Post on 24-Feb-2018
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I. INTRODUCTION
A. Overview
Community health nursing is important, aside from being a specialized field of
nursing practice. Community health nursing is one of the two major fields of nursing in
the Philippines; the other is in the hospital. Community nursing practice means different
things to different nurses, that is, for many, it emphasize the setting of practice; which in
other term, it is a nursing practice outside the hospital.
Community health nurse has different clients and these include the individual,
family, population group and community itself. Family as one of the client the very
important social institution that performs two major functionsreproduction and
socialization. t is generally considered as the basic unit of care in the community health
nursing for many reasons. t may contribute !nowingly or un!nowingly to the
development of health and nursing problems of its members. t also performs health
promoting, health maintaining and disease"preventing activities. n many cases, it is the
family that provides unfailing nursing care particularly to the chronically"ill members.
#mong the many family, it serves of prime importance is the role of the family
plays in providing emotional support and security to its members through love,
acceptance, concern and nurturing. $his affective component holds families together,
gives family members a sense of belonging, and develops a sense of !inship. $his is
accomplished by meeting the basic needs of its members% food, clothing, shelter and
provision of physically safe environment re&uire s!ills, !nowledge and economic
resources. n nursing profession, nurses consider the health of the family as a unit in
addition to the health of the individual family members.
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B. OBJECTIVES of the STUDY
$his care study provides goals or objectives which serve as an instrument in
comprehensively assessing the patient's health status and present condition. t also
focuses on the following aims%
(now the disease process)ow the environment affects such problem that a family is e*periencingPromote healthmpart !nowledge about health and wellness+mpower the family to ma*imize their abilities to achieve an optimum well being.
$he interaction with the family has helped students to appreciate the essence of
community health nursing. $hey played a special part for students to become an
effective health care provider.
C. SCOPE and LIITATION of the STUDY
n our community e*posure at -one , /ai!ingon, Cagayan de ro City,
the students chose among those households of which they have assessed needs to be
prioritized for care. )ome visits and family interactions were initiated to identify nursing
problems of the family.
$his study analyzes the interplay of the different factors that affect the family's
health status. )owever, the study is limited depending on the information being
disclosed by the family members and other sources and based on the objective aspects
as the family is being observed and monitored. $hrough constant interaction, the factors
that affect the family health were identified and appropriate interventions were done
utilizing the nursing process.
D. SI!N"ICANCE of the STUDY
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$he family care study was intended to provide information regarding the health
hazards, health deficits and health threats the family encountered. $hrough this study,
!nowledge and information about maintenance that is being imparted to them may be
able to ma*imized and prevent elements that would threaten their health.
E. SPOT AP
$he $aclindo family resides in -one , /ai!ingon, Cagayan de ro City. t is
appro*imately 0 !ilometers away from 1iceo de Cagayan 2niversity. t can either be
reached by ta!ing a private vehicle or by commuting3ta!ing a /ai!ingon route jeepney
at jeepney"stop located at Cogon and it cost 45php per person. t will ta!e about 65
minutes ride before reaching /ai!ingon if our point of reference is from 1iceo de
Cagayan 2niversity. f we are going to commute from the school going to 1egaspi's
7esidence, we are going to ride a hired"P28 going to /ai!ingon which cost 95php
student fare bac! and forth. $he road in going to /ai!ingon is moderately roc!y and
sometimes it's muddy and slippery during rainy season, but upon reaching the -ones in
/ai!ingon, it is already cemented. 2pon reaching zone , at the right end corner of the
road, you can see the house of :ana family, you will see at the corner a billiard table
and many people usually stays in there.
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II. #EALT# #ISTORYA. "AILY PRO"ILE
e$%er &
Na$e' r. 7onnel $aclindo
Ro(e' )usband
A)e'04 years old
Birthda*'9??
Addre++'/ai!ingon, Cagayan de ro City
#ei)ht'='4 inches
Ed,-ationa( Attain$ent'@econd year level, /@ Criminology
Re(i)ion'7oman CatholicO--,ation' >, >9?9
Addre++' -one , /ai!ingon, Cagayan de ro City
#ei)ht'= ft
0ei)ht'=9.6!g
Ed,-ationa( Attain$ent'Bocational, Culinary
Re(i)ion'7oman CatholicO--,ation'none
"ood and Dr,) A((er)ie+' Ao !nown and drug allergies
e$%er 1
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Na$e'#dela :ana
Ro(e' other of #deline :ana
A)e'4= years old
Birthda*'#pril >=, >9
Addre++' -one , /ai!ingon, Cagayan de ro City
Ed,-ationa( Attain$ent'
Re(i)ion'7oman Catholic
O--,ation')ousewife
In-o$e'none
"ood and Dr,) A((er)ie+' Ao !nown and drug allergies
e$%er 2
Na$e'#imee :ana
Ro(e' @ister"in"law of r. $aclindo
A)e'>= years old
Birthdate'#pril 00, >99
Addre++'-one , /ai!ingon, Cagayan de ro City
Ed,-ationa( Attain$ent'4thyear level
Re(i)ion'7oman Catholic
O--,ation'none
In-o$e'none
"ood and Dr,) A((er)ie+' Ao !nown and drug allergies
e$%er 3
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Na$e' rish :ana
Ro(e' @ister"in"law of r. $aclindo
A)e'>6 years old
Birthdate'#pril 00, >999
Addre++'-one , /ai!ingon, Cagayan de ro City
Ed,-ationa( Attain$ent'0nd year level
Re(i)ion'7oman Catholic
O--,ation'none
In-o$e'none
"ood and Dr,) A((er)ie+' Ao !nown and drug allergies
e$%er 4
Na$e'#udric! #hron $aclindo
Ro(e' son
A)e'> year old
Birthdate' Aovember 0, 05>>
Addre++'-one , /ai!ingon, Cagayan de ro City
Ed,-ationa( Attain$ent'A3#
Re(i)ion'7oman Catholic
O--,ation'A3#
In-o$e'A3#
"ood and Dr,) A((er)ie+' Ao !nown and drug allergies
B. "AILY #EALT# #ISTORY
Na$e' r. Ta-(indo5 R.
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n our first visit, we were not able to assess r. $aclindo since he was at wor! then.
/ut upon interviewing s. #deline :ana, she said that his husband is a cigarette smo!er
and an alcoholic drin!er. )e had no !nown illness bac! then aside from fever, cough
and colds. Dhenever he does not feel well, he medicates himself with /ioflu, Aeozep
and #la*an. Ao maternal and paternal history of hereditary disease.
Na$e' +. Yana5 Ade(ine
s. #deline claimed that she did not ac&uire any major illnesses aside from
minor symptoms such as headache, cough, fever and colds but was managed with
home medications bac! then. @he has heredofamilial disease of hypertension. @he had
a normal delivery in her >stchild and now she is months pregnant.
Na$e' r+. Ade(a Yana
on our interview, we were not able to assess rs. #ccording to s. #deline, her
mother delivered all of them through A@B< with no complications. @he has a
heredofamilial disease of hypertension and she only does self medication whenever she
does not feel well.
Na$e' +. Ai$ee Yana
s. #imee completed her immunizations at the /arangay )ealth Center and she
haven't ac&uired any major illness aside from headaches, colds and fever. @he had her
chic!en po* when she was ? years old.
Na$e' +. Iri+h Yana
s. rish also completed her immunization at the /arangay Center. @he had
never e*perienced any major illness and whenever she's not feeling well, she would just
ta!e $C medicines given by her mother. @he had her menarche when she was 9
years old.
Na$e' A,dri-6 Ahron Ta-(indo
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Completed his immunization at the /arangay )ealth Center and he had not
incurred any major illness. 2pon our interview, he has colds and cough and it has been
already 6 wee!s.
C. PRESENT #EALT# STATUS
IUNI7ATION
S-hed,(e Ta-(indo5 A,dri-6 Ahron
BC!
#eB&
#eB/
#eB1
DPT&
DPT/
DPT1
OPV&
OPV/
OPV1
ea+(e+
First level of assessment has been performed on the 4 members of the family during the 6
home visitations which cover the period starting Aovember 0"0 and 0. De
only met the wife because the husband has wor! and the other family members are at school.
$he only one left is the pregnant woman and her son who is still sleeping.
st
baby was still = months old.
Dith regards to their family planning, they are not using any family planning. #ll members
of the family have no !nown drug and food allergies.
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Dith regards to the !ind of food they eat, they seldom eat meat, their viand, if there's any,
was mostly canned goods, noodles and vegetables.
stassessment, the following data were gathered%
Na$e Te$era
t,re
P,(+e Re+irator*
rate
B(ood
Pre++,re
0ei)ht
#deline :ana 6.0 EC ?0bpm 05 cpm 9535 mm)g =9.6!g
#udric! #hron $aclindo 6.4 EC 9?bpm 0=cpm Ao bp cuff
available
9 !g
III. DEVELOPENTAL DATA
7obert )avighurst believes that learning is basic to life and that people continue
to learn throughout life. )e describes growth and development as occurring during si*
stages, each associated with from si* to ten tas!s to be learned.
)avighurst promoted the concepts of developmental tas!s in the >9=5s. #
developmental tas! is a tas! that arises at or about a certain period in the life of an
individual, successful achievement of which leads to his happiness and to success with
later tas!s, while failure leads to unhappiness in the individual, disapproval by society,
and difficulty with the later tas!s.
#ccording to )avighurst, in the infancy and early childhood, the developmental
tas!s of this level are% learning to wal!, learning to ta!e solid foods, learning to tal!,
learning to control the elimination of body wastes, learning se* differences and se*ual
modesty, achieving psychologic stability, forming simple concepts of social and physical
reality, learning to relate emotionally to parents, siblings and other people, and learning
to distinguish right from wrong and developing a conscience.
#ccording to +ric!son, the developmental tas! for infant is trust versus mistrust Gother
terms might be learning confidence or learning to loveH. nfants whose needs are met
and realized their discomforts are &uic!ly removed. nfants, who are cuddled, fondled,
played with and tal!ed to come to view the world as a safe place and people as helpful
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and dependable. )owever, when the care is inconsistent, inade&uate, and rejecting, it
fosters basic mistrust. nfants become fearful and suspicious of the world and of people.
$hey will carry this attitude through later stages of development. @uch children will be
Istuc!J emotionally at this stage even though they continue to grow and develop in other
ways.
Fortunately, because not all children achieved developmental tas! readily, each
tas! need not be resolved once and for all the first time it arises. $he problem of trust
versus mistrust, for e*ample, is not resolved forever during the first year of life, but
arises again at each successive stage of development. Children who enter school with a
sense of mistrust may come to trust a teacher who ta!es the trouble to ma!e him or her
trustworthy. Kiven this second chance, children who come through infancy with a vital
sense of trust intact may still have a sense of mistrust activated at a later stage if their
parents are divorced or separated under unpleasant circumstances.
+ric!son envisions life as a se&uence of levels of achievement. +ach stage
signals a tas! that must be achieved. $he resolution of the tas! can be complete, partial,
or unsuccessful. +ric!son believes that the greater the tas! achievement, the healthier
the personality of the person, failure to achieve a tas! influence the persons ability to
achieve the ne*t tas!. $hese developmental tas!s can be viewed as a series of crises,
and successful resolution of these crises is supportive to the person's ego. Failure to
resolve the crises is damaging to the ego. #fter attaining one stage, the person may fall
bac! and need to approach it again. #s nurses, we should be aware that environment is
highly influential in development. De can enhance people as well as infant's
development by being aware of their development stage, by providing opportunities. For
the individual to resolve his or her developmental tas!, and by helping the person
develop coping s!ills relative to stresses e*perienced at a certain level of growth and
development particularly, the infant stage
Krowing up is a comple* phenomenon because of the many interrelated facets involved.
People do not merely grow taller and heavier as they get older, maturing also involves
growth in their ability to perform s!ills, to thin!, to relate to people, and to trust or have
confidence in them.
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Krowth is generally used to denote an increase in physical size or a &uantitative change
while development is used to indicate an increase in s!ill or the ability to function and to
denote a &ualitative change. aturation is another word for development.
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:oung adulthood is the time when people are most capable of forming new concepts
and shifting their thin!ing in order to solve problems. stborn and in ta!ing care also of the baby
inside her womb.
:oh(%er)8+ Theor* of ora( Deve(o$ent
7onnel $aclindo and #deline :ana are now in the post"conventional level of moral
development. #t this time, the person is able to separate self from the e*pectations and rules of
others and to define morality in terms of personal principles. Dhen individuals perceive a
conflict with society's rules or laws, they judge according to their own principles. Domen often
define moral problems in terms of obligation to care and to avoid hurt.
#avi)h,r+t8+ Theor* of Deve(o$ent
$he couple who are young adults, have already selected each other, which is one of the
important developments of this stage in life. $hey are learning to live with each other, start their
own family, and rear their children properly. $hey manage their home, as parents of their
children.
IV. DESCRIPTION O" #OE AND ENVIRONENT
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"ACTORS DESCRIPTION SI!NI"ICANCE
T*e of ho,+e ade of bamboo and wood
with cement foundation
Can be a source of accident
hazards
So,r-e of e(e-tri-it* +lectrical Connection t gives them light at night
and power connection toother appliances such as $B
and 7adio
Di+tan-e of +o,r-e of
water
Common source of water is
from Icommon faucetJ
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V. "AILY COPIN! INDE
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$he purpose of the family coping inde* is to provide basis for estimating the
nursing needs of a particular family. t also helps nursing students to organize and plan
nursing care with precision so that care given is tailored to fit the particular family
situation.
1egend%
>" Ao competence6" oderate competence=" Complete competence
AREA @C#1+ 82@$FC#$APh*+i-a( Indeenden-e 6 #lthough the family can
ta!e care of themselves,
not all family members are
physically fit.Therae,ti- Co$eten-e 6 $he family was able to ta!e
specific maintenance
medications but not at all
times and they do not !now
how to properly prepare
herbal medicines:now(ed)e of hea(th
-ondition
= $he family !nows their
illnesses and ways on how
to minimize or prevent it in
any wayA(i-ation of rin-i(e+
of !enera( #*)iene
6 $here are times that the
family fails to apply general
principles in hygiene. $he
lac! of water supply causes
the family not to observe
hand hygiene all the time.#ea(th Attit,de+ = (nows the importance of
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having a good health. $he
family displays a full effort
to recognize need for
medical care.
E$otiona( Co$eten-e = $he family was able to deal
problems with courage. $he
family does not let poverty
become the reason for
them to give up."a$i(* Livin) = $hey have a good
relationship with each other.Ph*+i-a( Environ$ent 0 $he house is in poor
condition. $he family has
inade&uate living space.
Dindows are not screened
and foods are not properly
!ept and stored.U+e of Co$$,nit*
"a-i(itie+
4 $he family uses the
community facilities and
!nows appropriate person
to go to in terms of health
emergencies, but
sometimes they do not avail
some of the )ealth Centers
offer
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VI. SC#EATIC DIA!RA O" T#E "AILY #EALT# PROBLE
$he mother visits thehealth center as needed
for chec!"up and for
prenatal
2nsafe water source
for coo!ing
mproper waste
disposal
$he health center is
accessible about
>05 meters away
from their house.
Foreseeable crisis% $he income of the father
is not enough to provide the basic needs of
the family.
Financially unstable
@i* family members in the
family
$he mother
is a plain
housewife
and is
pregnant
r. $aclindo, has
resources on
providing the
needs of his
family but not in
all the members
of the house,
including
#deline's mother
and sister
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P):@C#1K+A+$C
BIOLO!ICAL
ENVIRONENTAL
Aoise
pollution2nsafe
water
source
Ao connection
of sin! into the
drainage
Ao proper
drainage
mproper
garbage
disposal
#ea(th Defi-it' Cough and fever
for 0 wee!s.
#ea(th Threat'mproper garbage
disposal, no drainage, presence
of breeding grounds of insects
and flies that may cause illness.
@usceptible for transmission of microorganisms
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VII. ANATOY AND P#YSIOLO!Y
UPPER RESPIRATORY TRACT
7espiration is defined in two ways. n common usage, respiration refers to the
act of breathing, or inhaling and e*haling. /iologically spea!ing, respiration strictly
means the upta!e of o*ygen by an organism, its use in the tissues, and the release of
carbon dio*ide. /y either definition, respiration has two main functions% to supply the
cells of the body with the o*ygen needed for metabolism and to remove carbon dio*ide
formed as a waste product from metabolism. $his lesson describes the components of
the upper respiratory tract.
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$he upper respiratory tract conducts air from outside the body to the
lower respiratory tract and helps protect the body from irritating
substances. $he upper respiratory tract consists of the following
structures%
$he nasal cavity, mouth, pharyn*, piglottis, laryn*, and upper trachea; the
oesophagus leads to the digestive tract. ne of the features of both the upper and lower
respiratory tracts is the mucociliary apparatus that protects the airways from irritating
substances, and is composed of the ciliated cells and mucus"producing glands in the
nasal epithelium. $he glands produce a layer of mucus that traps unwanted particles as
they are inhaled. $hese are swept toward the posterior pharyn*, from where they are
swallowed, spat out, sneezed, or blown out. #ir passes through each of the structures of
the upper respiratory tract on its way to the lower
respiratory tract. Dhen a person at rest inhales, air enters via the nose and mouth. $he
nasal cavity filters, warms, and humidifies air. $he pharyn* or throat is a tube li!e
structure that connects the bac! of the nasal cavity and mouth to the laryn*, a
passageway for air, and the esophagus, a passageway for food. $he pharyn* serves as
a common hallway for the respiratory and digestive tracts, allowing both air and food to
pass through before entering the appropriate passageways. $he pharyn* contains a
specialised flap"li!e structure called the epiglottis that lowers over the laryn* to prevent
the inhalation of food and li&uid into the lower respiratory tract. $he
laryn*, or voice bo*, is a uni&ue structure that contains the vocal cords, which are
essential for human speech. @mall and triangular in shape, the laryn* e*tends from the
epiglottis to the trachea.
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$he laryn* helps control movement of the epiglottis. n addition, the laryn* has
specialised muscular folds that close it off and also prevent food, foreign objects, and
secretions such as saliva from entering the lower respiratory tract.
LOWER RESPIRATORY TRACT
$he lower respiratory tract begins with the trachea, which is just
below the laryn*. $he trachea, or windpipe, is a hollow, fle*ible, but sturdy air tube that
contains C"shaped cartilage in its walls. $he inner portion of the trachea is called the
lumen.
$he first branching point of the respiratory tree occurs at the lower end of thetrachea, which divides into two larger airways of the lower respiratory tract called the
right bronchus and left bronchus. $he wall of each bronchus contains substantial
amounts of cartilage that help !eep the airway open. +ach bronchus enters a lung at a
site called the hilum. $he bronchi branch se&uentially into secondary bronchi and
tertiary bronchi.
$he tertiary bronchi branch into the bronchioles. $he bronchioles branch several
times until they arrive at the terminal bronchioles, each of which subse&uently branches
into two or more respiratory bronchioles.
$he respiratory bronchiole leads into alveolar ducts and alveoli. $he alveoli are
bubble"li!e, elastic, thin"walled structures that are responsible for the lungs' most vital
function% the e*change of o*ygen and carbon dio*ide.
+ach structure of the lower respiratory tract, beginning with the
trachea, divides into smaller branches. $his branching pattern occurs multiple times,
creating multiple branches. n this way, the lower respiratory tract
resembles an Iupside"downJ tree that begins with one trachea Itrun!J and ends with
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more than 0=5 million alveoli IleavesJ. /ecause of this resemblance, the
lower respiratory tract is often referred to as the respiratory tree.
IV.PATHOPHYSIOLOGY
Physical examination may
detect tachypnea and signs of
consolidation, such as crackleswith bronchial breath sounds.
Typical symptoms include
cough, fever, and sputumproduction
Irritation ofmultiplies
alveoli
Penetrate the sterile lower
respiratory tract (lungs)
oss e!ectiveness of
defense mechanism
"ctivation of defense
#rganisms enter the
respiratory tract
%treptococcus pneumoniae
Predisposing
factors
&ontributing factor
'acteria
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VIII. DRU! STUDY
!eneri- Na$e of ordered
dr,)
Paracetamol
Brand Na$e $empra
Date Ordered February >=, 0559
C(a++ifi-ation Aon"opioid analgesic;antipyretic
Do+e;"re=,en-*;Ro,te 6ml & 4h
e-hani+$ of A-tion Produces analgesic effect by bloc!ing pain impulses, by inhibiting
prostaglandins or pain receptors sensitizers; may relieve fever by acting
in hypothalamic heat regulating center
Se-ifi- Indi-ation For mild pain and fever
Contraindi-ation $o patient's going long"term therapy for chronic noncongestive angle"
closure glaucoma; hyponatremia; hypo!alemia; hepatic impairment;
adrenal gland failure' hypechloremic acidosis
Side Effe-t+;To9i- Effe-t+ Confusion; anore*ia; aplastic anemia; rash; renal calculi
N,r+in) Pre-a,tion 7eport signs of F3+ imbalance
Brand Na$e @albutamol
Date Ordered Aovember >9, 05>0
C(a++ifi-ation /ronchodilator
Do+e;"re=,en-*;Ro,te =ml , / URINARY AND !YNEL M pain L M urine L M color L M vaginal bleedingL M hematuria L M discharge L M nucturiaL M assess urine fre&uency, control, color, odor, comfortL M gyne bleeding L M discharge L*M no problemNENEURO'
L M paralysis L M stuporus L M unsteady L M seizureL M lethargic L M comatose L M vertigo L M treamorsL M confused L M vision L M gripL M assess motor, function, sensation, 1C, strengthL M grip, gait, coordination, speech L*M no problemUSCULOS:ELETAL and S:IN'L M appliance L M stiffness L M itching L M petechieL*M hot L M drainage L M prosthesis L M swellingL M lesion L M poor turgor L M cool L M flushedL M wound L * M pain L M ecchymosis L M diaphoretic moistL M assess mobility, motion gait, alignment, joint functionL M s!in color, te*ture, turgor, integrity L M no problem
graviduteru
s*
weeks
straie
back
pain
J.wala manJ, as
verbalized by the client
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$()ge"'ti%":
# % d)&pnea# % &m("ing 'i&(r)
# % c(g'
# % denied
e&p. # - % reglar # % irreglarDe&cribe: 4'e paien 'a& reglar re&pirai(n (f
20 cpm.
: &)mmerical lng e-pan&i(n
: &)mmerical lng e-pan&i(nCi&u*'ti%":
# % c'e& pain C(mmen&:
# % leg pain
# % nmbne&& (f
e-remiie - % denied
Hear ')'m # - % reglar # % irreglar
An"le dema :
l&e Car. ad. D em 82bpm
82bpm
C(mmen&: all pl&e& are palpable+f applicable
Nutiti%":
Die: Die a& (leraed# % 9 # % C(mmen&:
C'aracer# % recen c'ange in
;eig', appeie
# % &;all(;ing
difficl)# - % denied
# % denre& # - % n(ne
ll arial ;i' aien?- da)
# % rgenc) # % d)&ria
# % 'emaria
# % c(n&ipai(n # % inc(ninenceremed) n(ne # % p(l)ria
Dae (f a& @ # % f(le) in place
Dec. 25, 2012 #-% denied
# % diarr'ea c'aracer:n(ne
C(mmen&: @(;el (nd&:
9(rm(aci*e
Abd(minal Di&eni(n re&en # % )e& #- % n(
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# % ('er
# - % denied
# % m(i& # % c)an(ic
ra&'e&, lcer&, decbi& Bde&cribe &ie, l(cai(n,drainage
9( ('er alerai(n in &"in inegri)
ACTIVITY/ SA+ETY:
# % c(n*l&i(n C(mmen&:# % diine& %limied m(i(n
(f E(in&
imiai(n in
Abili) (
# % amblae# % ba'e &elf
# % ('er
#-% denied
# % FC and (rienai(n: aien i& (riened (per&(n, place, ime and dae.
Gai: # % ;al"er # % cane # % ('er
# % &ead) # % n&ead)# % &en&(r) and m((r l(&&e& in face
(r e-remiie& 9/A
# % F limiai(n&: aien can m(*e alle-remiie&
C$M+$RT/S,EEP/AWA-E:# - % pain C(mmen&:Bl(cai(n, freenc),
remedie&
# % n(cria# % &leep difficlie&
# % denied
# % facial grimace# % garding
# % ('er &ign& (f pain:
9/A# % &iderail relea&e f(rm &igned B60 )ear&
9/A
C$PING:
ember& (f H(&e'(ld: 5
(& pp(ri*e er&(n: '&band
Fb&er*ed n(n>*erbal be'a*i(r:
n(ne
Jdili man, maayo
man a!ong
panglawasJ, as
verbalized by the
client
Jsa!it ang a!o li!od
panagsa.J as
verbalized by client
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IV. NURSING SYSTEM REVIEW CHART
NAME: Adric" A'r(n 4aclind( DATE:December 27, 2012
V/S
HR:!8 bpm BP: n( bp cff a*ailable : 25cpm Temp: 37.? +C Weight: !"g
An #$% i& placed in 'e area (f abn(rmali). C(mmen a 'e &pace pr(*ided. +ndicae 'e l(cai(n (f'e pr(blem in 'e figre &ing #$%.
B. Nu!i"g
A!!e!!me"t II
SUB#ECTIVE $B#ECTIVE
C%mmu"i&'ti%":
# % 'earing l(&& C(mmen&:# % *i&al c'ange&
# - % denied
# % gla&&e& # % langage % c(nac len& # % 'earing aid
pil ie: 2mm # % &peec' difficlie&eaci(n: pil& eall) r(nd and reaced (
lig' acc(mm(dai(n.
EEEENT'L M impaired vision L M blindL M pain redden L M drainageL M gums L M hard of hearing L M deafL M burning L M edema L M lesion teethL M assess eyes ears noseL M throat for abnormality L*M no problemRERESP'
L M asymmetric L M tachypnea L M barrel chestL M apnea L M rales L * M coughL M bradypnea L M shallow L M rhonchiL*M sputum L M diminished L M dyspneaL M orthopnea L M labored L M wheezingL M pain L M cyanoticL M assess resp. rate, rhythm, pulse bloodL M breath sounds, comfort L * M no problemCACARDIOVASCULAR'L M arrhythmia L M tachycardia L MnumbnessL M diminished pulses L M edema L M fatigueL M irregular L M bradycardia L M mur murL M tingling L M absent pulses L M pain
#ssess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfortL*M L * Mno problem!A!ASTROINTESTINAL TRACT'L M obese L M distention L M massL M dyspagea L M rigidity L M painL M assess abdomen, bowel habits, swallowingL M bowel sounds, comfort L*M no problem!E!ENITO > URINARY AND !YNEL M pain L M urine L M color L M vaginal bleedingL M hematuria L M discharge L M nucturiaL M assess urine fre&uency, control, color, odor, comfortL M gyne bleeding L M discharge L*M no problemNENEURO'
L M paralysis L M stuporus L M unsteady L M seizureL M lethargic L M comatose L M vertigo L M treamorsL M confused L M vision L M gripL M assess motor, function, sensation, 1C, strengthL M grip, gait, coordination, speech L*M no problemUUSCULOS:ELETAL and S:IN'L M appliance L M stiffness L M itching L M petechieL*M hot L M drainage L M prosthesis L M swellingL M lesion L M poor turgor L M cool L M flushedL M wound L M pain L M ecchymosis L M diaphoretic moistL M assess mobility, motion gait, alignment, joint functionL M s!in color, te*ture, turgor, integrity L * M no problem
cough
fever
dry
skin
Jnormal manJ as
verbalized by the
mother
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$()ge"'ti%":
# % d)&pnea# % &m("ing 'i&(r)
n(ne
# - % c(g'
# % denied
e&p. # % reglar # % irreglarDe&cribe: 4'e paien 'a& irreglar re&pirai(n
(f 25 cpm.
: &)mmerical lng e-pan&i(n
: &)mmerical lng e-pan&i(nCi&u*'ti%":
# % c'e& pain C(mmen&:
# % leg pain
# % nmbne&& (f
e-remiie - % denied
Hear ')'m # % reglar # % irreglar
An"le dema :
l&e Car. ad. D em !8bpm
!8bpm
C(mmen&: all pl&e& are palpable+f applicable
Nutiti%":
Die: Die a& (leraed# % 9 # % C(mmen&:
C'aracer# % recen c'ange in
;eig', appeie
# % &;all(;ing
difficl)# - % denied
# % denre& # - % n(ne
ll arial ;i' aien5-da)
# % rgenc) # % d)&ria
# % 'emaria
# % c(n&ipai(n # % inc(ninenceremed) n(ne # % p(l)ria
Dae (f a& @ # % f(le) in place
Dec. 26,2012 # -% denied
# % diarr'ea c'aracer: n(ne
C(mmen&: @(;el (nd&:
9(rm(aci*e
Abd(minal Di&eni(n re&en # % )e& #- % n(
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# - % denied ra&'e&, lcer&, decbi& Bde&cribe &ie, l(cai(n,
drainage9( ('er alerai(n in &"in inegri)
ACTIVITY/ SA+ETY:
# % c(n*l&i(n C(mmen&:
# % diine& %limied m(i(n
(f E(in&
imiai(n in
Abili) (
# % amblae# % ba'e &elf
# % ('er
#-% denied
# % FC and (rienai(n: aien i& (riened (
per&(n, place, ime and dae.
Gai: # % ;al"er # % cane # % ('er
# % &ead) # % n&ead)# % &en&(r) and m((r l(&&e& in face
(r e-remiie& 9/A
# % F limiai(n&: aien can m(*e alle-remiie&
C$M+$RT/S,EEP/AWA-E:
# % pain C(mmen&:Bl(cai(n, freenc),remedie&
# % n(cria
# - % &leep difficlie % denied
# % facial grimace# % garding# % ('er &ign& (f pain:
n(ne
# % &iderail relea&e f(rm &igned B60 )ear& 9/A
C$PING:
ember& (f H(&e'(ld: 5
(& pp(ri*e er&(n: m('er
Fb&er*ed n(n>*erbal be'a*i(r:
n(ne
Jga cge lang sya ug
hila!J, as verbalized
by the mother
Jgalisod sya tulog
tungod saiya ubo. Jas
verbalized by mother
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IV.
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III. 3
4
a
k
u
h
a
m
i
ug
ili
m
n
o
n
n
g
a
tu
bi
g
sa
w
at
r
di
st
ri
ct
5
I-. as
v
er
o
r
e
c
o
g
n
i
6
et
h
e
p
r
e
s
e
n
c
e
o
f
t
h
e
c
o
n
d
it
i
o
n
o
nu
tes
,
th
e
fa
mil
y
wil
lbe
abl
e
to7
a. 8ecogni6e theimportance ofhaving asterili6eddrinkingwater.
b. 2numerate
illnessesthat maygain fromdrinkingunsteri1li6edwater.
c. %howreadinesstoimprovethe wayof living.
&e
+.#
a. Importance ofdrinkingsterili6edwater.
b. 9iseasesthat may
ac:uiredbydrinkingunsterili6ed water.
c. %terili6ation ofdrinkingwater.
III.
I-.
-.
n
of
th
e
stu
de
nt
nu
rse
.
-III.
I. 1
Ti
me
an
d
e!
ort
of
th
e
stude
nt
nu
rse
an
d
fa
mil
y
me
tes
,
go
al
wa
s
me
t7
the
famil
y
wa
s
abl
e
to
ap
pre
cia
te
the
im
po
rta
nc
e
of
dri
nki
ng
the
ste
rili
6e
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b
al
i6
e
d
b
y
"
v
an
c
e
;
a
-.
XXVI. O
bj
e
c
!"
e#
-II. 1
.
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CCIII.
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family care study. ur C. helped us in finding our patient since she was
familiar in the area and she already as!ed the /)D. @o what we did, we
introduced ourselves and we then started as!ing &uestions. De were able to
assess a pregnant woman and a child 5"= years old. De immediately
assessed the family members including the baby and unfortunately the
mother and the child were the only ones that we had assessed since the
father is at wor! and the siblings of the client is at school.
CC
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CCNN. De were than!ful to the family since they accepted us without any
hesitations and they entertained us. $hey answered our &uestions and they listen for
discussion with regards to imparting of information which really matters to them.
CC9>=(ozier, /arbara et. #l. Fundamental of Aursing. thedition. Pp. >95">90rong, 0">7eyala, 8ean P. et. #l. Community )ealth Aursing @ervices in the Philippines. 9 th
edition, pp. =0"=4
CCNN. Debliography
http%33www.unilab.com.ph3consumer3productsdetails.aspQeeeR6>
http%33www.brianmac.co.u!3physiol.htm
http%33en.wi!ipedia.org3wi!i3)umanmusculos!eletalsystem
CCNN.
CC
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CC