family case study
TRANSCRIPT
Family Case Study
Group-3 Subgroup 2 October 16,2009
San Pedro College
Kevin Van Eric O. Saballo St.NPamela Fel P. Suriba. St. N
Princess Andrea Obdulia Taojo, St. N.Kenu D. Ragonton, St. N.
Carla Mae C. Pascua, St. N.
Introduction
Community Health nursing is Specialized field of nursing which focuses on the promotion and maintenance of client’s optimum level of functioning through teaching and delivery of care wherein individual, family population and the community is the recipients of nursing care. The family, as the unit of interacting persons related by ties of marriage, birth and or adoption, serves as the buffer between the needs of the individual and the demands and expectations of the society. As we continue with our study about family, allow us to rule our mind regarding the significance of community health as nurses in assessing the needs of the community.
We, student nurses of San Pedro College, will be able to act as the extension of the community health nurses and act as an advocate of the community. We know that health is determined by various variables such as, physical, psycho-social, socio-economic, and other determinants. Understanding the multidimensional nature of health will enable us to address the client –family holistically and enables us to plan the course of intervention and implement it together with the family.
According to the United Nations Population Funds(UNFPA), the number of mothers dying provide glimpse of wide disparity between rich and poor as there are almost 5,000 percent more women dying in developing countries than in more
advanced economies. The lifetime risk of dying from pregnancy and childbirth causes is also very remote in
developed regions, with only one out of 7,300 women is at risk against 75 women per 7,300 in less developed regions. In
the Philippines, around 4600 women die every year and an average of 11 die per day due to pregnancy and childbirth complications as UN estimates. The Autonomous Region in Muslim Mindanao (ARMM) and other regions need more midwives, if the ideal ratio of midwife to the number of
deliveries per year is achieved, there will be lesser possibilities that a woman will die because of the complication and more
newborn could be saved.
In Davao City, City Health Office (CHO) data shows that 37 out of 100,000 mothers die in the city each day due to various reasons. Primary of these are the lack of pre-natal care and necessary vitamin supplementations during pregnancy. Majority of maternal deaths, they say, occur in rural areas as they have lesser access to health service or they rely solely on unskilled “hilot”.We choose the Auxillo Family to be the subject of this Family Case Study because we highly believe on the family’s willingness to learn and make changes for their own welfare. When we first enter the premises of their home, we felt their openness and cooperative attitude. As student nurses, we aim to gain new and validate our knowledge that we learned from
the four corners of the room and enhance our skills.
Objectives
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General Within 4 weeks span of immersion at Garcia Heights, Bajada,D.C. Dated September 17
to October 17, 2009, we will do our best as student nurses to deliver and promote health care to the community. Our general objective is to understand and know the health condition of the community and help improve its conditions through the use of our knowledge utilizing resources available for the community to benefit not only certain individuals but the whole society. Helping improve the community is one of the ways to deliver health promotion to the society. Understanding the community and sharing health teachings to the society can help elevate the condition of our society. Rendering health services to certain individuals influences the neighbourhood. Observing proper waste disposal make the community aware of the health condition of their environment. We would also like to find out how the family utilizes the resources available to cope up with the presence of health problems in the community.
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Specific Familiarize the rotation;
Look for patient as the center of our study;
Have the knowledge about present health condition of the community;
Conduct data base on a certain family;
Assess the health status of the community especially the family;
Utilize resources available for the wellness of the society;
Enumerate interventions that the family can apply to improve their way of living;
Increase knowledge that can help us in dealing with the community;
Exercise the skills we learned in our practice of community health nursing;
Know the factors that contribute to the health maintenance of the community;
Render health teachings that can help family improve health status;
Provide idea on what appropriate state of health is a must to maintain a healthy lifestyle;
Educate the family on ways that they can practice to improve and maintain health
Set an example that the family can follow to improve home environment; and
Be a model and serve as an inspiration to the community and as well as on the family of having a healthy practice of activities of daily living.
Initial Data Base
Demographic Data 184, Diamond st., Mineral village, Garcia Heights, Davao City
Family Data The family have been living at Garcia Heights for about 6
months. Davao City is their place of origin. They are three in the family with their religion as Independent Baptist.
Head of the FamilyName: Auxillo, Bonifacio
Age: 28
Position in the family: Father
Relationship to the head of the family: Head
Educational Attainment: College Graduate, BS in Marine Transportation
Occupation: Company Driver
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The FamilyName: Mabayo, MelizaAge: 27Position in the family: Wife/MotherRelationship to the Head: Live-in Partner Educational Attainment: High School Graduate
Name: Auxillo, Kate IzabelAge: 2Position in the family: EldestRelationship to the Head: Daughter
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Family Structure and Dynamics
The family is a common law family; Bonifacio and Meliza are living with each other as a couple without the benefit of a legal marriage. They have a one biological daughter.
Status Additional Information
Observable conflict between family members
noneWhen the family encounters a problem either major or minor problem, they immediately solve it by means of sincere conversation with each other. They make it a point that the condition of the problem doesn’t get worst.
Characteristic of communication
FormalWhen the family talk with each other, they use a Visayan language. They call each other by their nicknames. They also speak with a calm and soft voice. Most importantly, they avoid shouting to another person.
Interaction pattern between family members
Open to each other
The family have respect for each member. Kate, specifically, respects her parents and obeys most of the things her parents say. The couple respects and acknowledges the feelings, needs, and suggestions of each family member.
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Health Status of the Family
Weekly Dietary RecallDay 1 Day 2 Day 3 Day 4 Day 5
BreakfastFried egg, dried fish, and rice.
White loaf bread, hotdog, fried egg, and coffee
Tocino, hotdog, and rice
Fried egg, pandesal, and coffee
Chorizo and rice
LunchSinigang na baboy and
rice
Tinolang manok and rice
Pork adobo and rice
Pinakbet and rice
Nilagang baka and rice
DinnerPinakbet and rice
Inihaw na isda, rice, and banana
Tinolang isda and rice
Sinabawang gulay and rice
Ginisang kangkong and rice
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Day 6 Day 7
BreakfastDaing na bangus, rice, and coffee
Fried egg, pandesal, and
coffee
LunchChicken Adobo
and ricePork adobo and
rice
DinnerAdobo na Batung
and rice Pinakbet and rice
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Health Status of the Family
Family Members
Weight Height BMI Interpretation
Auxillo, Bonifacio
78kg 175.26m 25.3 Normal
Mabayo, Meliza
57.2kg 157.48m 23.2 -
Auxillo, Kate 11kg 84.5m 15.4 -
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Mr. Bonifacio Auxillo is still considered to have a normal Body Mass Index since the normal range for BMI is 20-25 and he has a BMI of 25.3 which still close to 25.
According to the General guidelines for Filipino children’s weights, the average weight of female 2 year olds is 12 kg or 26.5 pounds, the lower limit is 10.23 kg, and the upper limit is 13.64 kg. Since Kate is at 11kg, she is still in the normal weight for Filipino children.
Weight Gain Throughout Pregnancy
Pre-pregnancy
BMICategory Expected increase
in wt.
<19.8 Underweight More than 1 lb / week
<19.8-26.0 Normal 1 lb / week
>26.0-29.0 Overweight 0.66 lbs / week
Data from Susan G. Dudek(2001). Nutrition Essentials for Nursing Practice 4th ed. Lippincott Williams & Wilkins. Philadelphia, p. 283
Computations
Weight in 11 wks = 55.5 kg ; 16 wks = 57.2 kg
Total Weight Gain in 5 wks = 57.2kg – 55.5kg
= 1.7 kgs
in pounds = 1.7kg X 2.2 lbs/kg
= 3.74 lbs
Weight Gain per Week = 3.74lbs / 5 wks
= 0.748 lbs / week
Interpretation: 0.67lbs – 1lb is the average wt. gain
Ms. Meliza Mabayo has a Normal wt. gain
b.) Sleeping PatternThe regular retiring time of the family is 8:00 or 9:00 pm. They retire by
9:00pm for the reason that the father goes home by 8:00 pm from work. Both the father and the mother wake up at around 5:00 am because the father needs to prepare for work and the mother prepares the meal for their breakfast but most of the time retiring and getting up is dependent on the whims of the individual. Even though they have two bedrooms with one bed each room, the family sleeps together in one bed.
During the day, Kate sleeps by 10:00 am then wakes up by 1:00 pm. Subsequently, the mother sleeps 15 minutes after Kate started to sleep at around 10:15 am - 10:30 am then she wakes up by 12:15 to prepare their meal for their lunch.
The total hours of sleep of the father is 8 hours. For the mother, her total hours of sleep is at about 9 hours and 30 minutes. For Kate, her total hours of sleep is approximately 11 hours.
V. Health historyImmunization Status of the Family
Legend:
C – Complete
Family Member’s
Name
BCG DPT OPV Hep B MMR
Auxillo, Bonifacio
C C C C C
Mabayo, Meliza
C C C C C
Auxillo, Kate Izabel
C C C C C
Mrs. Meliza Mabayo is 4 months pregnant. She goes once a month for her prenatal check up in the Garcia Heights Health Center District B. Their daughter Kate was delivered normal.
For Meliza Mabayo:
Tetanus Toxoid Date
TT1 06/27/06
TT2 07/25/06
TT3 09/05/09
TT4 9/29/09
TT5 none
They have completed all the immunizations for BCG, DPT, OPV, Hepa B, and MMR. The mother has taken TT1 to TT4 but has no TT5.
VI. Values and Practices on Health Promotion
Health History of Illnesses 2 months ago
Family Member List of Illnesses Over the Counter Drug
Auxillo, Bonifacio Fever Paracetamol
Mabayo, Meliza Urinary Tract InfectionAntibiotic
Auxillo, Kate Urinary Tract Infection Amoxiclav
Mrs. Meliza Mabayo told us that 2 months ago she had Urinary Tract infection and she took an antibiotic. Her husband also had flu and had taken Paracetamol. Kate also had Urinary tract infection at the same date and took amoxiclav. No hereditary diseases such as diabetes mellitus and hypertension.
For health problems, the family act depending on the situation. As shown in the table, for manageable problems, they depend on over the counter drugs such as Paracetamol for Fever. For serious problems they refer to a physician either from the Health Center in Garcia Heights or from any hospital.
The family have adequate sleep everyday considering that the family sleep for 8 hours or more daily. The mother does household chores as an alternative for exercise. If the family has enough time to be with each other, they go to People’s Park and other amusement places for fun and bonding purposes. While in the People’s, they do brisk walking for about 15 minutes or more in exploring the place. They also watch movies when they have enough time as form of relaxation and bonding. In heir house, they mostly watch television and lie on the hammock for relaxation.
SOCIOECONOMIC CHARACTERISTIC
Members of Family with
income
Educational Attainment
Occupation Nature of Work Place of Work Monthly Income (Php.)
Auxillo, Bonifacio.
CG, BSMT Gasoline Tank driver
My Gas Company in
Bajada, Davao City
6,000
The total family income is Php 6,000. Meliza was a cook in a small restaurant in Tagum but she stopped working since she was pregnant with Kate. Another reason why she resigned was that there were conflicts in the restaurant between the co-workers and her.
In the family, Bonifacio Auxillo works for their family and he is the only source of the family’s income. Mr. Auxillo is a graduate of Bachelor Science in Marine Transportation at AGRO. Despite his educational attainment, he failed to acquire a job as seaman. Instead, he is currently working as a gasoline truck driver for My Gas Company in Bajada, Davao City.
According to the mother, the income of the father is just enough for their daily needs. Sometimes, there would be an excess in their budget allowance. The excess money is used to buy things such as clothes and sometimes used for outdoor activities like going to People’s Park.
VIII. HOME AND ENVIRONMENT
The type of the house is strong made with cement, wood, and other hard materials. It is owned by the mother of Mr. Bonifacio Auxillo. In relation to this, their lot is surrounded by cemented wall. Their house is a compound type in which there are 3 houses in one lot. Beside the house that the Auxillo family is living, the other 2 houses are rented by other families. It is composed of a 2 bedrooms, a living room, a dining room, and a comfort room. In each bedroom, there is one bed and an electric fan. There is also one cabinet for their clean clothes. They also have a basket for their used and soiled clothes. Their appliances inside the house are radio, television, DVD player, and electric fans. All the family members sleep only at the same bedroom.
BEDROOM
BEDROOM
COMFORT ROOMDINING ROOM
LIVING ROOM
8.33 m
9.64 m
a. Total Floor Area (TFA)
8.33 m X 9.64 m = sq m
Multipurpose room Single purpose room
Adult 3.0 sq.m 2.5 sq.m
Child 1.5 sq.m 1.26 sq.m
Infant 0 sq.m 0 sq.m
b. Total Space Requirement (TSR)
2 adults (single purpose room) X 2.5 sq.m. = 5 sq.m.
1 child (single purpose room) X 1.26 sq.m = 1.26 sq.m.
Total SR = 6.26 sq.m
c. Comparison of TFA vs. TSR
Conditions: TFA>TSR: Not overcrowdedTFA<TSR: Overcrowded80.32 sq.m > 6.26 sq.m : Not overcrowded
The total floor area (TFA) of the house is 80.32 sq m., and the total space requirement (TSR) of the family is 6.26 sq. m. The TFA is greater than TSR, therefore the house is not overcrowded.
d. Ventilation
There are a total of 21 windows; 18 windows with the same size and 3 windows half the size of the former.
Window opening (WO) = 0.59 X 1.3m = 0.767 sq.m
0.767 sq.m X 18 (number of windows) + 0.3835 X 3(number of small windows) = 14.96 sq.m
1.sq.m /80.32 sq.m X 100 = 18.625% : Fair ventilation
Scale:20% above – satisfactory18 – 19% - FairBelow 18% - Poor
The house is considered as having fair ventilation since the total window opening over total floor area for ventilation is 18.625% which is within the scale of 18-19% for fair ventilation.
e. Light Facility
The electricity is being supplied by Davao Light Power Company, which is a legal connection.
f. Drinking Supply
They have faucet type of water supply. The water is being supplied by Davao City Water District (DCWD), the water is treated therefore it is potable.
There are faucets inside the house, they store water in pails with cover and pail
dipper inside.
g. Kitchen
They use a “kalan” with the use of charcoal for heat as a means of cooking
food. The kitchen is generally clean when observed plainly but there are cockroaches
and some rats inside the house.
h. Drainage Facility
They have a blind drainage. The pipes lead to the big canal beside the
sidewalk.
i. Waste Disposal
They give off their waste materials to a garbage bin for their area.
They separate the biodegradable waste for decomposing and other trash such as leaves are burned.
j. Toilet Facility
The family has the flush type of toilet. It is located inside the house.
The septic tank is located five meters away from the house.
k. General Sanitary Condition
The house is partially clean. There is no presence of dirt on the floor because the floor is swept and cleaned frequently. Despite this,
there are still some rats and cockroaches which are only seen rarely.
l. Description of the community
The neighbourhood is old; the road is not yet cemented. Their neighbours are approachable and
friendly. They have formal communication with each other. Beside their house, there is a cement factory in which the family finds the workers the factory as an
annoyance. The family view the workers as disrespectful because they steal “santol” from their tree and they
throw the peelings in their house.
IX. AWARENESS OF COMMUNITY ORGANIZATION
The family is not aware of any organizations present in the community. As what the mother said, they do not know any organizations because they are still living for 6 months there.
Family Coping Index
Physical Independence
ADMISSION
RATING JUSTIFICATION
3 All family members whether or not there is infirmity or disability in one or more members are receiving the necessary care without interruption or delay, Mrs. Mabayo is able to manage her time in taking care of her child and meeting the needs of her partner. On the other hand, Kate is still dependent on her mother but not totally because Kate is already a toddler and can do some things on her own like eating. The partner is somewhat dependent on her wife by means of preparation of foods and thing.
DISCHARGE
RATING JUSTIFICATION
3 Still, the family is interdependent with each other.
Therapeutic competence
ADMISSION
RATING JUSTIFICATION
3 Some of he family members are carrying out some but not all of the treatments since the mother is not taking all the vitamins given to her and sometimes her partner is not taking medicines if having flu or fever.
DISCHARGE
RATING JUSTIFICATION
5 The family is able to demonstrate that they can carry out the prescribed procedures safely and efficiently after some health teachings rendered with the understanding of the principles involved and confidence and willingness.
Knowledge and health condition
ADMISSION
RATING JUSTIFICATION
1 Some of the family members are totally misinformed about the condition, like the mother who had just discovered that she is positive for proteinuria.
DISCHARGE
RATING JUSTIFICATION
3 The family has some general knowledge of the disease or condition but has not grasped the underlying principles and is only partially informed because she still has to visit the physician.
Application of principles of general hygiene
ADMISSION
RATING JUSTIFICATION
3 Failing some general principles of hygiene like the utensils that are not covered and since there are cockroaches noted it may contaminate the utensils. They seldom eat fruits and their habits of sleep and rest are adequate to needs.
DISCHARGE
RATING JUSTIFICATION
5 All family members accept to carry out preventive measure.
Health attitudes
ADMISSION
RATING JUSTIFICATION
5 Accept, understand and recognizes need for medical care in illness and for the usual preventive services.
DISCHARGE
RATING JUSTIFICATION
5 Still, the family accepts, understands and recognizes need for medical care in illness and for the usual preventive services.
Emotional competence
ADMISSION
RATING JUSTIFICATION
3 Both the mother and father are able to meet the usual stresses and problems of life and plan for happy and fruitful living however, one member (Kate) lacks security or maturity.
DISCHARGE
RATING JUSTIFICATION
3 Still, Kate lacks security because sometimes her mother is busy enough doing the household chores to keep an eye for Kate since Kate is still a toddler; her lack of immaturity is still present.
Family Living
ADMISSION
RATING JUSTIFICATION
5 Each member get along with each other, shows respect and affection. However, the child sometimes got temper tantrums which is considered normal for toddlers.
DISCHARGE
RATING JUSTIFICATION
5 Still, they show respect and affection for each other.
Physical Environment
ADMISSION
RATING DISCHARGE
3 The house needs some repair and paintings. There are some areas in the house which indicates the presence of fire and fall hazards. The neighbors are possibly to affect family’s health because of improper waste disposal, poor drainage which causes air and water pollution.
DISCHARGE
RATING DISCHARGE
3 Up to now, the family didn’t take actions on the presence of hazards in their house as well as the neighborhood who continuously causing wastes.
Use of community Facilities
ADMISSION
RATING JUSTIFICATION
3 The family knows about or uses some but not all of the available community resources that they need. The mother utilizes the health center for her pre-natal check-ups.
DISCHARGE
RATING JUSTIFICATION
3 Still, the family utilizes the health center for check-ups.
Family Eco Map
Health Center
Legend:Mother: Always:Father: Seldom:Daughter: Often:
Genogram
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Hypertension
Died when she gave birth to her youngest daughter due to bleeding
(+) traces of protein in the urine and UTI
Urinary tract Infection
Jose Mabayo
Jose Mabayo
Conchita Tiana
Mabayo
Conchita Tiana
Mabayo
Bonifacio Auxillo
Bonifacio Auxillo
Teresita Dayanan Mabayo
Teresita Dayanan Mabayo
Juvilyn MabayoJuvilyn
MabayoGenevieve
Reyes
g
Genevieve
Reyes
g
Meliza MabayoMeliza
MabayoAlexis
MabayoAlexis
MabayoJaime AuxilloJaime Auxillo
Marilou Sumunod
Marilou Sumunod
Melende Mendez
Melende Mendez
Bonifacio Auxillo Jr JJr.
Bonifacio Auxillo Jr JJr.
Theresa AuxilloTheresa Auxillo
Kate Mabayo Auxillo
Kate Mabayo Auxillo
Prenatal Assessment
Our client Meliza Mabayo is a 27 yrs. old housewife from Tagum City, was born on October 17, 1982. Pregnant for about 4 months and has a living child named Kate Izabel Auxillo, 2 yrs. old and a live-in partner named Bonifacio Auxillo, 28 yrs. old, a tanker driver of “my gas” gasoline station. The type of family they have is a common law family. They live at 184 Diamond Street, Mineral Village Garcia Heights, Davao City for about 6 months. They go to church as a whole as Independent Baptists. Noted to be non-hypertensive, non-diabetic and non-asthmatic. Has no family and past history of hypertension, diabetes and asthma.
VITAL SIGNSOn October 10, 2009 at 8:30 in the
morning, we conducted our physical assessment. Her vital signs were as follows: PR=82 regular beats/minute, RR=77 breathes/minute, BP=100/70 mmHg taken while sitting on the chair, CR=84 regular cycles/minute and T=36.5°C.
Meliza Mabayo is 157.48 cm in height and 57.2 kg in weight. Meliza Mabayo is a mesomorph with body built fairly developed and physical features that are appropriate in her age. She is well nourished and calm emotionally.
SKINOur client’s skin color indicated no
abnormalities. Her natural complexion which is fair, was observed during the assessment. Has a fair smooth warm skin. No lesions noted. Varicosities noted on both calf of lower extremities.
HEADHer head configuration is
normal. She has symmetrical facial movements and closed fontanels. Her hair is evenly distributed with no signs of hair loss. Her scalp is clean—free from any parasites, dandruff and wounds.
EYESNo tenderness and swelling was palpated on her
symmetrical eyelids. Her periorbital region has no apparent discoloration and palpable swellings. She has pinkish palpebral conjunctiva and glossy transparent bulbar conjunctiva. Her sclera is yellowish and her cornea and lenses are clearly observed with no arcus senilis and lesions. Both pupils are equal in size, and their reaction to light is brisk. Our client is able to read printed materials given to her and is not using eyeglasses. She has intact peripheral vision.
EARSHer external pinnae are symmetrical and no signs of tenderness
were palpated. No impacted cerumen is present in her external canal when a penlight was shone inside the ears. The patient was able to hear the whispered word and the tick of the watch elicited by the examiner on both ears, thus, her gross hearing is symmetrical.
NOSEHer nares are not exaggeratedly flaring. Her left and right nasolabial
folds are shallow. Her septum is found at the midline and her mucosa is reddish. Lesions are absent on the external and internal nares. She was asked to smell a cotton ball soaked in an alcohol solution, and she was able to determine what it was. Her gross smell is symmetrical. There were no signs of tenderness on her frontal and maxillary sinuses.
MOUTHNo dryness of lips was observed and lesions were absent. She has
pinkish oral mucosa and her tongue is at the midline. Her 1st, 2nd and 3rd left lower molar, 2nd right lower molar, 1st right and left upper premolar are noted to have dental cavities with missing tooth at the 1st right lower molar. Her gums were pinkish and her speech is intact.
PHARYNXNo dryness of lips was observed and lesions were absent. She has
pinkish oral mucosa and her tongue is at the midline. Her 1st, 2nd and 3rd left lower molar, 2nd right lower molar, 1st right and left upper premolar are noted to have dental cavities with missing tooth at the 1st right lower molar. Her gums were pinkish and her speech is intact.
TRACHEAHer trachea is at the midline and her cervical lymph nodes are not
tangible and palpable. The thyroids are normal as they rise back and forth whenever she swallows or drinks water. Able to freely move her neck to the left and right and vice versa. She can also extend and hyperextend them. There are no masses and enlargement seen on her neck.
LUNGSMeliza’s breathing pattern is regular. Her maximum respiratory rate is 77 bpm which was taken as vital sign. She has an anterior-posterior-lateral ratio of 2:1. Her lung expansion is symmetrical on both left and right thorax. Her vocal tactile fremitus is also symmetrical; Vibrations decreased as the examiner’s hands reach the lower thorax. Vibrations were best heard over the lungs. Normal breath sounds are auscultated during the examination. The vesicular sound is heard at the periphery of the patient’s lungs, bronchial sound is heard at the anterior part of her trachea and the broncho-vesicular sound is heard lateral to the her sternum. Crackles, wheezes and friction rubs were not noted.
BREAST
The breasts of our client Meliza are equal in size and symmetrical in shape. Striae not noted and tenderness or swellings were not palpated.
ABDOMEN
Inspection of the abdomen, there were no striae gravidarum and linea nigra noted. Upon palpation, we feel the fundus 1inch below the umbilicus.
EXTREMITIESHer peripheral pulses are strong but irregular.
There are no inflammation and clubbing on her nails. A Capillary Refill Test was done and blood returned within two seconds. Her muscle strength in both extremities is equally strong with symmetrical sizes. No edema on lower extremities noted. Romberg Test was performed and the patient showed off a coordinated gait. She was able to walk from one corner to another independently.
PRENATAL ASSESSMENT
Name: Meliza Mabayo
Age: 27 yrs. old
Last menstrual period: June 3, 2009
Estimated Date of confinement: March 10, 2010
Age of gestation: 15 weeks and 3 days
Height: 157.48 cm
Weight: 57.2 kg
Childhood Diseases: measles, chickenpox, UTI
GPAGravida-2Para-1Abortion-0
TPALTerm-1Preterm-0Abortion-0Labor-1
Immunization StatusTT1 As early as possible 06/27/06
TT2 4 weeks later 07/25/06
TT3 6 months later 09/05/09
TT4 1 year later 09/29/09
TT5
History of past pregnancy: NSVD (normal spontaneous vaginal delivery)
Blood type: type O
Prenatal visit: once a month
Where do you intend to give birth?
According to our client, she intends to give birth at the hospital.
Neurological system
Subjective: “Dili man naga-sakit akong ulo ug dili pud naga-hanap akong panan-aw. Murag normal lang gud akong paminaw.”
Cardiovascular system
Edema on ankle and fingers are not present. Varicose veins noted at the right and left lower extremities. Having a heart rate of 82 beats/min. and blood pressure of 100/70 mmHg. Fetal heart rate not recognize.
Respiratory system
Subjective: “naga-lisud ko ug ginhawa pag busog kayo ko.”
No presence of cough and colds.
Gastrointestinal system
Subjective: “naga-suka ko pero ginagmay lang man pero taga-buntag jud mag-suka ko tapos feel nako loud jud kaau e-kaon.”
Nausea, vomiting, poor appetite and dental problems is present.
Renal system
Subjective: “sige ko ihi bah pero gamay lang pajud kaayo. Naa man pud gud ko UTI dati pah pero naa ko gina-inum tambal kung mag-sakit.”
Protein in the urine is present during the test for urine by the use of the biosticks.
Endocrine system
Subjective: “wala man mi history sa diabetes.”
Goiter not present.
Reproductive system
Subjective: “dili man naga-sakit akong kinatawo, wala pud ko naga-bleed tapos dili pud naga-sakit akong tiyan.”
Bloody discharges, breast tenderness, breast infection and quickening not present.
Skin
As we inspect her skin, there is no presence of linea nigra, striae gravidarum and some skin irritations.
Skeletal system
Subjective: “matumba ko pag motindug, murag walay kusog labi na pag gikan molingkod.”
Leg cramps is present. No verbalize joint pains and bone deformities not noted.
Nutritional statusFood sources:
1.rice/pasta group-always
2.vegetable group-rarely
3.fruit group-rarely
4.meat-sometimes
5.fish-sometimes6.eggs-sometimes7.milk-never8.fats, oils-always9.sweets-never
Is/are there members in the family that smokes?
Yes. The father.
Post partum
As verbalize by the mother, she planned to feed her baby through breastfeeding and willing to submit her child for immunization.
Family planning
After delivery, she is willing to practice family planning through the use of pills because according to her it is expensive to have another child.
Prioritization of the Problem
Pre-eclampsiaKevin Van Eric O. Saballo St.N
CRITERIA SCORE COMPUTATION
ACTUAL SCORE JUSTIFICATION
1.Nature of the problem
2.Modifiability of the condition
3.Preventive potential
4.Salience
3
2
3
1
3/3x1
2/2x2
3/3x1
1/2x1
1
2
1
1/2
The problem is a health deficit and requires more immediate intervention.
The resources and interventions needed to solve the problem are available to the family.
The possibility and complications during labor and delivery and occurrence of abnormalities in the infant are prevented if preeclampsia is eliminated as early as possible.
The family recognizes it as a problem yet does not see the problem as needing immediate attention.
TOTAL SCORE 4 1/2
Presence of CockroachKenu D. Ragonton, St. N.
CRITERIA SCORE COMPUTATION
ACTUAL SCORE JUSTIFICATION
1.Nature of the problem
2. Modifiability of the problem
3. Preventive potential
4. Salience
2
2
3
0
2/3x1
2/2x1
3/3x1
0/2x1
2/3
2
1
0
The problem is a health threat.
The problem is easily modifiable since it only requires family resources to eliminate the problem.
The problem may be prevented by availing a location outside their house, still inside their area that is free from fire hazard.
The family does not perceive the condition as a problem.
TOTAL SCORE 3 2/3
Presence of mosquitoesPamela Fel P. Suriba St.N
CRITERIA SCORE COMPUTATION
ACTUAL SCORE
JUSTIFICATION
1.Nature of the problem
2.Modifiability of the condition
3.Preventive potential
4.Salience
2
1
3
2
2/3x1
1/2x2
3/3x1
2/2x1
2/3
1
1
1
It is a health threat.
It is a partially modifiable since there is a breeding site outside their house which is the canal and the water in the canal comes from the sack factory. The problem needs financial resources.
The problem is easily prevented by using mosquito nets and mosquito killers.
The family perceived it as a problem and does interventions.
TOTAL SCORE 3 2/3
Fall HazardPrincess Andrea Obdulia Taojo, St. N.
CRITERIA SCORE COMPUTATION
ACTUAL SCORE
JUSTIFICATION
1.Nature of the problem
2.Modifiability of the condition
3.Preventive potential
4.Salience
2
2
3
0
2/3x1
2/2x2
3/3x1
0/2x1
2/3
2
1
0
It is a health threat that requires immediate attention and adequate management since the child fell in the chair.
The problem is easily modifiable since the child just requires proper guidance from the care giver and resources and interventions needed to solve the problem are available to the family.
The problem can easily be prevented through the nurse and client effort.
The family do not perceived as a problem or condition needing change.
TOTAL SCORE 3 2/3
Fire hazardCarla Mae C. Pascua, St. N.
CRITERIA SCORE COMPUTATION
ACTUAL SCORE
JUSTIFICATION
1.Nature of the problem
2. Modifiability of the problem
3. Preventive potential
4. Salience
2
2
3
0
2/3x1
2/2x1
3/3x1
0/2x1
2/3
2
1
0
The problem is a health threat.
The problem is easily modifiable since it only requires family resources to eliminate the problem.
The problem may be prevented by availing a location outside their house, still inside their area that is free from fire hazard.
The family does not perceive the condition as a problem.
TOTAL SCORE 3 2/3
Family Nursing Care Plan
Possible Pre-eclamsiaKevin Van Eric O. Saballo
CuesSubjective:
“ngano diay kung naay protein ang ihi?” as verbalize by Ms. Meliza Mabayo
Objective:
October 2, 2009 October 9,2009
BP: 100/60 mmHg(+1) protein in urine (-) pedal edema
BP: 100/70 mmHg(+1) protein in urine (-) pedal edema
Family Nursing Problems Possible pre-eclamsia
Nursing Diagnosis Inability of Recognize the possible complication in pregnancy
due to lack of knowledge
Goal After nursing intervention, the family will appreciate the severity
of possible pre-eclamsia and take necessary measures to prevent.
Objectives After nursing intervention the family will:
Identify signs and symptoms of Pre-eclampsia that is present on her
Enumerate at least two possible complications associated with pre-eclamsia
ensure that Ms. Meliza Mabayo will have a prenatal check-up on the nearest prenatal day on the health center
Intervention PlanNursing Intervention Method Of Nurse-Family
ContactResources
1. Broaden the knowledge of the family on pre-eclamsia specifically:
a. Discus the signs and symptoms that is presented by the client
b. Discus possible consequence of failure to address the problem
2. Refer the mother to the physician for more accurate diagnosis of the clients condition
Home Visit Urine VialBioStics
Money for Transportation of the nurseTime and Effort of the nurse
EvaluationOctober 9, 2009
11:00 A.M
GOAL MET
The family was able to:
Identify that edema and Hypertension is not present but proteinuria is present
Verbalize two complications associated with pre-eclamsia specifically: cerebral palsy, preterm delivery.
Agree to go to the health center on October 13,2009 for checkup
Presence of CockroachKenu D. Ragonton, St. N.
Cues
Subjective: “Naa man ko makit-an na ipispanag
sa kusina naga kamang-kamang”
Objective:
- presence of cockroach in the kitchen(rare appearance)
- no cover for the kitchen utensils- retained plastic bags for garbage (1 plastic bag full of trash and the other one is half full)
- pieces of rice on the floor
Health Problems
Poor Home Environmental Sanitation:
Presence of resting sites of vectors of
diseases specifically cockroaches
Family Nursing Problems
Inability to provide a home
environment conducive to health maintenance and personal development due to Lack of knowledge of
preventive measures
Goal of Care
After 2 days of nursing intervention,
the family will be able to
fully understand the different
concepts involved in having
cockroaches
Objectives of Care
After 2 days of nursing intervention
the family will be able to:
a.) verbalize at least 4 adverse effects of
having cockroaches inside the house.
b) identify at least 3 preventive measures
for the deterrence of contamination
brought about by cockroaches
c) itemize at least 3 causes of having
breeding sites for cockroaches.
Nursing Intervention
1. Discuss with the family the complications of having vectors of diseases specifically for cockroaches.
2. Conduct a short orientation with the family about how to manage the occurrence of cockroaches:
a.) cleaning their house as often as possible especially when there are noticeable dirt and food on the floor; this is because dirt and food attracts the cockroaches.
b.) thoroughly assess any hidden portion of the house for anything like bottles and old materials especially in moist areas because cockroaches live mostly on moist areas.
c) provide a cover for the container of utensils; this is to prevent the cockroaches from contaminating them
d) immerse the utensils in boiling water to eliminate microorganisms.
e) immediately cover unfinished food and leftovers to prevent cockroaches from contaminating them.
Method of Nurse-Family Contact
HOME VISIT
Resources Required Human resources:
-Time and effort of the nurse and family members.
-Financial resources: money for the nurse transportation.
EVALUATION
October8,2009
“GOAL MET”
After 2 days of nursing intervention
the family was able to:
a) state 5 negative effects of having
cockroaches inside the house.
b) name 3 preventive measures for preventing contamination brought about by cockroaches.
c) enumerate 3 causes of having
breeding sites for cockroaches.
-Kenu D. Ragonton, St. N
Presence of mosquitoesPamela Fel P. Suriba St.N
DATE: October 2, 2009
CUES:
Subjective
“daghan kaayo lamok diri-a labi na sa kwarto tungod siguro na sa canal sa labas tapos ang silingan naga-pundo pud ug tubig sa tub sa ilang labas”
Objective
>canal outside the house
>stocked water outside the house
>no window screen
>front and back door always open
Family Nursing ProblemPoor home/environmental
condition/sanitation:
presence of breeding or resting sites of vectors of diseases specifically mosquitoes.
Nursing DiagnosisInability to make decisions with
respect to taking appropriate health action due to lack of knowledge as to alternative courses of action open to them.
Goalsafter 2 days of nursing intervention the family will be able to decide
on the appropriate action to prevent the diseases and maintain a healthy family.
ObjectivesAfter nursing intervention, the family will be able to:
a.) explain the consequences of having mosquitoes;
b.) select a method most appropriate for the problem;
c.) show some actions that can minimize the capability of the mosquitoes to enter their house.
Nursing Interventions
1. Discuss to the family the possible risk factors that will result to the occurrence of the problem that will lead to certain complications.
2. Analyze with the family the advantages and disadvantages of each alternative/method to encourage better decision making on the best option given the families situated possibilities.
3. Provide information on how a mosquito can affect an individual.
4. Emphasize to the family the importance of solving the problem.
5. Discuss to the family the importance of using equipment such as mosquito nets.
Nurse & client interaction
HOME VISIT
ResourcesHuman resources:
-Time and effort of the nurse and family members.
-Financial resources: money for the nurse transportation.
EvaluationAfter nursing interventions:
GOAL PARTIALLY MET
The family was able to:
-recognize the possible risk factor;
-select method appropriate for the problem such as using of “katol”
-show some actions that can minimize the capability of the mosquitoes to enter their house but not all actions done because they were not able to use mosquito nets during sleeping time ate night.
Fall HazardPrincess Andrea Obdulia Taojo, St. N.
CUES
Subjective:
“mahilig jud ni siya mag katkat-katkat, nahulog gani ni siya dinhi sa bangko last week”, as verbalized by the mother.
“naglaba man gud si mama tong nahulog ko”, as verbalized by the child.
Date: October 2, 2009
Objective:
-52 cm from the seat to the floor-70 cm from the arm of the chair to the floor- child is sitting in the arm chair- child jumping in the chair-contusions in the child’s left forehead noted- chairs are not connected- slippery floor
FAMILY NURSING PROBLEM:
Accident hazard specifically fall hazard
NURSING DIAGNOSIS :
Inability to recognize the presence of the condition or problem due to inadequate knowledge on the identified problem.
GOAL:
At the end of nursing interventions, the family will be able to identify the risk factors on the actual condition and make plans to modify the chair and to prevent any accidents.
OBJECTIVES:
After nursing interventions, the family will be able to:
a.) Recognize the possible risk factors with regards to the condition identified;
b.) Enumerate various ways on maintaining safety and to prevent fall hazards;
c.) Select course of action to correct and solve problem such as proper guidance of the child;
d.) Make plans to choose appropriate ways and materials necessary to prevent the toddler from sitting on the arm chair, jumping and playing on the chair;
e.) Identify positive outcomes upon planning the solution to the problem such as to avoid accidents.
NURSING INTERVENTIONS:
a.) Discuss with the family the possible risk factor that will result with the occurrence of the problem such as fall accidents that will lead to complications.
b.) Emphasize to the family the importance of solving the problem and on maintaining an environment which is safety.
c.) Provide suggestion about solving the problem and preventive measure such as:
- Proper guidance on the child
-put “harang” on the chair-give toys to divert attention
-put mat on the floor so that the child will play there instead on the chair
METHOD OF NURSE-FAMILY CONACT:
HOME VISIT
RESOURCES
Human resources:
Time and effort by the student nurse and client.Patience of the mother in taking care of the child
EVALUATION
After nursing interventions
GOAL PARTIALLY MET
The family was able to:
- recognize possible risk factors;
- enumerate ways on how to maintain a safety environment;
- Select course of action to correct problems but not all are included because they wasn’t able to put “harang” on the chair and put mat on the floor because according to the mother “hasol na man gud mag hipos-hipos uy”.
Fire HazardsCarla Mae C. Pascua St.N
oDATE: October 2, 2009
oCUES:Subjective:
“Sa kusina lng ko naga luto gamit ang kalan. Barato raman gud ang uling “.
Objective:-uses charcoal and “KALAN-for cooking.-cooking site is in the kitchen-“KALAN”is placed above a wooden table.
oFamily Nsg. Problem:Presence of fire hazard
oNursing Diagnosis:Inability to recognize the presence of fire hazards due to
their limited knowledge on fire prevention and combustion process.
o Goal:
After nursing intervention, the family’s site of cooking place will be in a location free from any forms of fire hazard.
o Objectives:
After nursing intervention, the family will be able to:
a. distinguish the possible threats with regards to the condition predicted.
b. identify the preventive measures on fire hazard.
c. specify different ways on retaining safety in the house.
d. transfer Cooking site to an appropriate and safe place for cooking.
o NURSING INTERVENTIONS:
Emphasize the risk factors with regards to the condition predicted.
Discuss with the family the possible implications of having a right place for cooking.
Propose ideas on how to solve the problem such as to transport cooking site outside their house but still inside there area as long as free from fire hazard.
o NURSE-CLIENT INTERACTION:
- Home Visit
o RESOURCES:
- Human resources:
Both the time of the family and the Nurse.
- Financial Resources:
Transportation’s expenses of the Nurse.
o EVALUATION:
After nursing interventions:
GOAL PARTIALLY MET
The family was:
Able to distinguish the possible threats with regards to the condition predicted.
Able to identify the preventive measures on fire hazard.
Able to specify different ways on retaining safety in the house.
Was not able to transfer cooking site to an appropriate and safe place for cooking.
Mother verbalized:“Ginaban-tayan man nako akong niluto.”