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Family Case
Presentation
Introduction
The health of the family is viewed as a whole
involving all its member and not individually. The
family is a basic unit of society and its members
should be empowered to maintain a healthy
status and lifestyle.
Each family is unique in way of recognizing
and meeting the needs of each member. The
family is the principal integer of health care
and/or a pillar in furnishing physical, spiritual,
emotional, social and financial supports for its
members. It is also the primary factor for the
growth and development of the members. The
health of each family member is very significant
and the way they live simply reflects their health
Objectives
General:
CHAPTER I:
FAMILY
ASSESSMENT
Family Structure
and
Characteristics
and Dynamics
Mr. E.V.
Age Sex
33
Date of
Birth
M 06/12/1979 Married
Occupation
Father
Grade II
Construction
Worker
Grade II
N/A
Grade III
N/A
Mrs. G.V 30
Mr. G.V
M 10/15/2005
Civil
Status
Position
in the Educational
Family Attainment
Single
1st
Child
A.2. Family
Structure
Status
Additional Information
Observable conflict
between family members
Characteristics of
Communication
Where:
(+) Positive/Good, observable, can
be seen
(-) Negative, inexistence, cannot
be seen
A.4. Decision-making
The father is responsible for
decision-making but he stills asks his
wife for the approval of his decisions.
With regards to health matters, the
mother is less responsible for
treating immediately the illness of
her children.
B.Socio-economic &
Cultural Factors
Allocations
Estimated Expenses
per day
Estimated Expenses
per Month
Food
Php 60.00
Php 1, 800.00
Drinking Water
Php 24.00
Allowance of the 3
children
Php 21.00
Php 420.00
Others (grocery)
Php 250.00
Cigarettes of Mr. E.
Php 20.00
Php 560.00
TOTAL:
Php 107
Php 3,054
B.2. Educational
Attainment
B.4. Awareness of
Community
Organization
The family is under the
program of 4Ps (Patawid
Pamilyang Pilipino Program) and
actively joins assemblies under
it. They are aware of other
community organization like
Igkampuran Community but
barely participate to it.
C. Home and
Environment
C.1. Description of the House
Their house is located in Camanci Sur,
Numancia, Aklan and placed approximately
50 meters away from the main road. It
surrounded by different trees and grasses.
The house is very open and only their
bedroom has covers. There is no front door.
The house is a combination of woods, metal
roof and other diverse materials such as
sacks blanket and tarpaulin.
The roof is made of galvanized iron. The
foundation of the house is made of wood
House Plan
C.2. Adequacy of
Living Space
Upon arrival to the house, you will see
there small space for their bedroom
with approximately 224 cm x 296 cm in
measurement and this also serves as
their dining area. The clean and dirty
clothes are scattered everywhere and
they have no proper place and storage
for all it. They have no proper kitchen,
living room as well as bathrooms.
C.3. Sleeping
Arrangement
They only have 1 bedroom, where the
couple together with their 4 children sleep.
Crowding Index
Formula:
Crowding index =
=6 Ratio or 6:1 room (6 person/1 room)
Result: 6 persons in 1 bedroom
Ideal: 2 persons in one room (2:1)
C.4. Adequacy of
Appliances and
Furniture
They dont have any electrical
appliances. They have 1
monoblocked chair and small
table where their water
containers and other kitchen
utensils are placed.
C.5. Presence of
Accident Hazards
The upper floor that is made of bamboo
slates has gaps that can lead to fall of
the children. Their ladder has no
handrails that can also lead to
accidentally fall. Their knife and other
sharps objects are just placed inside the
bedroom and can be easily reached by
the children. The swaying of the house
may lead to accidentally falling.
C. 13. Presence of
Electricity
They just tap on their neighborhood for
the source of their electricity.
C.16 Communication
and Transportation
The mother owns a
cellphone which is used for
communication and
emergencies. They use
tricycle for transportation
CHAPTER
II: REVIEW
OF SYSTEM
VITAL SIGNS:
Temperature: 36.9C/ax
Pulse Rate: 72 beats per minute
Respiratory Rate: 18 breaths per
minute
Weight: 61 kg
Height: 55 FT.
BMI: 22.34 (NORMAL)
OBSTETRIC/GYNECOLOGIC HISTORY
VITAL SIGNS
Temperature: 36.6C/ax
Pulse Rate: 70 beats per minute
Respiratory Rate: 21 breaths per
minute
Blood Pressure: 120/80 mmHg
Weight: 44 kg
Height: 410
BMI: 20.28 (NORMAL)
VITAL SIGNS:
Temperature: 36.5C/ax
Pulse Rate: 66 beats per minute
Respiratory Rate: 26 breaths per
minute
Weight: 19 kg
Height: 119 cm
BMI: 13.38 (SEVERE UNDERWEIGHT)
VITAL SIGNS:
Temperature: 36.7c/ax
Pulse Rate: 73 beats per minute
Respiratory Rate: 24 breaths per
minute
Weight: 17 kg
Height: 114 cm
BMI: 13.07 (SEVERE UNDERWEIGHT)
VITAL SIGNS:
Temperature: 36.2C/ax
Pulse Rate: 81 beats per minute
Respiratory Rate: 27 breaths per
minute
Weight: 10 kg
Height: 98cm
BMI: 10.20 (SEVERE UNDERWEIGHT)
VITAL
SIGNS:
Temperature: 36.7C/ax
Pulse Rate: 93 beats per minute
Respiratory Rate: 34 breaths per
minute
Weight: 7 kg
Height: 71 cm
BMI: 14 (SEVERE UNDERWEIGHT)
A.2 Physical
Assessment
INTEGUMENT
Skin
He has intact skin, has scars in legs and
hands, skin texture is rough and dry, warm
in temperature and no presence of moist.
Skin color is light brown and in skin turgor,
skin go back to its original shape in not
less than 2-3 seconds.
He uses soap for his skin care and take a
bath everyday.
Hair
He has dry, thick, black hair, evenly
distributed.
Scalp is intact and no scaling and lesions.
Nail
He has untrimmed and dirty nails, hard and no
clubbing observed.
Firmly attach to the nail bed.
Capillary refill not less than 2-3 seconds, and
cuts his nails once a week.
Head
Head is symmetrically at midline, still and erect.
Facial expressions are voluntary, often smiles,
eyebrows can raise, can close eyes tightly and no
lesions observed.
The heads range of motion is not limited and has
no complains regarding the head except for the
common/ usual headaches experienced if very
tired and stressed.
Eyes
Has rounded brown eyes and are
symmetrical, aligned from the tip of the
ears and are regular in shape.
Eyebrows are evenly distributed.
Eye movements are normal, eyelids are
equal in size, and covers approximately
both the eyeballs and symmetry in
blinking.
Eyelashes are curled up, bony orbits are
round and no lesions and are symmetrical,
eyeballs are equal in size, non-tender and
firm, both sclera are clear and moist, iris
are equal in shape with brown color
without vascularity.
Ears
Ears are light brown in color, no lesions,
uniform in shape and in line with the
canthus of the eyes.
Auricles are firm, smooth, non-tender, and
pinna recoils after folded. No presence of
nodules, swelling and pain upon palpation.
In external auditory canal, there is a
presence of wet, yellowish, small amount
of cerumen observed.
He clean his ear once a week with
cottonbuds.
Mouth
Lips are intact, free in lesions, dark brown
in color and slightly moist, no cracks,
swelling and cyanosis.
Mucosa and gums are moist, pink, intact
and no lesion, teeth are complete but with
decay and debris are present in the right
molar tooth.
Tongue has normal size, pink, moist and
intact.
Oral brushing is done at least once a
week.
Neck
Neck is brown in color, no lesions and
masses.
RESPIRATORY
Has the respiratory rate of 18 breathes per
minute, chest is symmetrical and do not
use accessory muscle upon breathing.
No nasal flaring noted.Upon auscultation,
no significant deviation is heard.
CARDIOVASCULAR
Upon inspection, no jugular vein distention
is observed.
No thrills, no murmurs and bruits are
heard and have a cardiac rate of 72 beats
per minute.
GASTROINTESTINAL
Abdomen is big in size and is round, skin is
intact and no lesions, rashes, scars.
Bowel sounds are normal, umbilicus is
inverted and in the midline with no bluish
discoloration and inflammations observed.
No bulges, tenderness, pain and enlarged
organs during palpation.
Usual bowel pattern is every day and
complains no unusual abnormalities felt
with brownish, formed a stool.
GENITOURINARY
He voids for about 5-6 times a day and no pain felt upon
urination.
He refused to assessed his GU system.
His sexual pattern is done once a week.
MUSCULOSKELETAL
His posture is erect, head is in the midline, and
body alignment is normal.
No presence of any spinal deformities and
gaits is normal.
Upon Romberg test, there is a slight swaying
of the body.
No involuntary movement is observed and has
no record of fall and trauma.
NEUROLOGIC
Behaviour is normal and facial expressions
are voluntarily.
He is alert, oriented, and memory is
normal, usually dont forget the past
things that happened.
He is alert and well oriented during the
visit and cooperates well to assessments.
All cranial nerves are active and intact
and he had no history of seizures,
paralysis, and other neurologic disorders.
ENDOCRINE
No history of endocrine disorder.
HEMAPOETIC
No bruises or hematoma noted to his
body and he claimed that he dont
have any history of bleeding
disorder.
LYMPHATIC
Upon palpation, no swollen of lymph
nodes are present.
INTEGUMENT
Skin
Skin is dark brown in color, intact, no
lesions noted, skin has a slightly rough
and dry texture with warm temperature
and has abrasions in both legs from
scratching of insect bites.
No presence of edema, and upon
assessing the skin turgor, skin go back to
its original shape in not less than 2-3
seconds.
Dont have any removed lesion, tattoos
and other skin disorders.
He uses soap for her skin care, and has no
access to any skin moisturizers but take a
Hair
She has dry, long black hair, evenly
distributed, scalp is intact and no scaling.
No signs of pediculosis.
Often uses
Nails
She has untrimmed and dirty nails, hard
and no clubbing observed, firmly attach to
the nail bed.
Capillary refill not less than 2-3 seconds.
Nail care is seldom done at least once in
two weeks.
Head
She has rounded head, still and upright in
position.
Facial expressions are voluntary, often
smiles, eyebrows can raise, can close her
eyes tightly and no lesions observed.
Upon assessing range of motion,
movements are not limited and no
complains aside from usual/common
headaches when stressed and tired.
Eyes
Eyes are symmetrical and canthus are aligned
from the tip of the ears, eyebrows are evenly
distributed, eyelids are equal in size, and covers
approximately both the eyeballs and symmetry
in blinking, her eyelashes are curled up.
Bony orbits are round and no lesions and are
symmetrical, eyeballs are equal in size, nontender and firm, both sclera are clear and moist,
iris are equal in shape with brown color without
vascularity.
She can read letters 2-3 ft far from her.
Ears
Ears have the same colour with the rest of
the body, no lesions, uniform in shape and
in line with the canthus of the eyes.
Auricles are firm, smooth, non-tender, and
pinna recoils after folded no presence of
swollen lymph nodes, swelling and pain
upon palpation.
In external auditory canal, there is a
presence of dirt outside the pinna.
Ears are cleaned only for about twice a
month.
Mouth
Lips are dry, but free of lesions, dark
brown in color and are cracked, mucosa
and gums are moist, pink, intact, and no
lesion.
Teeth are incomplete having one missing
tooth in the right molar and debris or
decay are present in her both left and
right molar tooth.
Tongue has normal size, pink, moist and
intact with papillae present.
Oral brushing is done only when necessary
(if about to go somewhere).
Neck
Brown in color, symmetrical, no lesions
and masses, full range of motion, and
neck is slightly long in size, proportional in
head and shoulder.
Trachea is in the midline and non-tender,
lymph nodes are non-palpable.
Breast
Skin in the breast area is smooth,
undimpled and has same color in the rest
of the skin.
Right breast is larger than the left breast,
no edema, lesions and masses.
Nodes are non-palpable, no other
discharges in the nipples, areola are dark
brown in color.
She breastfed her baby every 3hours or
depending on her babys demand.
RESPIRATORY
Upon observation, her respiratory rate is 21
breaths per minute, chest is symmetrical and
do not use of accessory muscle upon
breathing, no presence of masses and lesions.
Posture is good, chest skin is intact. No nasal
flaring, no barrel chest and spinal deformities.
She is a thoracic breather, trachea is in the
midline, no crepitus and other significant
deviation.
CARDIOVASCULAR
No abnormal findings noted, sounds are
timing in cardiac cycle with the cardiac
rate of 70 beats per minute.
GASTROINTESTINAL
Abdominal skin is intact, flat and no
tenderness, masses, scars or lesions
observed.
Umbilicus is in the midline and inverted
and has no signs of discoloration.
She has stated no complaints regarding
her gastrointestinal system.
Bowel movement is about every other day
with formed dark brown stool as stated.
GENITOURINARY
She refused to be assessed on the
reproductive area.
Has no complains of pain upon micturation
and has regular voiding movement.
Her sexual pattern is once a week.
MUSCULOSKELETAL
Head is in midline, and observed no spinal
deformities and has erect posture.
Has no observed involuntary movements
and has the full Range of Motion.
Has no problem or past history of
musculoskeletal dislocations and disorder.
NEUROLOGIC
She is alert and oriented upon
assessment, and respond to questions and
assessment measures though easily
destructed with her surroundings.
All cranial nerves are still active
ENDOCRINE
She claimed that she dont have any
history of endocrine disorder.
HEMAPOETIC
Upon inspection, there is no bruises or
hematoma noted to her body and dont
have any history of bleeding disorder.
LYMPHATIC
No swollen lymph nodes palpated.
OBSTETRIC RECORD
According to her obstetric record, she has
4 Gravida, 4 Para, 4 Term, 0 Preterm, 0
Abortion, 4 Live children and got married
last May 2014 at the age of 30 and she
was able to bear 4 children in the years
2005, 2007, 2008, and 2013.
She had her menarche when she was 14
years old and currently have a regular
menstrual period.
She delivered all her children via Normal
Spontaneous Vaginal Delivery at the
health center with a midwife.
Currently, she had her Depo Provera
injection as their family planning method
Hair
He has dry black hair, evenly distributed, scalp
is intact and no scaling.
Uses only shampoos for his hair care if
available.
Nails
He has untrimmed and dirty nails, hard
and no clubbing observed, firmly attach to
the nail bed.
Capillary refill not less than 2-3 seconds.
His mother cuts his nails every two weeks
or if necessary.
Head
He has rounded head still, and upright in
position.
Facial expressions are voluntary, always
smiles, eyebrows can raise, can close eyes
tightly and no lesions observed.
The heads range of motion is not limited
Eyes
Eyes are symmetrically aligned from the
tip of the ears, eyebrows are evenly
distributed, eyelids are equal in size, and
covers approximately both the eyeballs
and symmetrically blink eyelashes are
long and curled up.
Bony orbits are round and no lesions and
are symmetrical eyeballs are equal in size,
non-tender and firm, both sclera are clear
and moist, iris are equal in shape with
brown color without vascularity.
He can read letters 2-3 ft far from him.
Ears
Ears have the same colour with the rest of the
body, no lesions, uniform in shape and in line
with the canthus of the eyes, auricles are firm,
smooth, non-tender, and pinna recoils after
folded.
No presence of nodules, swelling and pain
upon palpation.
In external auditory canal, presence of white
scaling of the skin and dirt outside the pinna
are observed.
His mother cleans his with cotton buds only
for about twice to thrice a month.
Nose
The color is same as the face, mucosa lining
is smooth, intact, deep-pink and non-deviated
septum.
Upon palpation, nose is non-tender, no
discharges and dont experience runny nose.
He has a patent airway and claims no clogged
upon breathing.
Mouth
Lips are smooth, intact, and free of lesions,
pink in color and slightly moist. No cracks
swelling and cyanosis, mucosa and gums are
moist, pink, intact, and no lesion, deciduous
teeth are incomplete and debris or decay are
present in both molar tooth, tongue has
Neck
Brown in color, no lesions and masses, full
range of motion, and neck is short in size,
proportional in head and shoulder.
Trachea is in the midline and non-tender
Lymph nodes are non-palpable and has no
complains regarding his neck.
RESPIRATORY
Has the respiratory rate of 26 breathes per
minute.
Upon auscultation, normal lung sounds are
heard.
Chest symmetrically moves, do not use
accessory muscles upon breathing and no
nasal flaring is observed.
CARDIOVASCULAR
Upon inspection, no jugular vein distention
is observed and pulsations are note in the
neck vessels and other pulsation, no thrills
and heaves present, no murmurs and
bruits are heard.
Sounds are timing in cardiac cycle and
has 66 beats per minute as cardiac rate
recorded.
GASTROINTESTINAL
Abdomen is big and protruding with intact
skin and no lesions, rashes, scars
observed. Bowel sounds are normal.
Umbilicus is inverted and in the midline
with no bluish discoloration and
inflammations observed.
No bulges, tenderness, and enlarged
organs palpated and complain no pain felt
upon assessment.
Usual bowel pattern is done every other
day and complains no unusual
abnormalities felt and with formed light
brown stool.
GENITO URINARY
He voids for about 6-7 times a day.
He refused to assessed his GU system,
but claims that he never experience pain
and severe itchiness in his genital area.
MUSCULOSKELETAL
Posture is erect , head is in the midline,
and body alignment is normal.
No history of falls, no spinal deformities,
gait is normal, no complains of pain upon
movement and has no observable
involuntary movements.
NEUROLOGIC
Behaviour is normal and facial expressions
are voluntarily, he is alert, oriented and
playful.
All cranial nerves are active and intact
upon assessment.
ENDOCRINE
He claimed that she dont have any
history of endocrine disorder.
HEMAPOETIC
Upon inspection, there is no bruises or
hematoma noted to his body and dont
have any history of bleeding disorder.
LYMPHATIC
Hair
He has dry black hair, evenly distributed, scalp
is intact and no scaling.
Uses only shampoo if available.
Nails
His nails are observably untrimmed and dirty
but firmly attached to the nail bed.
Capillary refill is not less than 2-3 seconds.
His mother cuts his nails every two weeks or if
needs to be checked on school.
Head
Has symmetrically round head, upright and
erect, facial skin is intact and free from lesions.
Upon assessing range of motion, movement are
not limited and has no complains of head
Eyes
Eyes are symmetrical and canthus are
aligned from the tip of the ears, eyebrows
are evenly distributed, eyelids are equal in
size, and covers approximately both the
eyeballs and symmetry in blinking,
eyelashes are curled up.
Bony orbits are round and no lesions and
are symmetrical, eyeballs are equal in
size, non-tender and firm, both sclera are
clear and moist, iris are equal in shape
with brown color without vascularity.
He can read letters 2-3 ft far from him.
Ears
Ears have the same colour with the rest of
the body, no lesions, uniform in shape and
in line with the canthus of the eyes.
Auricles are firm, smooth, non-tender, and
pinna recoils after folded, no presence of
swollen lymph nodes, swelling and pain
upon palpation.
In external auditory canal, there is a
presence of dirt outside the pinna. his
mother cleanse his ears only when
necessary, itchy or at least once in two
weeks..
Nose
The color is same as the face, mucosa lining is smooth,
intact, deep-pink and non-deviated septum.
During palpation, nose is non-tender, no discharges and
dont experience runny nose.
No nasal flaring observed and has patent airway.
Mouth
Lips is intact, smooth and free from lesions, oink in color and
slightly moist, no cracks, swelling, and cyanosis.
Teeth are incomplete (deciduous) and debris or decay are
present in both right and left molar teeth with moist, pink,
intact and no lesion in the mucosa and gums.
Tongue has normal size, pink, moist and intact.
Oral brushing is done only when necessary or needs to be
checked in school.
Neck
Neck is brown in color, no lesions and
masses and lymph nodes palpated.
Has full range of motion and is
proportional to his head and shoulder.
Trachea is in midline and complains no
pain upon assessment.
RESPIRATORY
Has the respiratory rate of 24 breathes per
minute.
Chest symmetrically expand and do not
use accessory muscle upon breathing.
Upon auscultation, normal lung sound is
CARDIOVASCULAR
He is observably not cyanotic which
is an evidence of good blood
circulation.
No jugular distention is observed and
normal pulsations are noted.
He has a cardiac rate of 73 beats per
minute.
GASTROINTESTINAL
Abdomen is round and protruding with no
lesions, scars and rash.
Bowel sounds are normal, umbilicus is
inverted and at the midline with no bluish
discoloration.
No bulges, tenderness and pain upon
palpation.
Usual bowel movement is every other day
with no complains of abnormalities felt
and with brownish, formed stool.
GENITO URINARY
He voids 6-7 times in a day and no pain
felt upon urination.
MUSCULOSKELETAL
Body is well aligned, where extremities are
symmetrical in length, head is in midline
and gait is normal.
No spinal deformities and involuntary
movement is observed.
NEUROLOGIC
Behaviour is normal and facial expressions
are voluntarily.
He is alert, oriented and playful.
Cranial nerves are all intact and active.
ENDOCRINE
He claimed that she dont have any
history of endocrine disorder.
HEMAPOETIC
Upon inspection, there is no bruises or
hematoma noted to his body and dont
have any history of bleeding disorder.
LYMPHATIC
No swollen lymph nodes palpated.
INTEGUMENT
Skin
Has a dark brown skin color with warm
temperature
. No any other complaints aside from
observable skin lesions such as bites,
scars, and abrasion.
Has good skin turgor and has no tattoes
observed.
Takes a bath everyday and uses only soap.
Head
Has proportional size of the head to his body with
erect and still position, has good range of motion
and facial muscles are voluntary.
Has no complain regarding with the head except
from the usual/common headaches which are
tolerable.
Eyes
Eyes are both aligned, symmetrically blink, lashes
are curled up and show no abnormal findings
upon assessment, eyeballs are equal, non-tender
and firm.
Nose and Sinuses
Nose is smooth and intact with patent airways
and non-deviated septum, no discharges
observed and no nasal flaring.
Has no complains of pain and clogged in area of
Mouth
Has pink and moist lips with deep-pink
mucosa, tongue is voluntarily moved and
moist.
Has incomplete deciduous teeth and
decay in his both left and right molar
teeth.
Oral cleaning is done only if necessary or
if dental checked is to be done at school.
Neck
Has the same skin tone with the rest of
the body, trachea is in midline, and no
masses, lesions, and distentions palpated.
RESPIRATORY
He breaths 27 breaths per minute without the use
of accessory muscles and breathes in her chest
symmetrically.
Breathe normally without any other significant
sounds heard.
CARDIOVASCULAR
Pulsated 80 beats per minute without distention,
bruit, or hum.
GASTROINTESTINAL
Abdomen is round, big and protruding with
umbilicus in the midline and no signs of
discoloration.
Abdomen is non-tender, no masses and lesions
palpated.
Bowel movement is done every other with light
GENITO URINARY
Voids 5-7 times a day without pain felt, but
refuse for GU assessment.
MUSCULOSKELETAL
Has no spinal deformities with still and
erect posture.
Head is in the midline and has no history
of severe falls and musculoskeletal
problem, extremities are symmetrically
and non-edematous.
NEUROLOGIC
Respond actively to questions and
cooperate well.
Shows awareness of whats happening
during the entire visits.
Hair
Observed dry and brownish hair with
intact and no scaling scalp, found no
pediculosis.
Nails
Has untrimmed dirty nails with pinkish
color and no clubbing is observed.
Has good capillary refill and her mother
cuts and cleans nails seldom, usually done
once in two weeks.
Head
Head is symmetrically erect and still at
midline, full range of motion and
appropriate for developmental stage and
Eyes
Eyes are symmetrically aligned,
conjunctiva are pink, sclera and cornea
appears smooth, clear and moist, iris is
uniform in brownish color and in size,
pupils constrict and react to light.
Bony orbits are firm, non-tender and have
equal size, eyebrows are even and curled
up, both eyelids cover the eyeball,
symmetrically blink, no swelling and
tenderness palpated.
Ears
Ears are symmetrically aligned to the
outer cantus of the eye, auricles have
uniform shape and color without lesions
and masses. Ears recoil upon folding and
with whitish dry ear discharge. M.C.J.V.
reacts in sounds heard, evidence of good
hearing, the mother claims that she cleans
her childs ears for only twice-thrice a
month or if cotton balls is available.
Nose
Nose is in the midline and has same color
with the skin, both nares are patent upon
thorough assessment and had nondeviated septum.
Has clear watery discharge on first visit no
more other signs of significant deviations.
Mouth
Has a proportional lips in relation to the
head with pink, smooth, and slightly moist
lips.
Tongue is voluntary movable and
deciduous teeth are not yet complete.
She has not been brought to dental clinics
Neck
Proportional to the head and body, but has
skin rashes mocule.
No masses and distention palpated.
RESPIRATORY
Starting to breath using chest
symmetrically with respiratory rate of 34
breathes per minute.
No abnormal sound heard upon
auscultation, and observed no difficulty of
breathing.
CARDIOVASCULAR
Pulsated cardiac rate of 93 beats per
minute without any distentions, bruits, and
GASTROINTESTINAL
Has a round, symmetric but protruding
abdomen without skin lesions, masses and
tenderness, skin is intact and shows no claimed
abdominal pain.
Bowel movement is regular every morning with
loose bright stool.
GENITO URINARY
Is been using 2-3 diapers and voids for about 79 times a day, and observed light pink rash
(macules) in the genital area.
MUSCULOSKELETAL
Shows no deformities and able to move body
freely with her head still and erect in the
midline, extremities and voluntarily movable
NEUROLOGIC
Respond to sounds and playfully
communicate with others.
ENDOCRINE
She claimed that she dont have any
history of endocrine disorder.
HEMAPOETIC
Upon inspection, there are no bruises or
hematoma noted to her body and dont
have any history of bleeding disorder.
LYMPHATIC
No swollen lymph nodes palpated
2. NUTRITIONAL-METABOLIC PATTERN
3. ELIMINATION PATTERN
The
4. ACTIVITY-EXERCISE PATTERN
5. SLEEP-REST PATTERN
The mother wakes up at 4:00 in the
morning. She starts cook their breakfast
then when the other family members woke
up they will eat their breakfast together.
Exactly 6:00 in the morning the 3 sons and
the father are ready to leave the home. At
11:00 A.M. the mother finished cooking
their lunch and waits for the three sons to
come home. They eat dinner at 6:00 in the
evening. Usually they go to sleep at
exactly 8:00 P.M.
7. SELF-PERCEPTION, SELF-CONCEPT
PATTERN
8. ROLE-RELATIONSHIP PATTERN
Roles of each member
Mrs. G.V, the mother does all household
chores such as cleaning the house,
cooking, and doing the laundry. Most of
the time Mr. E. V is not at home because of
his occupation as construction worker but
then, he is responsible for marketing and
buying their foods. The eldest son is
responsible in taking good care of his
younger siblings, while the other children
dont have any responsibility in the family.
9. SEXUAL-REPRODUCTIVE PATTERN
B. Habits and
Practice on Health
Maintenance
and Disease
Promotion
Prevention
Adequacy of Rest/Sleep
Actual Hours of Sleep of the Family
Family
Members
Bedtime
Arise
Rest
Total
hours of
Sleep
Father
8:00 P.M.
4:00 A.M.
8 hrs
Mother
8:00 P.M.
4:00 A.M.
1-4 P.M.
8hrs
Children
8:00 P.M.
4:00 A.M.
11-4 P.M.
8hrs
16-18 hours
8-10 hours
Adolescent (13-18)
6-8 hours
Adult (45-70)
4-6 hours
Prenatal Care
The mother had regular prenatal care in
BHU for all her pregnancies.
Postnatal Care
Her postnatal care was rendered in
BHU.
Dental Health
Both parents and the youngest child did
not undergone dental check-up. The three
sons have undergone dental check-up
because of government program
implemented in school.
CHAPTER
III:
Computing and
Justifying Scores of
Health Problems
Criteria
1. Nature of the Condition or Problem Presented
Wellness State
Health Deficit
Health Threat
Foreseeable Crisis
2. Modifiability of the Condition or Problem
Easily Modifiable
Partially Modifiable
Not Modifiable
3. Preventive Potential
High
Moderate
Low
4. Salience
Scale:
A condition or problem, needing immediate attention
A condition or problem, not needing immediate attention
Not perceive as a problem or condition needing change.
Weight
3
3
2
1
2
1
0
3
2
1
1
2
1
0
Malnutrition
Criteria
Nature of the
problem
Health Deficit
Modifiability of the
problem
Easily Modifiable
Preventive potential
High
Salience of the
problem
Not a problem
Computation
Actual score
3/3x1
2/2x2
3/3x1
0/2x1
Total Score:
Justification
It is a health deficit that
requires immediate
management to eliminate
any untoward
consequences.
The problem is easily
modifiable if further
teaching will be provided
to the mother.
Susceptibility to other
diseases can be prevent if
malnutrition is eliminated.
Walking barefooted
Criteria
Nature of the
problem
Health Threat
Modifiability of the
problem
Easily Modifiable
Preventive potential
High
Salience of the
problem
Not a problem
Computation
2/3x1
2/2x2
Actual score
Justification
.67
3/3x1
0/2x1
TOTAL SCORE: 3. 67
Modifiability of the
problem
Easily modifiable
Preventive potential
High
Computation
Actual score
2/3x1
.67
2/2x2
3/3x1a
0/2x1
TOTAL SCORE: 3. 67
Justification
It is a health threat. The
family will easily acquire
disease.
The problem is easily
modifiable because the
family resources are
available and interventions
are feasible.
Occurrence of
communicable diseases can
be reduced or minimize if
cleaning the surroundings
is implemented at all times.
Modifiability of the
problem
Easily Modifiable
Preventive potential
High
Computation
2/3x1
Actual score
.67
2/2x2
3/3x1
0/2x1
Justification
It is a health threat because it is
conducive to breeding and
habitation of vectors of diseases.
(eg mosquitos)
It is easily modifiable, the
resources and intervention
needed to solve the problem are
available to the family.
The possibility of acquiring
disease can be prevented if the
family ensure a proper drainage
system.
It is not felt as problem. The
family is not concern about their
drainage system as long as they
have a place to pour out their
used water, it is alright to them.
Fire Hazards
Criteria
Nature of the problem
Health Threat
Modifiability of the
problem
Easily Modifiable
Preventive potential
High
Salience of the problem
Not a problem
Computation
Actual score
2/3x1
.67
2/2x2
3/3x1
0/2x1
Justification
It is a health threat because
it can lead to death of
family members.
It is easily modifiable
through relocation of their
cooking area from their
house.
Preventive potential
High
Salience of the
problem
Not a problem
2/3x1
Actual score
.67
2/2x2
3/3x1
0/2x1
Justification
It is a health threat because
it can lead to accidents
such as falling and cuts.
The problem is easily
modifiable, intervention
can be attainable through
filling the gaps on bamboo
floor, hammer the nails,
and secure stairs.
Accidents can be reduced
or minimize if hazards are
eliminated.
It is not felt as a problem
because the father is
always on his work and the
mother focus on the house
hold chores.
Smoking (father)
Criteria
Nature of the problem
Health Threat
Modifiability of the
problem
Easily Modifiable
Preventive potential
High
Computation
Actual score
2/3x1
.67
2/2x2
3/3x1
0/2x1
Justification
It is a health threat because
severe smoking can lead to
lung cancer and other
disease.
Through proper health
teachings to the father,
educating the father about
the risk of smoking and the
strategy to eliminate the
habits.
Occurrence of respiratory
disease can be prevented if
smoking habits is lessen
and eliminated.
Because the didnt want to
be warn and still insist of
smoking.
Modifiability of the
problem
Partially Modifiable
Preventive potential
High
Computation
Actual score
2/3x1
.67
1/2x2
3/3x1
1/2x1
.5
Justification
It is a health threat because the
family is risk of other
complications from suppressing
the urge to defecate.
It is partially modifiable. The
family easily dug a pit for their
defecation but had hard time to
find tarps to serve as wall.
Susceptibility to other
complications if there will be
toileting facilities for their
regular bowel movement.
The problem does not need
immediate attention. The family
planned to have proper toileting
facilities but failed to
implement it.
Ineffective breastfeeding
Criteria
Nature of the problem
Health deficit
Modifiability of the
problem
Partially Modifiable
Preventive potential
High
Computation
3/3x1
1/2x2
3/3x1
0/2x1
Actual score
1
Total Score : 3
Justification
It is health deficit because of
inability to initiate proper breast
feeding causing the breast to have
unequal size.
It is partially modifiable though the
mother dont have enough
knowledge regarding the problem,
she can continue and initiate breast
feeding in the smaller breast.
Rashes
Criteria
Nature of the
problem
Health Deficit
Modifiability of the
problem
Partially Modifiable
Preventive potential
High
Salience of the
problem
Not a problem
Computation
3/3x1
1/2x2
3/3x1
0/2x1
Actual score
Justification
1
0
Total Score: 3
Identified
Problems
Malnutrition
Walking Barefooted
Improper Waste
Disposal
Improper Drainage
System
Fire Hazard
Fall Hazard
Smoking (father)
Lack of toileting
Facility
Ineffective
Score
4
3.67
3.67
3.67
3.67
3.67
3.67
3.17
3
CHAPTER
FAMILY
IV:
NURSING
CARE PLAN
Goal of care
After 3 weeks of nursing intervention the
family will be able to:
Improve their nutritional status.
Know the importance of nutritious food
and have a balance diet.
Nursing Intervention:
Discuss the importance of nutritious foods
and proper way of preparing nutritious
foods.
Discuss how to attain balance diet.
Discuss the possible complications of the
signs and symptoms of malnutrition.
Evaluation:
Goals met. The family will be able to
prepare food properly.
Methods of Family-Nurse Contact:
Home Visit
Resources Required
Time and effort of both family and nursing
students.
Expenses for the transportation of the
nursing students.
Goal of care
After 3 weeks of nursing intervention the
family will be able to:
Recognize the benefits of wearing slippers.
Wear slippers at all times.
Nursing Interventions
Discuss briefly the benefits of wearing
slippers and disadvantages of not wearing
the slippers.
Provide clean footwear.
Evaluation:
Goals met. The family is able to identify
the importance of wearing slippers and
correctly perform wearing of slippers
provided to them.
Goal of care
After 3 weeks of nursing intervention the
family will be able to:
Maintain the cleanliness of their
surroundings.
Have adequate knowledge about the risk
of developing diseases brought by dirty
surroundings.
Nursing Intervention:
Discuss the pros and cons of dirty
surroundings.
Demonstrate the proper way of cleaning
the surroundings.
Evaluation:
Goals met. The family is able to identify
factors that can affect the health off family
members if poor environmental sanitation
is not eliminated.
Methods of Family-Nurse Contact:
Home Visit
Resources Required
Time and effort of both family and nursing
students to clean the environment.
Barangays pail, broom and shovel.
Money of nursing students for
transportation
Goal of Care:
Nursing Intervention:
Discuss the proper drainage system.
Help the family to enhance their drainage
system by digging deep.
Teach the family about maintaining of
good drainage system once a week they
should dig.
Educate the family about the benefits of
drainage system.
Evaluation:
Goals met: The family absorbed the
teachings and following the
recommendation of the nursing students
about the maintenance of drainage
system.
Method of Nurse-Family Contact
Home Visit
Resources Required
Time and effort of nursing students and
family members.
Shovel of the Barangay
Broom and dust pans
Goal of Care:
After 3 weeks of intervention the family
will be able to:
Relocate their cooking area to a safe
place.
Educate the family to relocate their
cooking area.
Discuss safety precautions.
Nursing Intervention
Discuss the risks of cooking area near/
under the house.
Educate the family to relocate their
cooking area.
Evaluation:
Goals unmet: The father is stubborn and
didnt want to be told. He still insists to
smoke because he doesnt feel any
complications in his body.
Method of Family Contact
Home Visit
Resources Required
Time and effort of the nursing student and
family members.
Expenses for the student nurse.
Goal of care
After 3 weeks of nursing intervention the
family will be able to:
Recognize the presence of hazard
Enumerate ways how to eliminate the
hazard.
Have sufficient resources to eliminate
hazards specifically falling.
Nursing Intervention
Discuss to the family the possible effects
of the problems and enumerate ways on
how to eliminate it.
Provide resources such as bamboo, nails,
tarpaulin and box.
Evaluation:
Goals met. The family learned how to
construct and modify needed facilities to
eliminate health threat.
Resources Required
Time and effort of both the family and
nursing students.
Financial assistance for the nursing
students expenses for materials needed
and transportation.
Nursing Intervention
Discuss the risk and diseases brought by
smoking.
Teach the father how to lessen the
smoking.
Advise the father to engage in activities
that will make him stop to smoke.
Discuss to the father the effects of his
smoking habits to the children.
Evaluation:
Goals unmet. The father is stubborn and
didnt want to be told. He still insist to
smoke because he doesnt feel any
Goal of care:
After three weeks of nursing intervention,
the family will be able to:
know the importance and advantages of
having toileting facilities.
Build and improvise toilet
Nursing Intervention:
Help the family dig a pit and build the
foundation of the toilet
Discuss the importance of having good
toileting facilities
Provide information about the
maintenance of toiletry
Evaluation
Goals met. The family is able to build and
maintain toilet facility.
Goal of Care:
After 3 weeks of nursing intervention, the
mother will be able to:
Have a knowledge about the benefits of
breastfeeding.
Demonstrate the proper breastfeeding
technique.
Nursing Intervention:
Explain the benefits of breastfeeding , the
mechanisms include in lactation, the
proper breast care and most especially the
proper breastfeeding position.
Discuss the importance of adequate
nutrition during lactation.
Assist the breastfeeding process as
needed.
Evaluation
Goal was met: The mother understands
the importance and benefits of
breastfeeding and unable to demonstrate
proper breastfeeding technique.
Method of Family-Nurse Contact
Home Visit
Resources Required
The time and effort of both the mother,
their daughter and the nursing students.
Money of the nursing students for
transportation.
Goal of Care:
After 3 weeks of nursing intervention, the
family will be able to:
Recognize the importance of good
hygiene.
Enumerate ways to reduce the spread of
rashes..
Nursing Intervention:
Instructed the family to wash the rashes
with antibacterial soap.
Teach the family how to perform proper
hygiene to reduce the spread of
Evaluation
Goals partially met. The rashes was
reduced and the family is able to take care
of each members.
Resources Required
Time and effort of both the family and
nursing students.
Material resource: Antibacterial soap.
CHAPTER V:
GENERAL HEALTH
TEACHING
CHAPTER VI:
CONCLUSION
RECOMMENDATION
Family
Mr.
pictures