normal Normal
C.General Appearance Area of Assessment Body built, height and weight in relation to client s age, lifestyle, and health Posture, gait, Relaxed, has an erect Actual Findings Proportionate height and weight Normal Findings Proportionate height and weight, has a healthy and active lifestyle Relaxed, has an Normal Interpretation/Analysis Normal
standing, sitting, and walking
posture and coordinated body movement
erect posture and coordinated body movement
Overall hygiene and grooming
The client is unclean. He doesn t comb his hair and he does not wear a t-shirt during the interview.
Clean and neat
Looks untidy.
Body and breath odor
Has no body and breath odor
Has no body odor as well as bad breath
normal
Signs of distress
No distress noted
Shows no signs of distress
Normal
Signs of health and distress Attitude Mood and affect Quantity and quality of speech
Has a healthy appearance
Normal
Cooperative Appropriate Understandable, moderate pace and soft voice
Cooperative Appropriate Has a fast pacing
Normal Normal Normal
D.Head to Toe PA Body Part Examined Skin Actual Findings The clients skin color is uniform; it has no presence of edema, no skin lesions; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Normal Findings Uniform skin color; has no presence of edema, no skin lesions; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Nails Convex curvature, angle of nail Convex curvature, Normal Interpretation/Analysis Normal
plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color in less than 4 seconds
angle of nail plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color generally less than 4 seconds
Skull
Rounded, smooth skull contour, symmetric; absence of nodules, masses and depressions
Normal
Scalp
Lighter than the skin color; no signs of tenderness
Normal
Hair
Evenly distributed thick hair, silky, smooth and resilient; no signs of infestations and infections
Normal
Face
Symmetric facial movements
Normal
Eyebrows
Evenly distributed hair, intact skin, symmetrically aligned and equal movement
Normal
Eyelashes
Evenly distributed hair and curled outward
Normal
Eyelids
Intact skin, no discharge, no discoloration, approximately 15 involuntary blinks per minute, bilateral blinking
Intact skin, no discharge, no discoloration, approximately 15 to 20 involuntary blinks per minute, bilateral blinking
Normal
Eyes
Bulbar conjunctiva are transparent, capillaries sometimes evident, sclera appears white; palpebral conjunctiva are shiny, smooth and pink in color; sclera appears white and clear; cornea are transparent, shiny and smooth; iris are brown, flat and round
Normal
Visual acuity
The client was able to read newsprint
Able to read newsprint Black, equal in size 37 mm in diameter; round smooth border; PERRLA
Normal
Pupils
Black, equal in size about 6mm in diameter; round smooth border; PERRLA
Normal
Extraocular muscles
The client s both eyes coordinated move in unison with
Both eyes coordinated move in
Normal
parallel alignment
unison with parallel alignment
Visual field
The client was able to see objects in the periphery
Able to see objects in the periphery Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible; able to hear ticking in both ears when performing watch tick test; sound is heard on both ears or localized at the center of the head (Weber Negative) when performing tuning fork test; AC hearing is greater than BC hearing
Normal
Ears
Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible; able to hear ticking in both ears when performing watch tick test; sound is heard on both ears or localized at the center of the head (Weber Negative) when performing tuning fork test; AC hearing is greater than BC hearing (positive Rinne)
Normal
(positive Rinne) Nose His skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender Skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender Mouth The client s lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules;has 20 milk teeth, (+)dental caries on molars and incisors, white color, shiny tooth enamel Lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules; 20 primary teeth, white to yellowish color, shiny tooth enamel Neck Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no masses Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no masses Respiratory Thorax anteroposterior to Thorax Normal Normal Not normal because of presence of dental caries Normal
transverse diameter in ratio of 1:2; symmetric chest, skin intact no tenderness, no lesions; full symmetric chest expansion (thumbs separate 3cm); bilateral symmetry of vocal fremitus and heard most clearly at the apex of the lungs
anteroposterior to transverse diameter in ratio of 1:2; symmetric chest, skin intact no tenderness, no lesions; full symmetric chest expansion (thumbs separate 3-5cm); bilateral symmetry of vocal fremitus and heard most clearly at the apex of the lungs
Cardiovascular
No mass, no nodules; symmetric pulse volumes, carotid artery has full pulsations, thrusting quality, remains the same when client breaths, head turns and changes from sitting to supine position
No mass, no nodules; symmetric pulse volumes, carotid artery has full pulsations, thrusting quality, remains the same when client breaths, head turns and changes from sitting to supine position
Normal
GIT
Skin of the abdomen is unblemished and uniform in color; no evidence of enlarged liver or spleen; symmetric movements during respiration; peristalsis not visible but palpable; audible bowel sounds
Skin of the abdomen is unblemished and uniform in color; no evidence of enlarged liver or spleen; symmetric movements during
Normal
through auscultation, no arterial bruits and friction rub; upon percussion, tympany over the stomach and gas-silled bowels, dullness especially over the liver and spleen or a full bladder, liver is 7cm in the midclavicular line and 5cm at the midsternal line; upon light palpation, no tenderness, relaxed abdomen with smooth consistent tension
respiration; peristalsis not visible but palpable; audible bowel sounds through auscultation, no arterial bruits and friction rub; upon percussion, tympany over the stomach and gas-silled bowels, dullness especially over the liver and spleen or a full bladder, liver is 612cm in the midclavicular line and 4-8cm at the midsternal line; upon light palpation, no tenderness, relaxed abdomen with smooth consistent tension
Musculoskeletal
Muscles are equal in size on both sides of the body, no contractures, no tremors, firm, smooth coordinated movements, equal strength on each side of the body Joints have no tenderness, swelling, crepitation or nodule and move smoothly
Muscles are equal in size on both sides of the body, no contractures, no tremors, firm, smooth coordinated movements, equal strength on each side of the body
Normal.
Bones have no tenderness or swelling Joints have no tenderness, swelling, crepitation or nodule and move smoothly
E.NEUROLOGIC ASSESSMENT
Mental status Area of Assessment Orientation Actual Findings Oriented to person, time and place Memory (immediate recall) Can recall a series of 4digits in sequence and 2 digits in reverse Recent memory Can recall recent events of the day Remote memory Can recall past events like in past years Normal Findings Oriented to person, time and place Can recall a series of 8 digits in sequence and 4 digits in reverse Can recall recent events of the day Can recall past events like in past years Normal Normal Slightly deviated findings Interpretation/Analysis Normal
Level of Consciousness Eye opening Motor response Spontaneous(4) Responds to verbal command(6) Verbal response Oriented and converses(5) Spontaneous(4) Responds to verbal command(6) Oriented and converses(5) Normal Normal Normal
Cranial Nerves Area of Assessment Olfactory Actual Findings The client was able to identify different mild aromas Optic The client was able to see objects in periphery while looking straight ahead Can see objects in periphery while looking straight ahead Normal Normal Findings Able to identify different mild aromas Interpretation/Analysis Normal
Oculomotor
Both eyes coordinated and move in unison with parallel alignment; PERRLA
Normal
Trochlear
Both eyes coordinated and move in unison with parallel alignment
Normal
Trigeminal
Blinks when sclera is slightly touched; able to feel light and deep sensation on the skin of the face and anterior oral cavity; able to clench teeth
Normal
Abducens
The client was able to move eyebrows bilaterally
Able to move eyebrows bilaterally
Normal
Facial
The client was able to
Able to raise eyebrows,
Normal
raise eyebrows, smile frown, puff out cheeks, close eyes tightly; able to identify various tastes Auditory The client was able to maintain upright posture and foot stance; able to hear spoken words. Glossopharyngeal The client was able to swallow, move tongue and identify various tastes Vagus The client was able to swallow; (+) sensation of pharynx and larynx; vocal cord moves when speaking Accessory The client was able to shrug shoulders and turn head from side to side against resistance Hypoglossal The client was able to protrude tongue at midline and move it from side to side
smile frown, puff out cheeks, close eyes tightly; able to identify various tastes
Able to maintain upright posture and foot stance; able to hear spoken words and vibrations of tuning fork Able to swallow, move tongue and identify various tastes
Normal
Normal
Able to swallow; (+) sensation of pharynx and larynx; vocal cord moves when speaking
Normal
Able to shrug shoulders and turn head from side to side against resistance Able to protrude tongue at midline and move it from side to side
Normal
Normal
Motor functions Gross Romberg Test May sway slightly but is able to maintain upright posture and foot stance May sway slightly but is able to maintain upright posture and foot stance Normal
Walking Gait Test
Has upright posture and steady gait with opposing arm swing; walks unaided maintaining balance
Normal
Stand on one foot with eyes closed
The client was able to maintain stance for 5 seconds
Maintains stance for at least 5 seconds
Normal
Heel to toe walking
The client was able to maintain heel-toe walking along a straight line
Maintains heel-toe walking along a straight line
Normal
Toe or heel walking
The client was able to walk several steps on toes or heels
Able to walk several steps on toes or heels
Normal
Fine Finger to nose test The client was able to repeatedly and rhythmically touch the nose Able to repeatedly and rhythmically touch the nose Normal
Finger to nose to nurse s finger
The client was able to performs with coordination and rapidity
Performs with coordination and rapidity
Normal
Finger to thumb
The client was able to rapidly touch each fingers to thumb on each hand
Able to rapidly touch each fingers to thumb on each hand
Normal
Alternate supination and pronation
Able to alternately
Normal
alternately supinate and supinate and pronate pronate hands at rapid pace hands at rapid pace
Sensation Pain The client was able to discriminate sharp and dull sensations Light touch The client was able to feel light tickling or touch sensation Temperature The client was able to discriminate between hot and cold Able to discriminate between hot and cold Normal Able to discriminate sharp and dull sensations Able to feel light tickling or touch sensation Normal Normal
Tactile Discrimination One to two point discrimination The client was to distinguish between a one or two point Can distinguish between a one or two point stimulus Normal
stimulus Stereognosis The client was able to recognizes common objects; able to identify numbers or letters written on palm Extinction Phenomenon The client was able to feel the point of stimulus. Both points of stimulus are felt Normal Recognizes common objects; able to identify numbers or letters written on palm Normal
Assessment for School Age
1.Physical/Biological
Name of the Client: RJ Age: 5 years old Sex: Male Birthdate: August 14, 2004 Address: 12th St. Pag-asa, Olongapo City Educational Attainment: Grade 1 School attended: Kalalake Elementary School Religious Affiliation: Roman Catholic
A.Measurements
Area of assessment Weight
Actual Findings 16.5 kgs.
Normal Findings 21 kgs
Interpretation/ analysis Abnormal. Deficit of 5.5 kgs in weight.
Height
97 cm
115 cm
Abnormal. Deficit of 18 cm in height.
BMI 17.5
B.Vital Signs Area of Assessment Temp PR RR Actual Findings 36.7 C 71 beats/min 18 breaths/min Normal Findings 36-37.5C 75-120 15-25 Interpretation/Analysis Normal Normal Normal
C.General Appearance Area of Assessment Body built, height and Actual Findings The client has small body Normal Findings Proportionate Interpretation/Analysis Not eating nutritious
weight in relation to client s age, lifestyle, and health Posture, gait, standing, sitting, and walking
built. Height and weight not appropriate for age.
height and weight, has a healthy and active lifestyle
foods
Relaxed, has an erect posture and coordinated body movement
Relaxed, has an erect posture and coordinated body movement
Normal
Overall hygiene and grooming
The client is unclean. He doesn t comb his hair and he does not wear a t-shirt during the interview.
Clean and neat
Looks untidy.
Body and breath odor
Has no body and breath odor
Has no body odor as well as bad breath
normal
Signs of distress
No distress noted
Shows no signs of distress
Normal
Signs of health and distress Attitude Mood and affect Quantity and quality of speech
Normal
Cooperative Appropriate Understandable, moderate pace and soft voice
Cooperative Appropriate Has a fast pacing
normal Normal Normal
D.Head to Toe PA Body Part Examined Skin Actual Findings The clients skin color is uniform; it has no presence of edema, no skin lesions; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Normal Findings Uniform skin color; has no presence of edema, no skin lesions; moisture in the skin folds; has uniform temperature; Interpretation/Analysis Normal
springs back to previous state when pinched Nails Convex curvature, angle of nail plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color in less than 4 seconds Convex curvature, angle of nail plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color generally less than 4 seconds Skull Rounded, smooth skull contour, symmetric; absence of nodules, masses and depressions Rounded, smooth skull contour, symmetric; absence of nodules, masses and depressions Scalp Lighter than the skin color; no signs of tenderness Lighter than the skin color; no signs of tenderness Hair Evenly distributed thick hair, silky, smooth and resilient; no signs of infestations and infections Evenly distributed thick hair, silky, smooth and resilient; no signs of infestations and infections Face Symmetric facial movements Symmetric facial movements Normal Normal Normal Normal Normal
Eyebrows
Normal
Eyelashes
Normal
Eyelids
Intact skin, no discharge, no discoloration, approximately 15 to 20 involuntary blinks per minute, bilateral blinking
Normal
Eyes
Normal
Visual acuity
The client was able to read newsprint
Able to read newsprint Black, equal in size 37 mm in diameter;
Normal
Pupils
Black, equal in size about 6mm in diameter; round smooth border;
Normal
PERRLA
round smooth border; PERRLA
Extraocular muscles
The client s both eyes coordinated move in unison with parallel alignment
Both eyes coordinated move in unison with parallel alignment
Normal
Visual field
The client was able to see objects in the periphery
Able to see objects in the periphery Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible; able to hear ticking in both ears when performing watch tick test; sound is heard on both ears or localized at the center of the head (Weber Negative)
Normal
Ears
Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible; able to hear ticking in both ears when performing watch tick test; sound is heard on both ears or localized at the center of the head (Weber Negative) when performing tuning fork test; AC hearing is greater than BC hearing (positive Rinne)
Normal
when performing tuning fork test; AC hearing is greater than BC hearing (positive Rinne) Nose His skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender Skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender Mouth The client s lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules;has 20 milk teeth, (+)dental caries on molars and incisors, white color, shiny tooth enamel Lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules; 20 primary teeth, white to yellowish color, shiny tooth enamel Neck Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no masses Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland Normal Not normal because of presence of dental caries Normal
ascends during swallowing; no masses Respiratory Thorax anteroposterior to transverse diameter in ratio of 1:2; symmetric chest, skin intact no tenderness, no lesions; full symmetric chest expansion (thumbs separate 3cm); bilateral symmetry of vocal fremitus and heard most clearly at the apex of the lungs Thorax anteroposterior to transverse diameter in ratio of 1:2; symmetric chest, skin intact no tenderness, no lesions; full symmetric chest expansion (thumbs separate 3-5cm); bilateral symmetry of vocal fremitus and heard most clearly at the apex of the lungs Cardiovascular No mass, no nodules; symmetric pulse volumes, carotid artery has full pulsations, thrusting quality, remains the same when client breaths, head turns and changes from sitting to supine position No mass, no nodules; symmetric pulse volumes, carotid artery has full pulsations, thrusting quality, remains the same when client breaths, head turns and changes from sitting to supine position Normal Normal
GIT
Skin of the abdomen is unblemished and uniform in color; no evidence of enlarged
Skin of the abdomen is unblemished and uniform in color; no
Normal
liver or spleen; symmetric movements during respiration; peristalsis not visible but palpable; audible bowel sounds through auscultation, no arterial bruits and friction rub; upon percussion, tympany over the stomach and gas-silled bowels, dullness especially over the liver and spleen or a full bladder, liver is 7cm in the midclavicular line and 5cm at the midsternal line; upon light palpation, no tenderness, relaxed abdomen with smooth consistent tension
evidence of enlarged liver or spleen; symmetric movements during respiration; peristalsis not visible but palpable; audible bowel sounds through auscultation, no arterial bruits and friction rub; upon percussion, tympany over the stomach and gas-silled bowels, dullness especially over the liver and spleen or a full bladder, liver is 612cm in the midclavicular line and 4-8cm at the midsternal line; upon light palpation, no tenderness, relaxed abdomen with smooth consistent tension
Musculoskeletal
Muscles are equal in size on both sides of the body, no contractures, no tremors, firm, smooth coordinated movements, equal strength on each side of
Muscles are equal in size on both sides of the body, no contractures, no tremors, firm, smooth
Abnormal Presence of crooked arm. It is arm set in an awkward angle.
the body The client have crooked arm. Joints have no tenderness, swelling, crepitation or nodule and move smoothly
coordinated movements, equal strength on each side of the body Bones have no tenderness or swelling Joints have no tenderness, swelling, crepitation or nodule and move smoothly
E.NEUROLOGIC ASSESSMENT
Mental status Area of Assessment Orientation Actual Findings Oriented to person, time and place Memory (immediate recall) Can recall a series of 3digits in sequence and 2 digits in reverse Recent memory Can recall recent events of the day Remote memory Can recall past events like in past years Normal Findings Oriented to person, time and place Can recall a series of 8 digits in sequence and 4 digits in reverse Can recall recent events of the day Can recall past events like in past years Normal Normal Slightly deviated findings Interpretation/Analysis Normal
Level of Consciousness Eye opening Motor response Spontaneous(4) Responds to verbal command(6) Spontaneous(4) Responds to verbal command(6) Normal Normal
Verbal response
Oriented and converses(5)
Oriented and converses(5)
Normal
Cranial Nerves Area of Assessment Olfactory Actual Findings The client was able to identify different mild aromas Optic The client was able to see objects in periphery while looking straight ahead Can see objects in periphery while looking straight ahead Normal Normal Findings Able to identify different mild aromas Interpretation/Analysis Normal
Oculomotor
Normal
Trochlear
Normal
Trigeminal
Normal
Abducens
Able to move eyebrows
Normal
move eyebrows bilaterally Facial The client was able to raise eyebrows, smile frown, puff out cheeks, close eyes tightly; able to identify various tastes Auditory The client was able to maintain upright posture and foot stance; able to hear spoken words. Glossopharyngeal The client was able to swallow, move tongue and identify various tastes Vagus The client was able to swallow; (+) sensation of pharynx and larynx; vocal cord moves when speaking Accessory The client was able to shrug shoulders and turn head from side to side against resistance Hypoglossal The client was able to protrude tongue at midline and move it from side to side
bilaterally
Able to raise eyebrows, smile frown, puff out cheeks, close eyes tightly; able to identify various tastes
Normal
Able to maintain upright posture and foot stance; able to hear spoken words and vibrations of tuning fork Able to swallow, move tongue and identify various tastes
Normal
Normal
Normal
Able to shrug shoulders and turn head from side to side against resistance Able to protrude tongue at midline and move it from side to side
Normal
Normal
Motor functions Gross Romberg Test May sway slightly but is able to maintain upright posture and foot stance May sway slightly but is able to maintain upright posture and foot stance Normal
Walking Gait Test
Normal
Stand on one foot with eyes closed
The client was able to maintain stance for 5 seconds
Maintains stance for at least 5 seconds
Normal
Heel to toe walking
The client was able to maintain heel-toe walking along a straight line
Maintains heel-toe walking along a straight line
Normal
Toe or heel walking
The client was able to walk several steps on toes or heels
Normal
Fine Finger to nose test The client was able to repeatedly and rhythmically touch the Able to repeatedly and rhythmically touch the nose Normal
nose
Finger to nose to nurse s finger
The client was able to performs with coordination and rapidity
Performs with coordination and rapidity
Normal
Finger to thumb
The client was able to rapidly touch each fingers to thumb on each hand
Able to rapidly touch each fingers to thumb on each hand
Normal
Alternate supination and pronation
Able to alternately
Normal
alternately supinate and supinate and pronate pronate hands at rapid pace hands at rapid pace
Sensation Pain The client was able to discriminate sharp and dull sensations Light touch The client was able to feel light tickling or touch sensation Temperature The client was able to discriminate between hot and cold Able to discriminate between hot and cold Normal Able to discriminate sharp and dull sensations Able to feel light tickling or touch sensation Normal Normal
Tactile Discrimination One to two point The client was to Can distinguish Normal
discrimination
distinguish between a one or two point stimulus
between a one or two point stimulus
Stereognosis
The client was able to recognizes common objects; able to identify numbers or letters written on palm
Recognizes common objects; able to identify numbers or letters written on palm
Normal
Extinction Phenomenon
The client was able to feel the point of stimulus.
Both points of stimulus are felt
Normal
ASSESSMENT FOR EARLY ADULT
A. PERSONAL DATA Name of the Client: Mr. X Age: 33 years old Sex: Male Birthdate: March 11, 1978 Address: 12th St. Pag-asa, Olongapo City Educational Attainment: Elementary undergraduate (Grade 2 level) Occupation: Scavenger Civil Status: Domestic partnership Religious Affiliation: Roman Catholic
B.
DEMOGRAPHIC DATA
Family History: The client s parents are still alive but the client has no knowledge of their health status. According to the client his grandparents all died of old age. He has 3 children all of which have not been ill according to him except for his second son who accidentally fractured his forearm last June and it had to be put in cast.
C. HEALTH HISTORY The client had mumps six months ago and he went to the health center to have it checked. He did not take any medicines for his mumps instead, he was advised by the health center workers to put a concoction of gumamela over it.
D. OCCUPATIONAL HISTORY The client works as a scavenger and he starts work at 5 am goes home at 9am and starts work again after lunch until 5 pm. And he reaches most of the city for scavenging, mostly in the areas of Sta. Rita and Kalaklan. He earns between 100 to 250 pesos in one day and he works six days a week.
E. PHYSICAL ASSESSMENT Height: 168cm Weight: 76 kg
BMI (wt/ht2): 26.9 BP: 140/100 PR: 75 bpm RR: 18 cpm
General Appearance Area of Assessment Body built, height and weight in relation to client s age, lifestyle, and health Actual Findings Proportionate, varies with health; BMI is 26.9 Normal Findings Proportionate height and weight, has a healthy and active lifestyle Interpretation/Analysis Not normal According to DOST, the normal BMI for adults is 18.5 24.9. Client s BMI falls into the category of overweight 25.0 -29.9 Posture, gait, standing, sitting, and walking Relaxed, has an erect posture and coordinated body movement Overall hygiene and grooming Body and breath odor Unclean and poor grooming Has body odor and breath odor Has no body odor as well as bad breath Not normal Poor hygiene practices result in body and breath odors. Body odors are caused by resident bacteria acting on body secretions. Cleanliness is the best deodorant (Kozier, 2008). Signs of distress No distress noted Shows no signs of Normal Relaxed, has an erect posture and coordinated body movement Clean and neat Normal Normal
distress Signs of health and distress Has an unhealthy appearance Has a healthy appearance Not normal Upon inspection of the skin, we noted some lesions on the feet and legs Attitude Cooperative but a little shy Mood and affect Quantity and quality of speech Appropriate Understandable, moderate pace and soft voice Appropriate Has a fast pacing Normal Normal Cooperative Normal
Head to Toe PA Body Part Examined Skin Uniform skin color; has no presence of edema,(+) skin lesions at both feet and legs ; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Uniform skin color; has no presence of edema, no skin lesions; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Not normal Skin lesions present on his feet specifically between toes which appear like linear cracks are indicative of athlete s foot and there are also secondary lesions on the legs which were caused by scratching which appear to be excoriations and crusts which arised to our suspicion that it is scabies which is a Actual Findings Normal Findings Interpretation/Analysis
contagious skin infestation by the itch mite (Kozier, 2008) Nails Convex curvature, angle of Convex curvature, angle of Normal nail plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color in less than 4 seconds nail plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color generally less than 4 seconds Skull Rounded, smooth skull contour, symmetric; absence of nodules, masses and depressions Scalp Rounded, smooth skull contour, symmetric; absence of nodules, masses and depressions Normal
Lighter than the skin color; Lighter than the skin color; Normal no signs of tenderness no signs of tenderness Evenly distributed thick hair, silky, smooth and resilient; no signs of infestations and infections Normal
Hair
Evenly distributed thick hair, silky, smooth and resilient; (+) flakes
Face
Symmetric facial movements Evenly distributed hair, intact skin, symmetrically aligned and equal movement Evenly distributed hair and curled outward
Normal
Eyebrows
Normal
Eyelashes
Normal
Eyelids
Intact skin, no discharge, no discoloration, approximately 15 or more involuntary blinks per minute, bilateral blinking
Intact skin, no discharge, no discoloration, approximately 15 to 20 involuntary blinks per minute, bilateral blinking Bulbar conjunctiva are transparent, capillaries sometimes evident, sclera appears white; palpebral conjunctiva are shiny, smooth and pink in color; sclera appears white and clear; cornea are transparent, shiny and smooth; iris are brown, flat and round Able to read newsprint; 20/20 vision on Snellen chart
Normal
Eyes
Normal
Visual acuity
Able to read newsprint
Normal
Pupils
Black, equal in size 3-7 mm in diameter; round smooth border; PERRLA Both eyes coordinated move in unison with parallel alignment Able to see objects in the periphery Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from
Normal
Extraocular muscles
Normal
Visual field
Able to see objects in the periphery
Normal
Ears
Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from
Normal
vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible Nose Skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender Mouth Lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules; 32 adult teeth white color, shiny tooth enamel Neck Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no
vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible Skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender Lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules; 32 adult teeth, white to yellowish color, shiny tooth enamel Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no Normal Normal Normal
masses Respiratory Thorax anteroposterior to transverse diameter in ratio of 1:2; symmetric chest, skin intact no tenderness, no lesions; full symmetric chest expansion (thumbs separate 3cm); bilateral symmetry of vocal fremitus and heard most clearly at the apex of the lungs Cardiovascular No mass, no nodules; symmetric pulse volumes, carotid artery has full pulsations, thrusting quality, remains the same when client breaths, head turns and changes from sitting to supine position GIT Skin of the abdomen is unblemished and uniform in color; no evidence of enlarged liver or spleen; symmetric movements during respiration Musculoskeletal Muscles are equal in size on both sides of the body, no contractures, no tremors, firm, smooth coordinated movements,
masses Thorax anteroposterior to transverse diameter in ratio of 1:2; symmetric chest, skin intact no tenderness, no lesions; full symmetric chest expansion (thumbs separate 3-5cm); bilateral symmetry of vocal fremitus and heard most clearly at the apex of the lungs No mass, no nodules; symmetric pulse volumes, carotid artery has full pulsations, thrusting quality, remains the same when client breaths, head turns and changes from sitting to supine position Skin of the abdomen is unblemished and uniform in color; no evidence of enlarged liver or spleen; symmetric movements during respiration Muscles are equal in size on both sides of the body, no contractures, no tremors, firm, smooth coordinated movements, Normal Normal Normal Normal
equal strength on each side of the body Bones have no tenderness or swelling Joints have no tenderness, swelling, crepitation or nodule and move smoothly
equal strength on each side of the body Bones have no tenderness or swelling Joints have no tenderness, swelling, crepitation or nodule and move smoothly
F. FUNCTIONAL HEALTH PATTERN
Functional Health Pattern Perception/Health Management
Pattern Describes Client's perceived pattern of health and well-being and how health is managed.
Observation/Assessment No regular checkup and when client feels ill, client goes to the barangay health center. Client consumes too much rice and less protein. He only drinks about six glasses of water a day.
Nutritional-Metabolic
Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply.
Elimination
Patterns of excretory function (bowel, bladder and skin). Includes client's perception of normal function.
Toilet is too far from the house so client needs to control bowels until he reaches it. Bowels are once a day. Urination depends on how much water he drinks.
Activity - Exercise
Patterns of exercise, activity, leisure and recreation. Exercise, hobbies.
Bicycling everyday while working is his only exercise. No recreational activity.
Cognitive-Perceptual
Sensory-perceptual and
Client gives inaccurate or
cognitive patterns.
incomplete information and limited knowledge due to his educational attainment.
Sleep-Rest
Patterns of sleep, rest, and relaxation.
Client takes at least 8-10 hours of sleep a day. No naps in the afternoon.
Self-Perception/Self Concept
Client's self-concept pattern and perceptions of self.
Client does not seem to be concerned about his appearance.
Role-Relationship
Client's pattern of role engagements and relationships.
Client assumes most of the daily chores in their house and he seems to be submissive to his wife as we have observed when his wife woke up and told him to cook their food.
Sexuality-Reproductive
Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern.
Normal.
Coping / Stress Tolerance
General coping pattern and effective of the pattern in terms of stress tolerance.
Client drinks alcohol whenever he has a problem.
Value - Belief
Patterns of values, beliefs (including spiritual), and goals that guide client's choices or decisions.
Client is a catholic but does not go to church every Sunday.
G. NEUROLOGIC ASSESSMENT
Mental status Area of Assessment Orientation Actual Findings Oriented to person, time and place Recent memory Can recall recent events of the day Remote memory Can recall past events like in past years Normal Findings Oriented to person, time and place Can recall recent events of the day Can recall past events like in past years Normal Normal Interpretation/Analysis Normal
Level of Consciousness Eye opening Motor response Spontaneous(4) Responds to verbal command(6) Verbal response Oriented and converses(5) Spontaneous(4) Responds to verbal command(6) Oriented and converses(5) Normal Normal Normal
Cranial Nerves Area of Assessment Olfactory Actual Findings Able to identify different mild aromas Optic Can see objects in periphery while looking straight ahead Normal Findings Able to identify different mild aromas Can see objects in periphery while looking straight ahead Normal Interpretation/Analysis Normal
Oculomotor
Normal
Trochlear
Both eyes coordinated and move in unison with parallel alignment Blinks when sclera is slightly touched; able to feel light and deep sensation on the skin of the face and anterior oral cavity; able to clench teeth Able to move eyebrows bilaterally Able to raise eyebrows, smile frown, puff out cheeks, close eyes tightly; able to identify various tastes Able to maintain upright posture and foot stance; able to hear spoken words and vibrations of tuning fork
Normal
Trigeminal
Normal
Abducens
Able to move eyebrows bilaterally
Normal
Facial
Able to raise eyebrows, smile frown, puff out cheeks, close eyes tightly; able to identify various tastes
Normal
Auditory
Able to maintain upright posture and foot stance; able to hear spoken words
Normal
Glossopharyngeal
Able to swallow, move tongue and identify various tastes
Able to swallow, move tongue and identify various tastes Able to swallow; (+) sensation of pharynx and larynx; vocal cord moves when speaking Able to shrug shoulders and turn head from side
Normal
Vagus
Normal
Accessory
Able to shrug shoulders and turn head from side
Normal
to side against resistance Hypoglossal
to side against resistance Normal
Able to protrude tongue Able to protrude tongue at midline and move it from side to side at midline and move it from side to side
Motor functions
Gross Romberg Test May sway slightly but is able to maintain upright posture and foot stance May sway slightly but is able to maintain upright posture and foot stance Normal
Walking Gait Test
Normal
Stand on one foot with eyes closed Heel to toe walking
Maintains stance for 5 seconds Maintains heel-toe walking along a straight line
Maintains stance for at least 5 seconds Maintains heel-toe walking along a straight line Able to walk several steps on toes or heels
Normal
Normal
Toe or heel walking
Normal
Fine Finger to nose test Able to repeatedly and rhythmically touch the Able to repeatedly and rhythmically touch the Normal
nose Finger to nose to nurse s finger Performs with coordination and rapidity Finger to thumb Able to rapidly touch each fingers to thumb on each hand Alternate supination and pronation Able to alternately supinate and pronate hands at rapid pace
nose Performs with coordination and rapidity Able to rapidly touch each fingers to thumb on each hand Able to alternately supinate and pronate hands at rapid pace Normal Normal Normal
Sensation Pain Able to discriminate sharp and dull sensations Light touch Able to feel light tickling or touch sensation Temperature Able to discriminate between hot and cold Able to discriminate sharp and dull sensations Able to feel light tickling or touch sensation Able to discriminate between hot and cold Normal Normal Normal
Tactile Discrimination One to two point discrimination Can distinguish between a one or two point stimulus Stereognosis Recognizes common objects; able to identify numbers or letters written on palm Extinction Phenomenon Both points of stimulus are felt Can distinguish between a one or two point stimulus Recognizes common objects; able to identify numbers or letters written on palm Both points of stimulus are felt Normal Normal Normal
Assessment for Toddler Name: Angel Age: 3 Sex: Female Birth Date: May 6, 2008 Birth Place: Olongapo A. Measurements Weight Height 9.5kg 67cm
B. Vital Signs Area of Assessment Temp PR RR Actual Findings 36.2 C 80 beats/min 19 breaths/min Normal Findings 36-37.5C 75-120 15-25 Interpretation/Analysis Normal Normal Normal
C. Head to Toe PA BODY PARTS Skin ACTUAL FINDINGS -Normal NORMAL FINDINGS -Varies from light to INTERPRETATION -normal
-Texture: Light brown in deep brown. color Lessions: No lesions is present -Generally uniform except in areas exposed to the sun -No edema -no abrasions or other lesions -when pinched,skin springs back to previous state.
Head
-round
-rounded
- The toddler does not
absence of nodules symmetric facial movements
-smooth, uniform consistency, absence of nodules or masses -symmetrical facial movements
have a normal head circumference
Eyes
Eyebrows: normal -Eyelids: normal -Eyeballs: normal Conjunctiva: Pallor -Sclera: Normal Pupil: Reacting with light
-hair evenly distribute -lids close symmetrically -15-20 involuntary blinks per minute. -depth about 3mm -3-7mm in diameter -illuminated pupil constricts Both eyes coordinate
-the toddler s eyes assessment is normal
Nose
Externares: Absence of any discharge -Nostril: normal
-symmetric and straight -no discharge or flaring -not tender, no lesions -mucosa pink -no lesions -nasal septum intact and in midline
-toddler s nose assessment has no deviation from normal
Mouth
-Lips: Pink in color -Odor from the mouth: Odor not present Teeth: Present Tongue: Pink in color
-Uniform pink color -soft, moist, smooth texture -symmetry in contour -ability to purse lips
-toddler s mouth assessment has no deviation from normal
Mucus membrane: - Absence of any enlargement of throat or lymph nodes 20 milk teeth
-smooth, white shiny enamel tooth -pink gums -smooth with no palpable nodules -20 teeth
Chest
- Breath sounds: Whistling sound bilaterally - RR: 27 cycles per min.
-chest circumference has grown greater than the head -Respirations slow slightly but continue to be mainly abdominal.
- toddler s chest assessment has no deviation from normal
Heart
- Heart sound: Normal - HR: 84 bpm
-heart rate slows from 110 to 90 bpm
-normal
Abdomen
- Absence of tenderness or swelling - Absence of any gas formation - Liver and spleen is palpable
-no tenderness -palpable liver and spleen -absence of gas formation
-normal
Extremities
- Properly range of motion of both upper and lower limb present
-can control extremities
-normal
Back
- Normal curves of spinal cord
-no curves in spinal cord -absence of lordosis,
-normal
- Absence of lordosis, kyphosis, scoliosis
kyphosis and scoliosis
D. General Appearance Area of Assessment Body built, height and weight in relation to client s age, lifestyle, and health Posture, gait, standing, sitting, and walking Relaxed, has an erect posture and coordinated body movement Proportionate, varies with health; BMI is 27 the client is underweight Proportionate height and weight, has a healthy and active lifestyle Relaxed, has an erect posture and coordinated body movement Overall hygiene and grooming Body and breath odor Has no body and breath odor Has no body odor as well as bad breath Signs of distress No distress noted Shows no signs of distress Signs of health and distress Attitude Mood and affect Quantity and quality of speech Has a healthy appearance cooperative Appropriate Understandable, moderate pace and soft voice Has a healthy appearance Cooperative Appropriate Has a fast pacing normal Normal Normal Normal Normal Not clean Clean and neat Does not know the proper hygiene normal Normal Not eating nutritious foods Actual Findings Normal Findings Interpretation/Analysis
ASSESSMENT FOR EARLY ADULT
A. PERSONAL DATA Name of the Client: Mrs. X Age: 24 years old Sex: Female Birthdate: June 14, 1987 Address: 12th St. Pag-asa, Olongapo City Educational Attainment: Elementary undergraduate (Grade 3 level) Occupation: Barker Civil Status: Domestic partnership Religious Affiliation: Roman Catholic
B. DEMOGRAPHIC DATA
C.HEALTH HISTORY
D.OCCUPATIONAL HISTORY The client works as a barker. E.PHYSICAL ASSESSMENT Height: 148cm Weight: 42 Kgs. BMI (wt/ht2): 19.1
General Appearance Area of Assessment Body built, height and weight in relation to client s age, lifestyle, and health Posture, gait, standing, sitting, and Relaxed, has an erect posture and Actual Findings Skinny, small in height and not too active. Normal Findings Proportionate height and weight, has a healthy and active lifestyle Relaxed, has an erect posture and Interpretation/Analysis Not normal because the client appears too skinny and her cheek are immersed. Normal
walking
coordinated body movement
coordinated body movement Clean and neat Not normal because she appears unkempt Has no body odor as well as bad breath Shows no signs of distress Not normal because of body and breath odor Normal
Overall hygiene and grooming Body and breath odor
Unclean and poor grooming Has body odor and breath odor
Signs of distress
No distress noted
Signs of health and distress Attitude
Has an unhealthy appearance Elusive and not cooperative
Has a healthy appearance Cooperative
Not normal because she looks too skinny Deviated
Mood and affect
Not appropriate
Appropriate
Not normal because it can affect their relationship with each other
Quantity and quality of speech
Has no quality in speaking
Has a fast pacing
Not normal
Head to Toe PA Body Part Examined Skin Uniform skin color; has no presence of edema, with skin lesions at both feet and legs ; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Uniform skin color; has no presence of edema, no skin lesions; moisture in the skin folds; has uniform temperature; springs back to previous state when pinched Actual Findings Normal Findings Interpretation/ Analysis Not normal because skin lesions present on his feet and legs are indicative of athlete s foot and scabies Nails fingernail and toenail bed Convex curvature, angle of Normal
color are pinkish.
nail plate about 160; fingernail and toenail bed color are pinkish and texture are smooth; intact tissues around the nails; highly vascular, prompt return of pink color generally less than 4 seconds
Skull
Rounded, s, symmetric; absence of nodules, masses and depressions
Normal
Scalp
Lighter than the skin color; no signs of tenderness Evenly distributed thick hair, silky, smooth and resilient; no signs of infestations and infections Symmetric facial movements
Normal
Hair
Normal
Face
Sunken cheek
Not normal Sunken Cheek indicates less Adipose Tissue.
Eyebrows
Evenly distributed hair, intact skin, symmetrically aligned and equal movement Evenly distributed hair and curled outward Intact skin, no discharge, no discoloration, approximately 15 to 20 involuntary blinks per minute, bilateral blinking
Normal
Eyelashes
Normal
Eyelids
Normal
Eyes
Bulbar conjunctiva are transparent, capillaries sometimes evident, sclera appears white; palpebral conjunctiva are shiny, smooth and pink in color; sclera appears white and clear; cornea are transparent, shiny and smooth; iris are brown, flat and round Black, equal in size 3-7 mm in diameter; round smooth border; PERRLA Both eyes coordinated move in unison with parallel alignment Able to see objects in the periphery Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible; able to hear ticking in both ears when performing watch
Normal
Pupils
Normal
Extraocular muscles
Normal
Visual field
Able to see objects in the periphery
Normal
Ears
Auricles color same as facial skin, symmetrical; aligned with outer canthus of eyes about 10 from vertical; mobile firm and not tender; pinna recoils after it is folded; distal third contains hair follicles and glands, dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown; normal voice tones audible; able to hear ticking in both ears when performing watch tick test;
Normal
sound is heard on both ears or localized at the center of the head (Weber Negative) when performing tuning fork test; AC hearing is greater than BC hearing (positive Rinne)
tick test; sound is heard on both ears or localized at the center of the head (Weber Negative) when performing tuning fork test; AC hearing is greater than BC hearing (positive Rinne)
Nose
Skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender
Skin color same as the face; symmetrical shape; symmetric nares; Client breathes freely on both nares; (-) nodules, masses; pink mucosa; clear watery discharge; no lesions; nasal septum is intact and in midline; maxillary and frontal sinuses are not tender
Normal
Mouth
Lips are dark, 23 adult teeth and yellowish color.
Lips are pink in color; soft, moist, smooth texture; symmetric contour; no nodules; 32 adult teeth, white to yellowish color, shiny tooth enamel
Not normal because of presence of dental caries
Neck
Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no masses
Good neck mobility, absence of tenderness on lymph nodes; trachea is in the midline of the neck; thyroid gland ascends during swallowing; no masses
Normal
Motor functions Gross Actual Findings Walking Gait Test Has upright posture and steady gait with opposing arm swing; walks unaided maintaining balance Normal Findings Has upright posture and steady gait with opposing arm swing; walks unaided maintaining balance Interpretation/Analysis Normal
RELATED LITERATURE
Pantawid Pamilyang Pilipino Program (4 P s) is a poverty reduction and social development strategy of the national government that provides conditional cash grants to extremely poor households to improve their health, nutrition and education particularly of children aged 0-14.
Pantawid Pamilya has dual objectives: Social Assistance - to provide cash assistance to the poor to alleviate their immediate need (short term poverty alleviation); and Social Development - to break the intergenerational poverty cycle through investments in human capital. Pantawid Pamilya helps to fulfill the country s commitment to meet the Millennium Development Goals, namely: Eradicate Extreme Poverty and Hunger Achieve Universal Primary Education Promote Gender Equality Reduce Child Mortality Improve Maternal Health
Targeting System The poorest households in the municipalities are selected through the National Household Targeting System for Poverty Reduction (NHTS-PR) implemented by the DSWD using the Proxy Means Test. This test determines the socio-economic category of the families by looking at certain proxy variables such as ownership of assets, type of housing, education of the household head, livelihood of the family and access to water and sanitation facilities.
Eligible Households Residents of the poorest municipalities based on 2003 Small Area Estimates (SAE) of NSCB; Households whose economic condition is equal to or below the provincial poverty threshold. Households that have children 0-14 years old and/or have a pregnant woman at the time of assessment; Households that agree to meet conditions specified in the program.
Set of Co-Responsibilities To avail of the cash grants beneficiaries should comply with the following conditions: Pregnant women must avail pre- and post-natal care and be attended during childbirth by a trained health professional; Parents must attend Family Development Sessions (FDS); 0-5 year old children must receive regular preventive health check-ups and vaccines; 3-5 year old children must attend day care or pre-school classes at least 85% of the time. 6-14 year old children must enroll in elementary or high school and must attend at least 85% of the time. 6-14 years old children must receive deworming pills twice a year.
Program Coverage Pantawid Pamilya operates in 80 provinces covering 734 municipalities and 62 key cities. The Pantawid Pamilya targets to cover 2.3 million households by end of 2011.
Program Cycle The implementation of Pantawid Pamilya Program follows the 8-step cycle starting from the 1) selection of target areas, 2) supply side assessment, 3) selection of household beneficiaries, 4) registration and validation of beneficiaries, 5) Family Registry preparation, 6) initial payment, 7) verification of compliance and 8) 2nd and succeeding release of cash grants.
Program Package Pantawid Pamilya provides cash grants to the beneficiaries to wit: P6,000 a year or P500 per month per household for health and nutrition expenses; and P3000 for one school year or 10 months or P300/month per child for educational expenses. A maximum of three children per household is allowed. A household with three qualified children receives a subsidy of P1,400/month during the school year or P15,000 annually as long as they comply with the conditionalities. The cash grants shall be received by the most responsible person in the household, usually the mother, through a Land Bank cash card. In cases where payment through cash card is not feasible, the beneficiaries shall be provided their cash grants through an alternative payment scheme such as over-the-counter transactions from the nearest Landbank branch or offsite payments through Landbank.
Reference: http://pantawid.dswd.gov.ph

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CITY OF OLONGAPO GORDON COLLEGE COLLEGE OF NURSING

FAMILY NURSING CASE PRESENTATION

Submitted to: Mr. Bryan Dimen, RN

Date: August 17, 2011

BRIEF FAMILY HISTORY

FAMILY STRUCTURE AND CHARACTERISTICS

A.GENERAL FAMILY RELATIONSHIP

III. SOCIO ECONOMIC

IV.FAMILY HEALTH STATUS

B.FELT FAMILY NEEDS

Adequacy of Living Space

C.HEALTH BELIEFS (PRACTICES)

HOME AND ENVIRONMENT

HEALTH AND SANITATION

WATER SUPPLY SANITATION PROGRAM

PROPER EXCRETA AND SEWAGE DISPOSAL PROGRAM

FOOD SANITATION PROGRAM

VI. AWARENESS OF COMMUNITY ORAGANIZATIONS

VII. PRIORITIZATION OF PROBLEMS

IMPROPER GARBAGE DISPOSAL

ACTUAL SCORE 0.67

NATURE OF THE 2/3 X 1 PROBLEM

It is easily modifiable because the resources are available and

interventions are feasible.

The family does not perceive this as a health problem.

INAPPROPRIATE OR INADEQUATE HYGIENIC PRACTICES

ACTUAL SCORE 0.67

JUSTIFICATION It is health threat because

NATURE OF THE 2/3 X 1 PROBLEM

unhealthy lifestyle can greatly affect the health of the family.

infections caused by viruses and bacteria.

INADEQUATE LIVING SPACE

CRITERIA NATURE OF THE PROBLEM

ACTUAL SCORE 0.67

JUSTIFICATION It is a health threat because it makes communicable diseases easily transmitted

INABILITY TO ATTAIN PROPER NUTRITION

ACTUAL SCORE 0.67

JUSTIFICATION It is health threat because it can lead to other diseases

NATURE OF THE 2/3 X 1 PROBLEM MODIFIABILITY 1/2 X 2

It is partially modifiable because the decision to change this

It is highly preventable potential because if solved nutritional

LIVING TOO CLOSE TO A RIVER

ACTUAL SCORE 0.67

NATURE OF THE 2/3 X 1 PROBLEM

The preventive potential is low because accident hazard like

PROBLEM IMPROPER GARBAGE DISPOSAL INAPPROPRIATE HYGIENIC PRACTICES

TOTAL SCORE 3.67 3.67

3.34 2.67 1.34

IX.FAMILY NURSING CARE PLAN

IMPROPER GARBAGE DISPOSAL

METHODS OF NURSE FAMILY CONTACT

TIME AND DATE

Short term: After

aidsAugust 6, 2011 to9-10am

- Minsan yunggarbage disposalAfter mga nakakalakal

discuss the topic of garbage disposal. proper

thepossible effect ofof improper

Time and effort of the nurse and the family.

proper garbagegarbage disposal one s health. -Identify the and in

personalbiodegradable, disposal. non

Expenses teaching and

-the garbage sdevelopment

in their house isdue to lack ofbiodegradable Long term: scattered