Republic of the Philippines Cavite State UNIVERSITY (CvSU) DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite

Family Case Study

SUBMITTED BY: Montano, Leomar G. January 2012

FAMILY NAME ADDRESS :

Agapay Family

# 43 Malainen Luma, Naic, Cavite

FAMILY DYNAMICS

NAME OF MEMBERS Mr. JL.B. Mrs. DR.B.

AGE 24 19

SEX M F

CIVIL STATUS Married Married

POSTION Husband Wife

Educational Attainment H.S. undergraduate H.S. graduate

The Agapay Family is a extended one. Mr. JL.B. and Mrs. DR.B. were married on April of 2011. The family resides at the house of Jl.Bs father along with his father and other siblings family. Even at early age marriage the couple dont quarrel much. It can be observed that the couple was only starting a family and DR.B was 6 months pregnant. They able to understand the differences between them and they able to solve together the problems that they experiences. Because the couple were residing at the house of JL.Bs father, problems between the family are solve through the help of all the members of the household with such observations, the good communication and relationship and good harmony of the house can be seen. The main source of the family income came from fishing. According to DR.B their estimated monthly income was 4,000 pesos which was allotted for their food and other basic expenses. To add up, the daily expenses of the family was 150 pesos mainly for food of the whole family. The community can be said to be have simple life and a peaceful place for living. Even though the quality of life was not so good, it can then be said that the place was conducive

for living. The family also shows involvement to the community, the couple have many friends on the community and when there are any gathering they make themselves available to join.

HOME LIVING AND ENVIRONMENTAL CONDITION The house can be said to be a typical type of house at the community. It was made of nipa and bamboo with the total floor area of 40 sq.meters. Even though the window are small the place can be describe as a windy area due to the place of the house which makes the house well ventilated. The furniture of the house were mostly made from wood especially their bed and the place where the clothing were place. The house dont have any electricity so they only use lamp at night for their lighting. Fire wood or charcoal are the things used by the family to prepare their food which was been kept only through a covering. Artesian well was also the source of their water for every day needs including for drinking which were kept to large covered container with faucet. The family have their own comfort room with septic tank place outside their house. Blind drainage and open burning can also be observe as the setting of the house. When the student nurse visited the house, he doesnt observed any rodents or insects on the house but the dog are just roaming around that has the possibility that other person may be biten.

Nutritional Assessment Anthropometric Data NAME OF MEMBERS Mr. JL.B. Mrs. DR.B. HEIGHT 163 cms. 157 cms. WEIGHT 50 kgs. 48 kgs. BMI 18.9 19.35 WEIGHT CLASSIFICATION Normal Norma

It can be seen that both couple has normal body weight and can be said that they able to eat enough food every day. According to them, fish was the usual food that they eat with rice with the reason that fishing was their primary source of income. Vegetables are also the food preferences of the family according to them. As verbalized by DR.B, they dont eat meat frequently because of the financial reasons but eventhough they are contended that they able to eat 3 times a day or for sometimes even 5 times at day.

I. HEALTH HISTORY A. Demographic Data Husband  Clients Name  Gender  Age  Birth Date  Birth Place  Marital Status  Race  Religion  Address  Telephone No.  Educational Background  Occupation Wife  Clients Name  Gender  Age  Birth Date  Birth Place  Marital Status  Race : : : : : : : DR. B Female 19 years old January 28, 1992 Ternate, Cavite Married Filipino : : : : : : : : : : : : JL.B Male 24 years old October 03, 1987 Bucana Proper, Ternate, Cavite Married Filipino Roman Catholic Bucana Proper, Ternate, Cavite None High School (4th year) Fisherman

 Religion  Address  Telephone No.  Educational Background  Occupation

: : : : :

Roman Catholic Bucana Proper, Ternate, Cavite None High School Graduate None

B. Source and Reliability of Information The source of information about the clients was from both of them. Both patients, has been interviewed upon the house visit of the student nurse from January 4 to 7, 2012. Both of the client was coherent and reliable through the observation of the student nurse.

C. Past Medical History or Past Health 1. Pediatric/ Childhood and Adult Illness According to both JL.B and DR.B, they only experienced common colds, cough and fever during their childhood. They also recalled that they both had chicken pox and measles before, but he failed to remember the time when he had these illnesses. 2. Injuries Jl.B recalled that he had an injury on his foot where he had a big laceration. According to him he had been brought to the hospital and had stitches on it. 3. Serious/ Chronic Illness Both patient doesnt experience any chronic or serious before and at present time.

4. Hospitalization Both patient doesnt have any hospitalizations before. 5. Operation Both patient had no record of any operation. 6. Immunization According to both patient, they able to complete all the immunizations through the immunization program of the health centers. 7. Allergies According to both JL. B and DR., they dont have any allergies to foods, dusts, medications or other allergens. 8. Medication Both of the patients told the student nurse that they only take over the counter drugs such as paracetamol, neozep, mefenamic and e.t.c. without any consultation with the doctor when they are feeling sick. At this point, DR.B presently takes FeSO4 (ferrous sulfate due to anemia she was experiencing when she got pregnant. 9. Last Examination Patiet JL.B told that due to the very long years that he had his last examination, he forgot when it was. While on other hand, Patient DR. B had her last obstetric checkup at the barangay last December 21 at Sapang health center.

F. Family History
R.B 50 y/o A&W A.B. L.D. Unknown 45 y/o Hypertension R.A 26 y/o Asthma JL.B. R.B M.D 17 y/o A&W 26 y/o Asthma DR.B 19 y/0 Anemia S.D 45y/o Asthma

24 y/o A&W

- Female

LEGEND:
- Patient - Male - Deceased

Interpretation:

The genogram above show the family background of both JL.B and DR.B. It shows that at the side of JL.B, one of his siblings got asthma which can then be said to be a hereditary disease. Even though, JL.B was alive and well and dont have any disease that may be acquired from his family. In other hand, the parents of DR.B both have hereditary disease such as asthma and hypertension. Because of that, her older brother had asthma liker her mother. Also, there was a possibility hypertension may be acquired at older age so healthy life style should be done to prevent acquiring such disease.

D. Socio-Economic Patient JL.B and DR.B were staying at the house of JL.Bs father with his other siblings. The house can be seen at the end of the river near the beach shore. The house total floor area was 40 sq.meters made of light materials such as nipa and some unused roof. Even though the windows are small and few, the ventilation can be said to be well ventilated because of the windy environment due to the air current from the sea. The house doesnt have electricity so the family only uses kerosene to have light on night. The family also used wood fire to cook their food and artesian well for their water needs and drinking source. It can be observe that open dumping and blind drainage was the usual scenario of the community. Their financial needs was been supported by the family business which was fishing. Their monthly income was 4,000 pesos which was been used to their daily expenses of 150 pesos. According to BR.D the income of the family is just enough for their daily living so other allotment of the income is not that prioritize when budgeting the income.

E. Developmental History Patient JL.B Psychosocial Model (Erik Erickson): This theory has eight distinct stages, each with two possible outcomes. According to the theory, successful completion of each stage results in a healthy personality and successful interactions with others. Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time.

1. Trust versus Mistrust (birth 18 mos) Patient JL.B. has great memories with his parents and relative especially during his childhood memories because he had been cared and love. He also gain many friends which he trust allot and able to socialize with other persons without any problem During the interview, the patients trust and confidence toward the student nurses were highly observed since she was able to answer personal questions about his life and experiences. 2. Autonomy versus Shame and Doubt (18 months 3 y/o) According to JL.B his parents made him responsible in doing things which made him independent on making his decisions and doing some actions. He recalled that at early years his father let him help in their farm land which he able to learn farm works. Through this, Patient P.A. developed sense of autonomy. He gained confidence and security in his own ability to survive in the world. 3. Initiative versus Guilt (3-6 y/o) During this stage, Patient P.A started to have friends and playmates. According to the patient, his parents trust him in doing some household jobs and allow him to go outside and play with other children. He is also very friendly at their barangays and he is well known for having many friends. In this stage of development, he acquired initiative. 4. Industry versus Inferiority (6-12 y/o) According to JL.B, since childhood was industrious and always helping his father at the sea and fishing. He also helps his fellow fisherman whenever they need help. With this practice, the patient able to do things and help other people with simple things even though no one tells him to do so.

5. Identity versus Role confusion (12-18y/o) During his puberty, he mingles even more to other peer groups. He also had a deep perception of being a man and its difference to the other gender. He had know his self better and having privacy to other. He also had dreams and goal in life especially when he got married. 6. Intimacy versus Isolation (18-30 y/o) Patient P.A. stated that with his puberty he courted many girls in their barangays until he became committed and started to have a long life relationship with his wife where he able to have an good intimate relationship. And that intimacy resulted to a positive way and he able to have his own happy family.

Cognitive Stages of Development (Jean Piaget) Patient BR.B Jean Piaget (18961980) explored how intelligence and cognitive functioning developed in children. He believed that human intelligence progresses through a series of stages based on age with the child at each successive stage demonstrating a higher level of functioning than at previous stages. In his schema, Piaget strongly believed that biologic changes and maturation were responsible for cognitive development. The theory of Piagets cognitive development consist of four stages namely sensory stage(birth 2yearold), preoperational stage(2-6 y/o), concrete state (6-12y/o) and formal operational stage (12-15+y/o). According to the theory any failure to successfully pass any of the stage may alter or may take effect to the cognitive maturity of the person. With the age of patient DR.B. of 19 years old, it shows that the patient should be able to pass the first three stages and he should now be at the formal operational stage. Upon the communication of the student nurse and the patient, it shows that the patient was shy to express

her feelings at first and dont talk when the nurse dont ask something about her but at later time of visit and communication she able to communicate well by explaining and expressing her thoughts in every topic the student nurse asked her. Upon communication, the student nurse also able to observed that the patient was coherent/ aware of the time and her surroundings. With all the observation by the student nurse, it shows that the patient able to pass the theory of developmental stages by Jean Piaget.

F. Functional Assessment 1. Health Perception-Health Management Pattern JL.B Patient JL.B has no known disease upon the interview of the student nurse. He was well and physically healthy. He dont have any vices and according to him he always eat healthy food because he know the risk of eating fatty foods such as hypertension etc. Patient JL.B. also understands the importance of healthy habit and had a high health perception and importance to it. DR.B Mrs. DR.B experiences had become anemic when she had been pregnant. Because of lack of financial resources, she dont have any maternal food supplement. She goes only to health center for her maternal checkup and free medicine and vitamins for her. She is neither a smoker nor an alcohol drinker. Her pregnancy make her more responsible to her family, both of her husband was excited to have a baby and they will do all things to make the baby healthy on her womb. For Mrs. DR.B her form of exercise is her household chores. Home is free from accident.

2. Nutritional Metabolic JL.B Patient JL.B usually eats 3 times a day and drink for about 8-10 glasses daily. At the morning he usually eats 3 pieces of pandesal and a cup of cofdee. At lunch he always eats 2 cups of rice and fish. According to JL.B the family always eats fish and vegetable because it was the primary source of their income and another reason was lack of financial support so they only eat meat occasionally. He can usually eat one whole fish which is usually fried or with vinegar. Also according to the patient the food he eats at lunch is just the same with what he eats on dinner. In some instance he also eats between meals specially when they go fishing at the sea with the same variety and amount as he eats at lunch and dinner. DR.B According to Mr.s DR.B the variety of foods that she eats was the same as what her husband eats. According to her, the only difference was the amount of rice that she eats compare to her husband. She only eats one cup of rice on lunch and only half cup of rice at night. She doesnt eat between meals because for her she was only at the house and do only simple choirs so she doesnt need to eat that much. 3. Elimination Pattern JL.B Patient JL.B defecates every day. His usual stool color is yellow and has not experienced any changes in its color and there are no discomfort when defecating.

He urinates three to four times a day about 600 cc without any difficulty and without any noticeable changes in color or concentration of urine. His usual urine color is yellow. He summarized that she has normal urinary and fecal elimination pattern. DR.B Mrs. DR.B normally eliminates her waste once daily. She characterized it as brown in color and is not soft neither hard. She also verbalized that she doesnt feel any pain or difficulties whenever she was defecating. She also urinates 4-5 times daily; amber-yellow in color. She does not feel any pain during urinary elimination. She does not perspire frequently 4. Activity Exercise Pattern Patient JL.Bs ADLs on an average day consists of the following:  wakes up at 3:30 am  eats breakfast and make self ready for fishing  4:00 am go with his father fishing at the sea  7:30 am arrive at home, clean the boat the fishes being caught  Stay at home with his wife and member of the house  Eats luch at around  1 3 pm he takes a nap  3-6 pm he goes at the neighbors and talk with them sometimes he plays basket ball  7:00 pm he eats dinner  7-8:30 pm go to his relatives to watch television  Around 9 he go to sleep

Patient BR.Bs ADLs on an average day consists of the following:  wakes up at 5:30 am  eats breakfast  6:30 clean the house and the surrounding  9:30 cook food for luch  Eats luch at around 12 noon  1 4 pm she takes a nap  6 pm prepare food for dinner  7:00 pm she eats dinner  8:30 pm prepares and go to sleep 5. Sleep-Rest Pattern JL.B Patient JL.B. usually sleeps for four hours from 9pm to 3:30am. He verbalized that his almost seven hours of sleep and a nap for about 3 hours at the afternoon is all he want to say that he rested enough. Before going to sleep, patient JL.B, prays. Other than that he, doesnt have any rituals before going to sleep. He doesnt experience sleep disturbances such as nightmares and urinating at night. But upon the first night at the hospital the patient verbalized that he was disturbed by the noise and being uncomfortable on his bed. To sum up, the patient doesnt experience any problem when sleeping DR.B

The same with JL.B, patient DR.B was contended on the hours of sleep every day. According to her, she sleeps for about 8 to 9 hours a day plus her nap at the afternoon for about 2 to 3 hours. According to her, she doesnt experience any disturbance on her sleeping pattern. She doesnt have any know rituals before going to sleep except for praying or giving thanks to God for the day that she had. 6. Cognitive Perceptual Pattern The family does not experiences difficulty with their vision, hearing, smelling, touching and tasting faculties. As of the moment, the couple is the only ones who can process decisionmaking. Based on the Physical Examination, all family members have good sense organs functions, as evidenced by the nurses observance on their behavior during home visits. 7. Self-Perception-Self-Concept Pattern Both JL.B and DR.B. have a good perception about them self and even though they experience low quality of life, they is still positive in their life as individual and as a couple and dont have any personal problem. They help on the household and can do their specific part as a son/daughter, husband/wife and siblings to other house members. They are also contented on on their life but they both dream for a good future to their soon to be birth baby. They also percepts the importance of health. 8. Role and Relationship Pattern Both JL..B and DR.B had a good relationship as a couple. They also had a good relationship between the other household members of the extended family of JL.B. When the family have problems, every one cooperate to solve it. Both couple also know their role as a

parent in the future and it can be observed that both couple were excited to the birth of their baby in the future. 9.Sexuality Reproductive Pattern Mrs. DR.B. admitted that they are still sexually active. When given a scale of 1 to 10, where 10 is the highest, she chose 8 to represent her level of satisfaction regarding their sexual desire before she got pregnant but because of her pregnancy, according to her the activity and satisfaction reduced from 8 to 6. 10. Coping- Stress Pattern According to both couple, because of their young life and early marriage there are frequent stressful situation that happen between them. But through understanding and good communication both partners able to cope with it. According to JL.B when he was stress he just go with his friends and play basketball or pool near the house while on other hand, BR.B sleep or watch television at their neighbor to cope to the stress in her life. Also according to both of them, prayers are their best solution to their problem. 11. Value-Belief Pattern Patient JL.B and DR.B. consider their family as the most important thing in her life, It is also their major source of hope and strength. They have a very great belief with God and for them God is the reason for all of this things and only God knows what will happen next and only God can help us with all our problems in life. With this belief, Patient JL.B and BR.B just pray when they have problems.

REVIEW OF THE SYSTEM AND PHYSICAL EXAMINATION Patient JL.B General assessment: conscious and coherent Initial vital signs: T=36.8C, PR=73 bpm, RR=17 cpm, BP=120/80 mmHg Area Assessed A. General / Overall Health State y State of health y Speech Review of Systems Normal Findings Actual Findings Inspection wala naman akong nararamdama ng kakaiba sa katawan ko palagay ko naman ay wala akong sakit p Speaks clearly, and responds to questions quickly p Unilateral, Firm, developed muscle p Speaks clearly, Normal findings and responds to questions quickly Normal findings Significance

y Body Built

p Ectomorph

y Mood

p Mild anxiety; expresses feelings which correspond to the situation

p Mild anxiety; expresses feelings which correspond to the situation

Normal findings

p Active and participates well. B. Integumentary Skin y Color Medyo maitim talaga ako dati pa p Light brown, tanned skin (vary according to race)

p Looks very active and participates well. Inspection p Dark pigmentation

Normal findings

Normal findings

y Soles and palms

Wala naman akong nararamdama

p Lighter colored palms, soles

Inspection p Pale colored palms, soles

Normal findings

y Moisture

ng kakaiba o mga nangangati sa balat ko

Moist

Inspection/Palpation p Moist skin

Normal Findings

Normal findings y Texture p Smooth and soft Palpation p Rough and thick Normal findings y Temperature p Normally warm p Skin snap back immediately for 1-2 seconds Medyo madumi ang kuko ko di ko pa nagugupitan p Transparent and smooth Palpation p Cold Normal findings Palpation p Skin snaps back immediately after 2 seconds. Inspection p Transparent and smooth Inspection p pinkish

y Turgor

Skin appendages a. Nails

Normal findings

Nail beds

p Pinkish

Normal findings

Nail base

p Firm

Inspection p Firm

Normal findings

Capillary refill

p White color of nail bed under pressure should return to pink within 2-3 seconds p Diamond shaped window

Inspection/Palpation p White color of finger nail bed Normal findings under pressure returns to pink within 4 seconds

Angle between nail bed

p Early Clubbing

Normal findings

b. Hair Distribution

p Evenly distributed

Inspection p Unevenly Distributed

Normal findings

Hair color

Di pa ko naliligo mula nung naconfine punas-punas lang

p Black

Inspection p Black

Normal findings

Hair texture

p Smooth

Inspection/Palpation p Sticky; flaky

Normal findings

C. Head y Shape Wala akong sugat sa ulo p Normocephal ic. Inspection/Palpation p Normocephali c Normal findings

y Contusions y Lesions y Lacerations

p p p

Absence of contusion Absence of lesions Absence of laceration

p p p

Absence of contusion Absence of lesions Absence of laceration

Normal findings Normal findings Normal findings

D. Eyes y Eyes Malinaw pa naman ang aking paningin p Parallel to each other Inspection p Parallel to each other Normal findings

Pupils

p Symmetri -cal in size, extension, hair texture and movement

Normal findings Inspection p Symmetrical in size, extension, hair texture and movement

Eyebrows

p Distributed evenly and curved outward

Inspection p Distributed evenly and curved outward

Normal findings

p Same color as the skin y Eyelashes p Blinks involuntarily

Inspection p Same color as the skin p Blinks involuntarily Normal findings

Eyelids

p Do not cover the pupil and the sclera, lids normally close symmetri -cally p Light pink in color p Transparent, shiny

p Do not cover the pupil and the sclera, lids Normal findings normally close symmetrically Normal findings

Conjuncti -va

Inspection p Pale Inspection p Transparent, shiny

Normal findings

Sclera

Normal findings

Cornea

p Clearly visible

Inspection p Clearly visible Normal findings

Iris

E. Ears y Ear canal opening Lagi naman akong naglilinis ng tainga kaso ngayon mga nakaraan araw nakakaligtaan ko kasi nga meron akong ibang nararamdama n p Free of lesions, discharge or inflamma -tion p Canal walls pink p Waxy, flaky, brown cerumen Inspection p Free of lesions, discharge of inflammation Normal findings

p Canal walls pink p Presence of some waxy brown,flaky

Normal findings

Cerumen

Normal findings

cerumen Inspection (whisper test) p Client hear words when whispered

Hearing Acuity

p Client normally hear words when whispered

Normal findings

Color

p Uniform to skin

Inspection p Uniform to skin

Normal findings

Texture p Smooth to touch

Inspection p Smooth to touch Inspection p Auricles are aligned with the outer canthus

Normal findings

Alignment to outer canthus

p Auricles are aligned with the outer canthus wala naman akong sipon at hindi talaga ako sipunin

Normal findings

F. Nose and Sinuses y Shape, size and skin color

p Smooth, with same color as the face

Inspection p Smooth, with same color as the face (pale)

Normal findings

Lesions Nares

p Absence of lesions p Oval, symmetric and without discharge

Inspection Normal findings p Absence of lesions Inspection Normal findings p Oval, symmetric and without discharge

G. Mouth and Throat y Lips

Wala akong sumasakit na

p Pink and

Inspection p Moist lips

Normal Findings

ngipin pero marami na kong bungi y Buccal mucosa Isang beses sa isang araw ako nagkakape

moist Normal findings Inspection p Glistening pink soft p Pale soft moist without moist without lesions lesions Normal findings p Slightly pink in color and moist Inspection p Slightly pink in color and moist Normal findings Inspection p Moist, slightly rough on dorsal surface medium to dull red, smooth movement Inspection p Yellowish discoloration of the teeth, with carries and only 28 teeths Inspection p Absence of mouth sores Normal findings \ May be due to lack of dental checkup and poor dental health

Gums

Tongue

p Moist, slightly rough on dorsal surface medium to dull red, smooth movement

Teeth

p Firmly set and shiny, 32 teeth; no dentures

Mouth sores

p Absence of mouth sores

Inspection p Pinkish, not inflamed; grade 0 Inspection p Pinkish, midline, not inflamed Normal findings Normal findings

Tonsils

p Pinkish, not inflamed; grade 0

Uvula

p Pinkish,

midline, not inflamed

Inspection p Hard palatedome-shaped Soft Palatelight pink

Normal findings

Hard and soft Palate

p Hard palatedome-shaped Soft Palatelight pink nahihirapan akong huminga kapag nakahiga ako kaya lagi akong nakaupo p Resonant

J. Respiratory y Thorax and Lungs

Percussion p Resonant

Normal findings

Respiratory rate

Auscultation p Broncovesicu p Broncovesicul lar heard ar heard over over major major bronchi bronchi p 12-20 cpm p 17 cpm Inspection p Skin same color with the rest of the body Auscultation p Normoactive with the range of 20 per minute Inspection p Flat abdomen

Normal findings

Normal Findings.

L. Gastro -intestinal y Abdomen

Parang lumalaki ung tiyan ko,parang may tubig

p Skin same color with the rest of the body

Normal findings

Bowel sounds

Abdomen Contour

p Normoactive with the range of 535 per minute p Rounded or Flat

Normal findings

Normal Findings

N. Genitalia y Penis

Testes

Foreskin may not be present should retract and return easily with clean smooth Refused: Not Assessed skin underneath. p Location of each testis should be entirely in sac, left slightly lower than right.

REVIEW OF THE SYSTEM AND PHYSICAL EXAMINATION Patient DR.B General assessment: conscious and coherent Initial vital signs: T=37.1C, PR=60 bpm, RR=24 cpm, BP=90/60 mmHg ROS includes System history of complaints- all subjective A. General/ Overall Health State  Ayos naman ako at ang baby ko minsang nga lang ay medyo nanghihina ako dahil ako ay anemic. Vital Signs:  Blood Pressure90/60 mmHg  Pulse Rate60 bpm  Respiratory Rate- 24 cpm  Temperature37.1 C
o

PE- includes assessment via IPPA- all objectives Normal Findings Significance

 Blood Pressure120/80mmHg  Pulse Rate60-100 bpm  Respiratory Rate16-20 cpm  Temperature36.5- 37.5 oC

 Normal Findings  weak appearance deviated from normal

 Appears as stated age

 Appears to be stated chronological age

 Conscious and coherent  Weak appearance  Oriented to time, place and others

 Conscious and coherent  Absence of weakness  Aware of place, time and others

B. Integument  Skin  wala naman akong nakikitang kakaiba sa balat ko

Inspection:  Patient P.A has moist skin with dark brown color. It is uniform all over the body.  There lesions at the right foot  Presence of wrinkles  Absence of bruises  Absence of rashes Palpation:  Skin is warm to touch

Inspection:  Varies from light to  Normal deep brown  Uniform in color Findings

 Absence of lesions and masses.

 Absence of wrinkles  Absence of bruises  Absence of rashes Palpation:  Skin is warm to touch  Normal edema of the lower

 Slight edema of lower extremities

 Slight swelling or edema  Absence of

extremities are normal to a pregnant person

 No tenderness  Hair  medyo dry ang Inspection: buhok ko siguro dahil lang yan sa panahon  Silky, black colored with white colored hair

tenderness

Inspection:  Hair should be evenly distributed, silky and black in color . Normal Findings

 Some area seems to have lesser hair

distribution  There are no lesions, infestations or flakes present.  Absence of lesions, infestations or flakes.  Normal

 Nail

 Eto medyo madumi na kuko ko kalilinis ko lang kasi ng mga kaldero.

Palpation:  Smooth  Capillary refill in 2 seconds

Palpation:  Smooth  Prompt return of capillaries less than 3 seconds Normal Findings

 Hard and immobile  Smooth Inspection:  Pink and round nail bed  Thick nails and with 160 nail base
o

 Hard, immobile  Smooth Inspection  Pale and round nail Due to low RBC bed  Thick nails  160 nail base
o

level in blood manifestation can be observd on nail bed

C. Head  Wala naman akong nararamdaman g masakit sa ulo ko

Inspection:  Symmetrical, rounded head positioned at the midline

Inspection:  Round (normocephalic and symmetrical, with frontal, parietal, and occipital prominences)  Head centered

 Normal

 Symmetric facial features and movements  Head can move freely without discomfort  No lesions Palpation:  No palpable nodules and masses

 Symmetric facial movements.

 Head can move freely without discomfort  Absence of lesions Palpation:  Absence of nodules and masses

D. Ears

 Bingi yan kung minsan as verbalized by the patients daughter .

Inspection:  Ear color is the same as the skin color  Symmetrical ears  Aligned with outer canthus of eyes

Inspection:  Ear color is the same as facial skin color  Symmetrical  Auricle aligned with outer canthus of the eye

 Normal Findings.

Palpation:

Palpation:

 Not tender and Firm

 Firm and nontender

E. Respiratory

 Wala naman akong nararamdamang kahit ano sa pag hinga ko palagay ko naman ay normal ito .

Inspection:  Intact skin  No tenderness  No masses  Symmetrical  Symmetrical structures

Inspection:  Intact skin  No tenderness  No masses  Symmetrical  Symmetrical placement of all structures

 Normal.

 Equal shoulder height Respiratory rate:  24 cpm

 Bilaterally equal shoulder height Respiratory rate:  Normal respiratory rate: 16-20 cpm  Slightly faster than normal due to low oxygen level on blood  Normal Findings  The circulation was on the borderline of normal value, it can be interpreted that manifestation

Auscultation:  Clear breath sounds

Auscultation:  Clear breath sounds

F. Cardiovascular

 Dati pag napapagod ako medyo nasakit kung minsan ung dibdib ko pero ngayon naman wala

Palpation: Pulse Rate:  60 bpm  No vibration or in the aortic, pulmonic, or tricuspid area

Palpation: Pulse Rate:  Normal Pulse Rate: 60- 100 bpm

pulsations palpated  No vibration or pulsations palpated in the aortic, pulmonic, or

akong nararamdama n..  Capillary refill in 4 sec.  Regular rhythm apical pulse

tricuspid area  Capillary refill: 0-3 sec.  Regular rhythm apical pulse

of anemia can be observe

 Identical radial and  Identical radial and

Auscultation:  90/60 mmHg

Auscultation:  BP: 110/70 120/80 mmHg

G. Urinary

 Wala naman akong nararamdamang kahit ano kapag naihi ako ayos naman.  Noong wala ako sa ospital malakas akong uminom ng tubig.  Urine color: Yellow

 Urine output is 2 D upon the end of the shift  Urine color: amber to yellow

Normal

H. Genitalia

No verbalization

We have not assessed the clients genital area.

Not Assessed

Not Assessed

I. Musculoskeletal

 di ko magalaw ung kaliwang bahagi ng katawan ko.

Inspection:  10 fingers and 10 toes are present.  Evenly

Inspection:  10 fingers and toes are present

 Normal Findings

 Evenly distributed

distributed weight  There is absence of fractures or even dislocations  There are absence of swelling  Equal size on both sides of the body  Muscle weakness  No tremors  Firm  No nodules Palpation:  Absence of palpable masses  No tenderness

weight

 No fractures or even dislocation

 Absence of swelling

 Equal size on both sides of the body

 No muscle weakness  No tremors  Firm  No nodules Palpation:  No palpable masses  Absence of tenderness

FAMILY TYPOLOGY FAMILY NURSING PROBLEM  Inability to provide a home environment conducive to health maintenance related to: a. financial constraints b. inadequate knowledge on preventive measures c. inadequate knowledge on the threats imposed by the familys home condition

CUES and DATA Subjective:  Gasera ang ginagamit naming ilaw sa bahay wala kasi kaming kuryente.  Gawa yan ng ulan. Nilagyan namin ng plastic para hindi tumulo ang tubig.  : Hindi naman nangangagat yan [dog]. as verbalized by the mother Objective:  House is made of light materials: plywood and nipa  Flooring is not cemented and muddy  Mother put carton on the floor to absorb the rain water that entered the house  The outside of the house is slippery esp. during the rainy season  Presence of water on the plastic on the underside of the roof  The family uses mosquito net at night  Unsanitary home environment which may be conducive to reproduction of mosquitoes  The dog is tied up on the corner of the house or sometimes, on the clothesline

HEALTH PROBLEM  Poor home and environmental condition as a health threat a. fire hazards b. fall hazards c. presence of breeding sites of mosquitoes d. presence of an unvaccinated dog

Subjective  Anemia as a health deficit. y Nang nagpacheck up ako sa center eh anemic daw ako at binigyan ako ng gamut na ito Objective y Look to be weak y Bp of 90/60 y 60 cpm y 24 bpm y Pale color nail bed y Slow capillary refill

 Inability to provide adequate nursing care to the sick or vulnerable members of the family related to: -Lack of necessary equipment for care Inadequate family resources, specifically financial resources Inability to provide a home environment conducive to health maintenance related to inadequate family resources specifically financial and physical resources.

SCALING of PROBLEM Poor home and environmental condition CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION The condition is a health threat to the family. This problem pertains to the fire and fall hazards, presence of breeding sites of mosquitoes and dogs. The problem is highly modifiable given the time resources of both the nurse and the family. It also almost does not require financial resource. If the problem is solved, there is a high chance to minimize health threats associated with the accident and health

Nature of the Problem

2/3 x 1

0.67

Modifiability of the Problem

2/2 x 2

Preventive Potential

3/3 x 1

Salience of the Problem

0/2 x 1

hazards present in the house. The family does not acknowledge this as a problem because they have inadequate knowledge on what the implications of these conditions are.

TOTAL SCORE

3.67

Asthma as a health deficit Category Nature of the problem Computation 3/3 x 1 = 1 Justification The problem is a health deficit and requires immediate care. Resources of the community and of the nurse are available, but resources if the family are inadequate to handle it properly. They are exposed to allergens, they are not doing much preventive measures. The duration of their condition is very long already. They openly express their concern regarding the matter.

Modifiability of the problem

1/2 x 2 = 1

Preventive potential Salience TOTAL

1/3 x 1 = 1/3 2/2 x 1 = 1 3 1/3

RANKING OF PROBLEMS PROBLEM  Asthma as a health deficit  Poor home and environmental condition

SCORE 3.33 3.67

RANKING 1 2

Asthma as a health deficit INTERVENTION PLAN Method of Nurse - Family Nursing Interventions Contact After the After the nursing 1. Broaden the knowledge Home visit and nursing intervention: of the family regarding health intervention, A) The client asthma itself. teachings. the client will be able to A.Discuss what asthma and her fully understand actually is. family will the problems and B.Discuss what may be able to complications of trigger asthma attacks. understand anemia. C.Discuss what the B) The client will complications asthma importance be able to might have. of their understand the 2. Teach the importance of environment importance of a the environment and its to the care of clean effects on asthma. their environment to 3. Introduce alternative condition the care of ways on how to help and be able anemia. control asthma. to perform C) The client will alternative be able to and proper maintain an care environment conducive to the proper care of anemia. D) The client will be able to understand / GOAL OF CARE OBJECTIVES OF CARE

HEALTH PROBLEM 1. Anemia as a health deficit.

FAMILY NURSING PROBLEMS Inability to provide adequate nursing care to the sick or vulnerable members of the family related to: -Lack of necessary equipment for care Inadequate family resources, specifically financial resources Inability to provide a home environment conducive to health maintenance related to inadequate family resources specifically

Resources Required Material Resources: Various refferences regarding asthma Alternative ways to help control asthma. Human Resources: Time from both the nurse and the family to conduct a proper health teaching along with the home visit. Financial Resources: Money for transportation of the nurse.

financial and physical resources.

know alternative ways to help their condition. E) The client will be able to perform alternative ways to help their condition.

Poor home and environmental condition FAMILY NURSING PROBLEM  Inability to provide a home environment conducive to health maintenance related to: d. financial constraints e. inadequate knowledge on preventive measures f. inadequate knowledge on the threats imposed by the familys home condition OBJECTIVES OF CARE NURSING INTERVENTION S  Enumerate the observed parts of the house and the surroundings that may contribute to possible fire and fall accidents  Enumerate possible ways to prevent these accidents  Discuss the health threat of the present breeding sites of mosquitoes  Discuss possible actions to be taken to prevent health problems related to the presence of mosquitoes  Analyze with the couple the magnitude of the problem

CUES and DATA Subjective:  Gasera ngayon ang ginagamit namin kasi wala pa kaming kuryente gawa ng bagyo.  Gawa yan ng ulan. Nilagyan namin ng plastic para hindi tumulo ang tubig.  Medyo mainit kaya lagi kami nasa labas o kaya sa bahay ng biyenan ko.  Dati dalawa yan [window], inalis lang yung isa kasi bawal daw

HEALTH PROBLEM  Poor home and environmental condition as a health threat e. fire hazards f. fall hazards g. presence of breeding sites of mosquitoe s h. presence of an unvaccinat ed dog

GOAL OF CARE

EVALUATION

 After one  After one day of day of nursing nursing intervention, the intervention, family will be the family able to: will be able a. acquire to provide a knowledge home on possible environment preventive conducive measures to to health be taken to maintenance prevent fire and fall accidents b. explain the health threat associated with their current home environment c. plan on how to properly isolate the dog from the children d. acquire knowledge

yung nakaharap sa may pintuan.  : Hindi naman nangangagat yan [dog]. as verbalized by the mother Objective:  House is made of light materials: plywood and nipa  Flooring is not cemented and muddy  Mother put carton on the floor to absorb the rain water that entered the house  The outside of the house is slippery esp. during the rainy season

on what implicated by poor the presence of ventilation is the dog e. explain the  Enhance the possible couple problems awareness of that may possible arise from resources to be poor able to get the ventilation dog vaccinated f. determine and more actions the isolated from family will the children probably  Encourage the take to family to take improve the action on house improving their ventilation current home g. express and willingness environment to take condition action on improving home

 Presence of water on the plastic on the underside of the roof  The family uses mosquito net at night  Unsanitar y home environment which may be conducive to reproduction of mosquitoes  The dog is tied up on the corner of the house or sometimes, on the clothesline

Impaired Dentition
ASSESSMENT NURSING DIAGNOSIS BACKGROUND KNOWLEDGE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Meron na akong mga bungi

Isang bes isang araw ako kung mag toothbrush

Impaired dentition related to ineffective oral hygiene as manifested by 28 teeth, yellow discoloration of teeth and accumulation of plaques and carries.

Due to poor oral hygiene, plaques and other bacteria in the mouth were not cleaned away that cause oral problems specifically tooth damage.

Long term goal: Display healthy gums, mucous membranes and teeth in good repair. Short term goal: After 2 hours of comprehensive nursing interventions the client will be able to:  Recognize the importance of good oral hygiene  Learn and demonstrate some of the proper oral hygiene.

The student nurse:  Evaluate the current oral / tooth status of the patient  To determine the need for instructions, and to be able to know the appropriate teachings to be done.  To inspire the patient to participate to the health teaching of the student nurse.

Objective: y 28 teeth y Brown discoloration of teeth y Accumulation of plaques

 Explain the importance of good oral hygiene and proper dentition  Teach proper oral hygiene to the patient like proper brushing of teeth and stop smoking.

 For the patient to have idea how to took care of his tooth.

 Ask the patient to demonstrate the activities being done.

 To assess if the patient able to understand what was being taught.

Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
ASSESSMENT Subjective: jNanghihina ako,kadalasan hindi ko matapos ang mga gawain ko
(Im feeling weak, I cant even complete my chores) as

NURSING DIAGNOSIS Activity intolerance related to imbalance between oxygen supply (delivery) and demand.

BACKGROUND KNOWLEDGE Short term: After 8 hours of nursing interventions the patient will: jReport an increase in activity tolerance including activities of daily living. jDemonstrate a decrease in physiological signs of intolerance. jDisplay laboratory values within acceptable range. Long term: After months of nursing interventions, the patient: jIs free form weakness and risk for complications has been prevented.

PLANNING Independent: jAssess patients ability to perform normal task or activities of daily living. jNote changes in balance/ gait disturbance, muscle weakness. jRecommend quiet atmosphere, bed rest if indicated. jElevate the head of the bed as tolerated. jProvide or recommend assistance with activities or ambulation as necessary, allowing patient to do as much as possible. Plan activity progression with

INTERVENTION jInfluences choice of interventions or needed assistance. jMay indicate neurological changes associated with vitamin B12 deficiency, affecting patient safety or risk of injury. jEnhances rest to lower bodys oxygen requirements, and reduces strain on the heart and lungs. jEnhances lung expansion to maximize oxygenation for cellular uptake. jAlthough help may be necessary, self esteem is enhanced when patient does some things for

EVALUATION

verbalized by the patient. Objective: jFatigue. jGreater need for sleep and rest. jV/S taken as follows: T: 36.9 P: 60 R: 23 y BP: 90/60

patient, including activities that the patient views essential. Increase levels of activities as tolerated. jIdentify or implement energy saving technique like sitting while doing a task. Collaborative: jMonitor laboratory studies. Hb or Hct and RBC count, arterial blood gases (ABGs).

self. Promotes gradual return to normal activity level and improved muscle tone or stamina without undue fatigue. jEncourages patient to do as much as possible, while conserving limited energy and preventing fatigue. jIdentifies deficiencies in RBC components affecting oxygen transport and treatment needs or response to therapy.