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Liceo de Cagayan University513%OYG&DUPHQ&DJD\DQGH2UR&LW\'SPPIKISJ2YVWMRK

IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS OF NCM5O1205RELATED LEARNING EXPERIENCE (RLE)

Family Case Study

Submitted by:

Akima Grace R. Matias

Submitted to:

Mrs. Sylvia S. Garcia, RN, MAN

December 17, 2010

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TABLE OF CONTENTS

I Introduction 3

a. Overview of the study 4

b. Scope and Limitation of the Study 4

II Spot Map

a. Narrative

III Family Profile 5

IV Family Health History 7

V Present Health Status 8

a. Nursing Review Chart

VI Integrated Management of Childhood Illness 15

VII Home and Environment 18

a. Housing

b. Water Supply

c. Toilet Facility

d. Kitchen

e. Garbage disposal

f. Drainage System

g. Domestic Animals

h. Food Storage

i. Neighborhood

j. Community Facilities

VIII Family Coping Index 21

IX Schematic Diagram 23

X Family Care Plan 25

XI Actual Implementation 28

XII- Recommendation 30

XIII Evaluation 31

XIV Bibliography 32

XV Appendices 33

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I. INTRODUCTION

A. OVERVIEW OF THE STUDY

Community Health Nursing is a unique blend of nursing and public health practice woven

into a human service that properly developed and applied has tremendous impact on human

well being. Its responsibilities extend to the care and supervision of individuals and families in

their home, in places of work, in schools and clinics. It is one of the basic services of health

departments. The community health nurses, as members of the health team, are expected to

integrate within the context of family health care, the priority programs of the Department of

Health.

Everyone has his own definition of what is a family. The meaning of family is different to

every one of us. All definitions adapt to all families. A universal family is a nuclear family. The family

consists of adults of both sexes who are married the adults have biological children and socializes

them. By socializing their children they are transmitting the culture of their generation to their

children. The family helps bring about harmony and integration in society. Other institutions have

nowadays taken on these functions.

Children are usually the reflection of their parents. They carry on whatever they learn from

their parents onto their own. Children need the love and care from both parents, so they will not

feel incomplete. It takes two to have children, and those two should raise the child together with all

the love they have to offer.

The familys major roles are to protect and socialize its members. Among the many functions

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. In addition to providing

an emotionally safe environment for members to thrive and grow, the family is also a basic unit of

physical protection and safety. This is accomplished by meeting the basic needs of its members:

food, clothing, and shelter. Provision of a physically safe environment requires knowledge, skills,

and economic resources. The adult members through employment secure the economic resources

needed by the family.

Family X is an extended family composed of their own two children and parents of the

wifes side. They live at Zone 3 Baikingon, Cagayan de Oro City. They were renting a house that

cost a hundred per month. The head of the family is a government employee as a construction

worker while the wife is a plain housewife.

I chose this family because they fit the required criteria for the family case study such as

the family income is below eight thousand, family that has a maximum of six members with

childrens age from zero to five years, and with a geriatric member. This family has the income

of six thousand to six thousand five hundred a month; they are six in the family; the wifes

parents, the couple and their two children.

The objective of the study is to smooth the progress of putting into practice of family-

oriented nursing care and make certain an organized approach in the delivery of the nursing

services to the families in the community, purposely in the application of nursing process. It

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aims to identify health problem of a family within the community. As student nurses, we could

give and apply some nursing interventions that are applicable and attainable within the

community health services. Also to offer some health teaching strategies for our clients such as:

1.) Visit the health center in their Barangay as a way maintaining health status of the family.

2.) How the environment affects such problem that the family experiencing and,

3.) How can a member of the family team help the family to deal with such problems?

On the later part the actual implementation and health teachings is given means on

setting up and evaluating the care at the family level. And lastly, to show and document the

array of services that nurses provide at the family level.

B. SCOPE AND LIMITATION OF THE STUDY

This study focuses to the prevention of health problems, and promotion of health by the family

X.

The scopes of this study are as follows:

y The family must be a resident of Zone 3, Baikingon CDOC.

y The family must be assessed and cared for by the student in-charge for at least 6 visits.

y The students must have the consent coming from the family to make them the subject

of the study.

y The scope of the study includes the family members personal and health profile and

spot map of their residence, the chief complain of the family member with a health

problem and the family members, the history of present illness of the member with a

health problem, the nursing assessment, the family coping index, the integrated

management of childhood illness, the family health plans and the actual implementation

of different interventions given to the family.

y The different references were also part of this study, which encompasses the use of the

different community health nursing books, nursing care plan books and other sources

which served as guide throughout the study.

II. SPOT MAP (Narrative)

From the point of reference which is Liceo De Cagayan University, we used a private vehicle

during our travel and paid 50.00 php each student back and forth but when riding a public

utility vehicle, the terminal is situated in the northwest of the cogon market. The fare for adults

is 40.00 php and for students senior citizen is 38.00 php. We did not follow the route of the

public utility vehicle going to Baikingon. We started out travel by passing through the National

Highway and passed by many landmarks such as Makro, RER, and other landmarks that isfamous within the busy streets of the National Highway. We passed through the Bulua gym,

and went straight ahead until we arrived at the bridge of the Iponan River and went straight

ahead again and followed the dusty and rocky roads going to Baikingon. Approximately we

travel about 14 kilometers from the point of reference to the area of destination which is

Baikingon and the travel time is approximately 30-45 minutes. The roads were dusty and some

were well cemented but the travel was worthwhile and enjoying.

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III. FAMILY PROFILE

Head of the familyName : R. B

Position in the family : Husband

Gender : Male

Age : 25 years old

Civil status : Married

Birth date : May 27, 1985

Birth place :Cagayan de Oro City

Citizenship : Filipino

Religion : Roman Catholic

Occupation : Construction Worker

Monthly income : Php 6000

Mother

Name : J. N

Position in the family : Wife

Gender : Female

Age : 24 years old

Civil status : MarriedBirth date : May 8, 1950




Occupation : Housewife

Monthly income : None

Grand father

Name : A. N

Position in the family : Grandfather

Gender : Male

Age : 63 years old


Birth date : August 31, 1947




Occupation : None


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Grand mother

Name : N. Y

Position in the family : Grandmother

Gender : Female

Age : 57 years old


Birth date : July 12, 1953




Occupation : None


Son

Name : M. B

Position in the family : Son

Gender : Male

Age : 4 years old

Civil status : Child





Occupation :None


Daughter

Name : M. B

Position in the family : Daughter

Gender : Female

Age : 3 years old

Civil status : Child





Occupation : None


IV. HEALTH HISTORY

Mr. R. B

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Mr. R. B is 25 years old and currently resides in Zone 3, Baikingon, Cagayan de Oro City.

He works as a construction worker whose income is just enough for their family. He was

delivered through a Normal Spontaneous Vaginal Delivery. According to Mr. R. B he had

completed his immunization. He does not have any food and drug allergies. And he cant

remember anyone from his parents and grandparents having serious illnesses that he might

inherit. He cannot recall of having any serious illnesses in the past six months. But he

remembered of having cough and colds due to climate change. He left it untreated without

taking any medications. He was never been confined nor brought to a hospital for treatment.

Mrs. J. B

Mrs. J. B is 24 years old and a plain housewife. Her menarche began when she was 13

years of age. Her 2 children were delivered at Health Center through Normal SpontaneousVaginal Delivery (NSVD) with no complications noted during the course of pregnancy, labor, and

delivery. She had prenatal checkups at the Barangay health center. She was able to breastfeed

her children. According to Mrs. J. B she was not been confined to a hospital before and nor

experienced any serious illness. Just like her husband she only experienced cough, and colds,

which were just treated by self-medication, such as over the counter drugs.

Mr. A. Y

Mr. A. N is 63 years old and resides in Zone 3, Baikingon. He has a hearing problem and

first noticed it when he was in high school it was from his mother side and due to due to the

financial constraints his disease was not able to treat his illness. He had been hospitalized in JR

Borja Hospital for his hypertension and was given Captopril for his home medication but due to

the side effects like dizziness he stops taking the medication.

Mrs. N. Y

Mrs. N. Y is 57 years old and an old resident of Baikingon. She had 2 children and

delivered them through a Normal Spontaneous Vaginal Delivery. She was not able to recall any

past illnesses and was never been hospitalized or brought for treatment. She denied of having

any heredofamilial disease. But she recalled of having cough and colds few weeks prior to our

visit.

Child M. B

M. B is 4 years of age and the eldest child in the family. He was born in the health

center through a Normal Spontaneous Vaginal Delivery. He was normal and had no

complications noted. He was also completed his immunization. And was never been brought to

the hospital or experienced any serious illnesses. According to his mother he experienced fever,

cough, and colds days prior to our fist assessment. He was treated with paracetamol for 2 days.

Child M. B

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LEGEND: Day 1 Day2 Day3 Day4 Day5 Day6

M. B is 3 years old and resides in Zone 3, Baikingon. She is the youngest in the family

and was delivered through a Normal Spontaneous Vaginal Delivery in the Health Center. She

had completed her immunization and was never been brought to the hospital for treatment.

Like her brother she also experienced cough and cold but without fever. She was not able to

take any medications according to her mother.

V. PRESENT HEALTH STATUS

Part A.

Father

During the visit, Mr. R.B was warm to touch and the vital signs are within normal range.

He doesnt show any signs of being sick. He is participative and cooperative. He is an

occasionally drinker.

Mother

During the visit, Mrs. J.B was warm to touch. Her upper teeth are lacking. She has no

vices. She was also participative and cooperative to us during our visit. She also doesnt have

any chronic disease and medications maintain.

Grandfather

During the visit, Mr. A.Ys BP was 130/80mmHg, and it is already in the pre-hypertensive

stage, and he stated that when he is at work or doing something strenuous, he feels a sudden

neck pain, and when he goes to the health center, his BP rises to 140/100 mmHg. He is

maintaining medications before but had stop taking captopril lately because he feels

drowsiness. He said that it started when he was still 25 years old and because he was smoking

at least 1 pack of cigarette a day, and is not physically active, he was not surprised to have this

illness.

Grandmother

During the visit, Mrs. N.Y was not sick and doesnt show any signs of being sick, she is

very cooperative and responsive. She is well and doesnt have any vices; she is also not

maintaining any medications for a chronic disease.

Children

During the visit, their children were having colds, and the eldest was the first who got

it and passed it to the youngest. It started last November, and their mother said its because of

the climate change. They were not taking medicines for it, because their mother said its only

normal for their age, she will just give her children more water and soup in meals. They dont

have any vices yet for their still child.

Part B. Nursing system review chart

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PHYSICAL ASSESSMENTName:A.Y

Vital Signs:PR:76bpm/78/72/76/78/78 RR:20cpm/22/20/24/22/20;

BP:130/80mmHg/130/90/140/90/130/90/130/90/140/90;Temp:36.5C/36C/37.2/37/37.2/36.4 Height:56 ft ; Weight: 65 kg

EENT:[ X ] blurred vision [ ] blind [ ] pain redden [ ] drainage[ ] gums [ X ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [ ] teeth

Assess eyes ears nose throat for abnormality [ ] no problem

RESP:[ ] asymmetric [ ] tachypnea [ ] barrel chest

[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum

[ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored[ ] wheezing [ ] pain [ ] cyanoticAssess resp. rate, rhythm, depth, pattern, breath sounds, and comfort[x] No problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses[ ] edema [ ] fatigue [ X ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain, Assess heart sounds, rate rhythm,Pulse, Blood Pressure, circ., fluid retention, comfort [] No problem

GASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass [ ] dyspagea [ ] rigidity [ ] pain

Assess abdomen, bowel habits, swallowing, bowel sounds, and comfort[x] No problem

GENITO URINARY AND GYNE[ ] pain [ ] urine colour [ ] vaginal bleeding [ ] hematuria[ ] discharge [ ] nocturia, Assess urine frequency, control,Colour, odor, comfort, gyne bleeding, discharge [x] no problem

NEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip

Assess motor function, sensation, LOC, strength,Grip, gait, coordination, orientation, speech[x] No problem

MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin colour [ ] flushed[ ] atrophy [ X ] pain [ ] ecchymosis[ ] diaphoretic [ ] moist

Assess mobility, motion, gait, alignment, joint function Skin colour, texture, turgor, integrity [X] No problem

Blurredvision(firstvisit upto

lastvisit)

Hardofhearing

BP:

130/80mmHg,130/90,

mmHg,140/90mmHg,13

0/90mmHg,130/90mmH

g

Joint pain

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PHYSICAL ASSESSMENT

Name: N.YVital Signs:PR: 80bpm/76/72/74/72/78 ; RR20: 18cpm/20/22/20/18/ ; BP: 90/70mmHg/90/70/

100/70/90/70/90/70/9070 ; Temp: 36.2C/ 36.5/36.8/37.2/37/37.2 ; Height: 52 ; Weight: 37kgEENT:[ ] impaired vision [ ] blind [ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [] teeth

Assess eyes ears nose throat for abnormality[x]no problem

RESP:[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum[ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored[ ] wheezing [ ] pain [ ] cyanotic

Assess resp. rate, rhythm, depth, pattern, breath sounds, and comfort[x] No problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses[ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain, Assess heart sounds, rate rhythm,Pulse, Blood Pressure, circ., fluid retention, comfort [x] No problem






MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [] cool [ ] deformity[ ] wound [ ] rash [ ] skin colour [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis[ ] diaphoretic [ ] moist

Assess mobility, motion, gait, alignment, joint function Skin colour, texture, turgor, integrity [X] No problem

Skin warm

to touch,

skin warm

to touch

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PHYSICAL ASSESSMENTName: J.BVital Signs:PR: 86bpm/82/82/86/86/84; RR: 22cpm/20/18/20/20; BP:100/90100/80/100/90/110/80/100/80/11080 Temp:

37.3C/36.5C/37.2C/37/36.8/37;Weight: 40kg Height: 52EENT:[ ] impaired vision [ ] blind [ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [ X ] teeth

Assess eyes ears nose throat for abnormality [ ] no problemRESP:[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum[ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored[ ] wheezing [ ] pain [ ] cyanotic


CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses[ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain, Assess heart sounds, rate rhythm,Pulse, Blood Pressure, circ., fluid retention, comfort [x] No problemGASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass [ ] dyspagea [ ] rigidity [ ] pain

Assess abdomen, bowel habits, swallowing, bowel sounds, and comfort[x] No problemGENITO URINARY AND GYNE[ ] pain [ ] urine colour [ ] vaginal bleeding [ ] hematuria[ ] discharge [ ] nocturia, Assess urine frequency, control,Colour, odor, comfort, gyne bleeding, discharge [x] no problemNEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip


MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ X ] hot [ ] drainage [ ] prosthesis [ ] swelling

[ ] lesion [ ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin colour [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis[ ] diaphoretic [ ] moist

Assess mobility, motion, gait, alignment, joint function Skin colour, texture, turgor, integrity [ ] No problem

Upper teeth

lacking

Skim warm

to touch,

Skin warm

to touch

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PHYSICAL ASSESSMENTName: R.BVital Signs:PR: 88bpm/90bpm/86bpm/92/88/86 ; RR: 24cpm/20cpm/22cpm/20/22/22; BP: 120/90mmHg/ 110/90mmHg/ 120/90mmHg/110/80/120/80/110/80 ; Temp:

37.4C/36.8C/36.3C/37.2/36.5/37.2 ; Height: 57 Weight: 64klsEENT:[ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [] teeth


RESP:[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum[ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored

[ ] wheezing [ ] pain [ ] cyanoticAssess resp. rate, rhythm, depth, pattern, breath sounds, and comfort[x] No problem







MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ X ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin colour [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis[ ] diaphoretic [ ] moist


Skin

Warm to

touch,

Skin

Warm to

touch,

Skin

Warm to

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PHYSICAL ASSESSMENTName: M.Y (eldest)Vital Signs:PR: 94bpm/90bpm/90bpm/92/88/96 ; RR: 24cpm/20cpm/22cpm/20/22/22; BP: noneTemp: 37.2C/36.9C/36.5C/36.3/37.4/37.2 ; Height: 3ft Weight:12kg

EENT:[ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [] teeth [ X ] Colds












Colds

Skin

warm to

touchSkin

warm to

touch,

Skin

warm totouch

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PHYSICAL ASSESSMENTName: M.Y (youngest)Vital Signs:PR: 9obpm/94bpm/96bpm/92/90/96 ; RR: 24cpm/22cpm/20cpm/20/22/22; BP: noneTemp: 37.2C/37.3C/36.5C/37.4/36.5/36.6 ; Height: Weight:

EENT:[ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [] teeth [ X ] Colds












Colds

Skin

warm to

touch,

Skin

warm to

touch,

Skin

warm to

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VI. INTEGRATED MANAGEMENT of CHILDHOOD ILNESSES

Childsname:M. B Age: 51 months oldSex:Male Weight:12 kilogram Temp: 36.5C, 36.7C,37.2C, 36.9CASK: What are the childs problems? Cold

Initial visit? _____ Follow-up visit? _

_

ASSESS CLASSIFYCHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEEDVOMITS EVERYTHINGCONVULSIONSABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN

YES__NO

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes_ No_For how long?

y Count the breaths for one minute. _21_breaths per minute. Fast breathing?y Look for chest indrawing?y Look and listen for stridor.

No Pneumonia:Colds

DOES THE CHILD HAVE DIARRHEA? Yes___ No

For how long? ___days

Is there blood in the stools?

y Look at the childs general condition.

Abnormally sleepy or difficult to awaken?

Restless or irritable?

y Look for sunken eyes.

y Offer the child fluid. Is the child:

Not able to drink or drink poorly?

Drinking eagerly, thirsty?

y Pinch the skin of the abdomen. Does it go back:

Very slowly (longer than 2 seconds)?

Slowly?

No Dehydration

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C or above) Yes__ No_

Decide Malaria Risk

y Does the child live in malaria area? No

y Has the child visited a malaria area in the past 4 weeks? No

If malaria risk, obtain a blood smear.

y Look or feel for stiff neck.

y Look for runny nose.

+ Pf Pv - Not done

y For how long has the child had fever? __days

y If more than 7 days, has fever been present every day?

y Has the child had measles within the last 3 months?

Look for signs ofMEASLES

y Generalized rash and

y One of these: cough, runny nose. Or red eyes.

If thechild hasmeaslesnoworwithin thelast 3 months:

y Look for mouth ulcers

If yes, are they deep and extensive?

y Look for pus draining from the eye

y Look for clouding of the cornea.

Decide Dengue Risk: Yes__ N o_

_

If dengue risk, then ask:

y Has the child had any bleeding form the nose or gums or in the vomitus or stools?

y Has the child had black vomitus or black stool?

y Has the child had abdominal pain?

y Has the child been vomiting?

y Look for bleeding from nose or gums

y Look for skin petechiae.

y Feels for cold and clammy extremities.

y Check capillary refill ___seconds.

y Perform tourniquet test if child is 6 months or older and has no other signs and has fever for

No Fever:

No Malaria

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y More than 3 days.

DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No_

y Is thereearpain?

y Is thereeardischarge?

If yes, forhowlong? ___days

y

Look forpusdraining from theeary Feel for tenderswelling behind theear.

No Ear Infection

THEN CHECK FOR MALNUTRITION AND ANEMIA

y Look for visible severe wasting.

y Look for edema of both feet

y Look for palmar pallor.

Severe palmar pallor? Some palmar pallor?

y Determine weight for age

Very Low? Yes, underweight.

No Anemia but

underweight

CHECK THE CHILDS IMMUNIZATION STATUS completely immunized

Record lost _________

(Date)

CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older

Is the child six months of age or older? Yes_

_ NO__

_March 2007

Has the child received Vitamin A in the past six months? Yes__ No_

Vitamin A needed

today

Yes_

No__

ASSESS CHILDS FEEDING ifchild has ANEMIA OR VERY LOW WEIGHT orless than 2

yearsold.

y Do you breastfeed your child? Yes___ No____

If Yes, how many times in 24 hours? ___ Times. Do you breastfeed during the night? Yes___

No__

y Does the child take any other food or fluids? Yes__ No___

If Yes, what food or fluids? Rice, vegetables, fish. And meat. Water, juice, coke

How many times per day? 3 times. What do you use to feed the child? Spoon ,fork, plate

If very low weight for age: How large are servings?10-15 spoons per meal

Does the child receive his/her own serving? Yes

__ who feeds the child and how? child himself

y During the illness, has the childs feeding changed? Yes __ No___

If yes, how? Decrease

Feeding Problems:

ASSESS OTHER PROBLEMS: none

IMCI MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Childsname:M. B Age: 39 months oldSex: Female Weight:15 kilogram Temp: 37.2C_

ASK: What are the childs problems? NoInitial visit? _____ Follow-up visit? _

ASSESS CLASSIFYCHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEEDVOMITS EVERYTHINGCONVULSIONSABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN

YES__NO

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes_ No

_For how long?

y Count the breaths for one minute. _27_breaths per minute. Fast breathing?y Look for chest indrawing?y Look and listen for stridor.

No Pneumonia:

DOES THE CHILD HAVE DIARRHEA? Yes___ No__For how long? ___daysIs there blood in the stools?

y Look at the childs general condition.Abnormally sleepy or difficult to awaken?Restless or irritable?

y Look for sunken eyes.y Offer the child fluid. Is the child:

No Dehydration

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Not able to drink or drink poorly?Drinking eagerly, thirsty?

y Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)?Slowly?

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C or above) Yes__ No_Decide Malaria Risk

y Does the child live in malaria area? Noy Has the child visited a malaria area in the past 4 weeks? No

If malaria risk, obtain a blood smear.y Look or feel for stiff neck.y Look for runny nose.

+ Pf Pv - Not doney For how long has the child had fever? __daysy If more than 7 days, has fever been present every day?y Has the child had measles within the last 3 months?

Look for signs ofMEASLESy Generalized rash andy One of these: cough, runny nose. Or red eyes.

If thechild hasmeaslesnoworwithin thelast 3 months:

y Look for mouth ulcersIf yes, are they deep and extensive?

y Look for pus draining from the eyey Look for clouding of the cornea.

Decide Dengue Risk: Yes__ N o

_

If dengue risk, then ask:y Has the child had any bleeding from the nose or gums or in the vomitus or stools?y Has the child had black vomitus or black stool?y Has the child had abdominal pain?y Has the child been vomiting?y Look for bleeding from nose or gumsy Look for skin petechiae.y Feels for cold and clammy extremities.y Check capillary refill ___seconds.y Perform tourniquet test if child is 6 months or older and has no other signs and has fever fory More than 3 days.

No Fever:No Malaria

DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No_y Is thereearpain?y Is thereeardischarge?

If yes, forhowlong? ___days

y Look forpusdraining from theeary Feel for tenderswelling behind theear.

No Ear Infection

THEN CHECK FOR MALNUTRITION AND ANEMIA

y Look for visible severe wasting.y Look for edema of both feety Look for palmar pallor.

Severe palmar pallor? Some palmar pallor?y Determine weight for age

Very Low? Yes, underweight.

No Anemia normalweight

CHECK THE CHILDS IMMUNIZATION STATUS completely immunizedRecord lost _________

(Date)

CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or olderIs the child six months of age or older? Yes_

_ NO__

_ June 2008Has the child received Vitamin A in the past six months? Yes__ No_

Vitamin A neededtodayYes_No__

ASSESS CHILDS FEEDING ifchild has ANEMIA OR VERY LOW WEIGHT orless than 2yearsold.

y Do you breastfeed your child? Yes___ No____If Yes, how many times in 24 hours? ___ Times. Do you breastfeed during the night? Yes___No__

y Does the child take any other food or fluids? Yes__ No___

If Yes, what food or fluids? Rice, vegetables, fish. And meat. Water, juice, cokeHow many times per day? 3 times. What do you use to feed the child? Spoon ,fork, plateIf very low weight for age: How large are servings?1.5 cups per mealDoes the child receive his/her own serving? Yes

__ who feeds the child and how? child herselfy During the illness, has the childs feeding changed? Yes __ No___

If yes, how? Decrease

Feeding Problems:

ASSESS OTHER PROBLEMS: none

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VII. HOME AND ENVIRONMENT

A. HOME AND ENVIRONMENT

HOUSING

They rent their house with a 100php a month, constructed with woods and their roof

made of nippa. The area of their house is not enough to occupy six persons because the

limited space that the house has. They only have one room that is used by the couple

for sleeping while the grandparents utilized the space outside the room which is also

used as the dining area during meal time together with their grandchildren. The house is

not thoroughly clean and things are not properly arranged due to limited space, they

dont have drainage. But still, the house is not hazardous because it doesnt have a

stairs and other unfinished construction. The distance to the neighbor is very near

because they are just renting and constructed their using the firewall of the neighbor as

their wall.

B. WATER SUPPLY

The source of their drinking water is from their own faucet and sometimes there is no

water, because they are just tapping water from the neighbor. They store it in a 4 liter

water container with cover. Regarding the source of the drinking water it is considered

as not safe since they were not practicing proper boiling of the water before consuming

C. TOILET FACILITIES

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The family doesnt have their own toilet and they are using the neighbors CR and two

families are using it, and the type is water-sealed, and it is located at the back of their

house, approximately 10 meters. The toilets odor is not that offensive

D. KITCHEN

They have a dirty kitchen inside their house and is located at the side of their house.

They are using wood for cooking rice and vegetables in a small pot. They store their left

over foods in the plastic container and just on top the table.

E. GARBAGE DISPOSAL

The Yanez family was disposing their garbage by means of burning it all in their

backyard. The government facilities that were assigned on collecting the garbage were

not able to reach the barangay area thats why the community decided to just burn all

their garbage. The family was not practicing garbage segregation before burning them.

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F. DRAINAGE SYSTEM

The Yanez family does not have any drainage system in their house surroundings; the

draining water just goes directly to the soil ground outside their house.

G. DOMESTIC ANIMALS

The family has a dog and a derby chicken. The dog is tied under their sink, partly inside

the house, and defecates and urinates where he is tied, the family just bury the dogs

feces and cover the urine with soil. The derby chicken is the head of the familys pet; it

is tied inside their house.

H. NEIGHBORHOOD

The familys house is located across the barangay hall, the distance of each house is

very close, and some are built with only one wall apart. The families in that specific

place are already very familiar with each other. The house is very near from the health

center, approximately 100 meters away.

I. COMMUNITY FACILITIES

The house is very close to the barangay hall, approximately 30 meters away. It is also

very near to the school where their kids studied which is the beside Baikingon

Elementary school, the school also located the barangay covert court where in all

community program are being conducted. The health center also is very accessible

because of its distance; it is just a 100 meters away from their house.

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VIII. FAMILY COPING INDEX

The objective of this indicator is to present a benchmark for approximating thenursing needs of a particular family, thus Family Coping Index. It is the coping capacityand not the underlying problem that is being rated, and it is designed to record family

rather than individual coping capacity. In public health nursing, the family cannot beseen only as a factor that affects health; rather, the family is the patient.

Legendary:5 Complete competence

3 Moderate competence1 No competence

9 Areas ofNursing

Concerns

Rating Justification Statement

1. PhysicalIndependence 5

The members are all able to move without assistanceand difficulty. They do their activities of daily livingwithout aid. They are independent in moving aboutand using their musculoskeletal system but there isone member of the family with abnormalities in thephysical independence (Mrs. A.Y).

2. TherapeuticCompetence

3 The parents are aware on what to do if a memberfells ill. Although, the distance of the health center isnear but because of financial problems that's whythey cannot provide enough and/or appropriateinterventions. The parents are aware of their lapsesin therapeutic competence. They are aware of theirfinancial difficulties, which is the primary reason fornot having or following the appropriate procedure ortreatment, having appliances and even enoughclothes for the children.

3. Knowledge ofHealth Condition

3 The mother is knowledgeable on salient health issuesand responsibilities. Yet due to financial problems,health issues are overlooked. But as a mother sheconsiders immunization as essential for her childshealth. Immunization of the children was complete.

4. Application ofPrinciples of

General Hygiene

3 . The family sleeps well but sometimes they dont eatnutritious foods. Their source of water is from faucet

which is only available at the barangay hall. They donot practice sterilization or healthy habits in foodstorage and preparation. Even though aware ofhygienes importance, the family does not practicegood hygienic skills. Yes they take a bath everydaybut their source of water for bathing and washingclothes are from barangay hall water source and isnot available sometimes., eating habits andmaintenance of healthy lifestyle are not taken intoconsideration that much.

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5. HealthAttitudes

3 The parents are concerned about the health of themembers of the family yet they do not participateactivelyin maintaining optimum health due to financial

constraints. Also, the family lacks informationregarding healthy lifestyle and healthful ways towardimprovement of life. Parents, as much as possible,want to protect their children from any harm butthen, they lack money and information for them tocarry out the right health care for the family.

6. EmotionalCompetence

5 The family are competent enough emotionally. Theycan manage their own problems and also handlestress just like any other family does. The parents

take responsibility their only child and to theirextended family. They also discipline and teachalways their children the morals of life. The familylives harmoniously at home. Even though conflictsarise, they really see to it that they would discusseach concern in a calm manner.

7. Family Living 3 There is high concern within the family, especiallywith regards to their interrelationship with others.The parents discuss decision- making. The child is not

yet open for suggestion to decision-making since theyare still young and difficult to comprehend theircurrent situations. Others respect individualrelationships of each member of the family Decision-making is shared among its members except onyoung member. Each has his or her own part or rolein the family, which is well respected.

8. PhysicalEnvironment -

3 The familys house space is not good enough for thefamily.They cook their food inside their housewherein they just use earthly pot and used wood asfuel. They live in a place wherein its not congestedbut then the distances between their neighbours arenot that so far from each other. The houseenvironment is not fitted for them , because of thepresence of pests and accident hazards in theircommunity. Also their house is in poor condition, thatthey can possibly acquire serious diseases. Their food

storage is unsanitary. Though it is covered with cloth,sometimes insects and other small animals couldcrawl inside the dish organizer.Having a earthy pot used for cooking inside thehouse is really a fire hazard because some of the coalfire might come in contact with their wood wall.

9. Use ofCommunityFacilities

3 The mother is aware of the available resources in thecommunity, both in health and education. But theycannot utilize the health facilities due to busy doinghousehold chores. They go to the health center ifneeded.

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Family Health

Schematic Presentation of Family Health Proble

Mother seldom attends

community meetings and

gatherings in thezone.

Political

Socio-Cultural Factors Biological Factors

Economic

Income: Php 6,000/month

Father: Construction Worker

Mother: Housewife. She doeshousehold chores and takes care The familys knowledge

about some service providedby the barangay healthcenter is limited only.Financially unstable family, the

couples income is not enough to

support the small family as a

Foreseeable Crisis.

Health threat: the

to performing

practices in dealin

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Biological Factors

Genetic Physical

*Poor Personal Hygiene*Hypertension Paternal side

There is a possibility that their

offspring will acquire the

disease.

The family is prone of havingdiseases.

Genetic Hypertension as a

Health Threat

Poor Personal Hygiene as a

Health Threat

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Environmental Factor

Housing H2O H2O Toilet

The house was

not well

constructed.

There drinking

water is not

sterilized

They have a

communal

toilet.

There source

of water is

through a

faucet found in

the barangay

hall.

The family is

unable to

maintain good

hygiene

The family is

prone to accidentsThey have the

possibility of

acquiring water

borne diseases

They have less

privilege to use

the toilet

Health Threat:

*Accident hazard:

Presence of sharp and pointed objects*Fair home and environmental sanitation and condition:

Inadequate living space

Polluted water supply

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Priority number 1:

CUES

HEALTH

PROBLEM

FAMILY NURSING

PROBLEMS

GOAL OF

CARE

OBJECTIVES OF

CARE

INTERVENTION

MEASURES

Subjective

igo-igorapudangkita

saakobana,dili judsiya

ina.ana ka daku pang

suportasapamilya as

verbalizedby themother

Objective:

Income P6,000 per

month

Presence of

Low family

income as a

foreseeable

crises

Inability to provide

home environment

conducive to health

maintenance and

personal

development due

to:

y Inadequate

family

resources,

specifically:

y Financial

constraints/limit

ed financial

resources

At the end of

3 days of visit,

The family will

find enough

resources

that could

sustain family

health needs.

At the end of

nursing

intervention the

family will Identify

ways to utilize

family income

wisely and earn

money from extra

work.

y Encouraged the fam

to find additional way

to earn money.

y Encouraged family

prioritize needs. Foo

should always b

available especially f

their child.

y Encouraged the fam

to minimiz

unnecessary

spending like buyin

junk foods.

Family Care Plan

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CUES

HEALTH

PROBLEM

FAMILY

HEALTH

PROBLEM

GOAL OF

CARE

OBJECTIVES OF CARE INTERVENTIONS

MEASURE

M

O

FA

C

SUBJECTIIVE:

Sa reservoir rame didto

sa barangay ga kuha ug

tubig para imnon as

verbalized by the client

OBJECTIVE

Unboiled

drinking

water

Un cleaned

drinking

water

container

Unsafe

drinking

water as

health

threat

Inability to

recognize

possible

health

threats

on unsafe

source of

drinking

water and

practices

At the end of

3 days the

family will be

able to obtain

necessary

measures to

prevent

acquiring

diseases

from the

unsafe

source of

drinking

water and

practices.

At the end of nursing

intervention the family will

be able to:

a.) Filter first the

water from the

reservoir

b.) recognize the

importance of

boiling drinkingwater first before

consuming

c.) Clean the

drinking water

container

regularly and

cover it properly

d.) Avoid exposing

the container to

sun light rays to

prevent

formation of

algae

1.) Encourage thefamily to filter the

water by using,

such as: clean

clothes, water

filterer

2.) Educate the

family to boil

water for 10 to

15 minutes

3.) Inform the familyto use clean and

well cover

container

4.) Instruct them to

place the

container in a

place that cannot

easily seen by the

sunlight

H

V

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Priority number 3:

CUES

HEALTH PRBLEM FAMILY NURSING

PROBLEMS

GOAL OF

CARE

OBJECTIVES OF

CARE

INTERVENTION

MEASURES

Subjective:

y Grabe jud ang

basura dani,

gasunogon

nako para ma

kuhaan

Objective:

y Garbage isscattered

around the

house

y The backyard is

infested with

flies

Improper garbage

disposal as a

Health Threat

Inability to provide a

home environment

conducive to health

maintenance and

personal development

due to:

a. frustration felt

caused bythe recent

natural

calamity

b. Inadequateknowledge of

the

importance

of hygiene

andsanitation.

After nursing

intervention,

the family will

improve their

means of

disposing

garbage.

After nursing

intervention, the

family will be able

to:

a.) recognize that

improper garbage

disposal is a health

hazard and is

unfriendly to the

environment

b.) consider other

means of garbage

disposal

1. Discuss with the

family the importance

of proper garbage

disposal

2. Discuss alternative

ways in disposing

garbage.

3. Discuss the threat

that vectors such as

flies could pose to their

health.

4. Encourage the

family to rise above

the calamity they

encountered

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IX. ACTUAL IMPLEMENTATION

First Visit

During my first day of visit, I introduced myself to the family, stated the purpose &

duration of visit, and established good rapport with them. I interviewed the family with regardsto the names, birthdays, educational attainment, occupation, monthly income, religion, and

heredo-familial diseases of the family. We took their vital signs and were able to do physical

assessment. Unfortunately I wasnt able to interview and take the vitals of the head of their

family since he was with his job.

We gave partial health teachings regarding proper hygiene as well as sanitation. The family

was able also to understand the teachings. I also examined the weight of their children and

assess with the use of IMCI.

Second visit

I still could not see any changes in the family since the house was still untidy, their

children were wearing dirty clothes and havent taken a bath yet, so again we told the family

that they need to have their house clean if they want to have a clean environment, free from

any diseases. The mother was encouraged to provide a food that are nutritious like vegetable

and fruit and avoid junk foods.

I also imparted additional health teachings with regards to management of the grand

fathers disease condition we stressed out the importance of avoidance of caffeine beverages

and smoking cessation. Also I taught pt on boiling lemon grass as alternative regimen for his

HPN.

Third visit

I was able to see some changes with regards to the surroundings of the family. Grasses

were cut very short in frontage and the mother cleaned the house. As I continue to inspect

every detail of the house, its fulfilling to the part of the student nurse that they were listening

and willing to cooperate in fulfilling the objectives of this care study.

I was able to stay long with the family and unfortunately I wasnt able to meet the head

of the family because of the same reason. And I instructed them again to go to the health

center to avail free medication, regular check- up and prenatal check up then I invited them to

attend our culminating activity.

Fourth Visit

I provided health teachings related to environmental sanitation and how to fix their

garbage by not throwing it anywhere or burning them up because it can affect the respiratory

system of the residents and specially the young children that are playing near their house. I

associated learning to them behind the importance of environmental sanitation and the benefits

that will gained towards the proper disposal of their garbage. I also evaluated them with the

activities that were given during the culminating activity and the essential knowledge and skills

that would help the family generate an income; we did not stayed for long and bid farewell to

the family leaving them with teachings that would uplift their lifestyle.

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Fifth Visit

I instructed the family to conscious enough in food handling because they have a higher

risk for diseases because of improper food handling. Even they dont have enough utensils to

provide enough food for the family as well as to keep their food safe from any foreign vectors

that could bring bacteria that may contaminate the food during the course of cooking. Also the

person cooking the food must also be aware of the cleanliness of his/her hands because he/she

is directly involve with the food, in other words hes the one holds, prepares and cooks the food

for everybody. These factors can affect to the consistency of the food and its patency to be

safe enough and to be consumed.

Sixth Visit

I ended our last visit with a productive one, were we gathered all the necessary

teachings for the family. I provided them with knowledge pertaining the disease that may

occur in each of the family member. I explained the causes of diarrhea and how to prevent and

how to cure it when one of them has it. We taught the client about making a homemade

oresol. We taught the family the ways of making it, by using a tablespoon of salt, 8 teaspoon

of sugar and one liter of sugar. We explain the importance of the homemade oresol and the

means of using it, also we included the important thing about this regimen that it can be only

be effective with the span of 24 hours and if the diarrhea is still present, the family must make

a new mixture to replace the fluids and electrolytes that were lost during the excretion of the

feces. We also gave health teachings to the management of their domestic animals and the

disadvantages that the family could acquire if they dont properly anticipated the risk for freeing

their pets and it could provide a big problem to each member of the family if they dont tie

them up and secure them in an area away from their children and to the other residents.

X. RECOMMENDATION

The student nurse have identified and prioritized problems and needs with the family.

The student nurse have also created a care plan on how to deliver the best nursing care for the

family to address their needs. The following below are propositions and commendations

recognized by both the student nurse and family:

y The family should maintain a healthy and clean environment. They must clean their

surroundings to avoid the presence of vectors of diseases.

y The family should also maintain proper hygiene such as taking a bath regularly, trimming

their nails, frequent changing of clean clothes especially when come in contact with filthy

objects or experienced wetness of the back, refraining from walking barefooted, brushing of

teeth frequently, and proper and regular hand washing.

y They must also reorganize their cooking practices in terms of food preparation and handling

as well as keeping their kitchen utensils in a covered storage to avoid getting it

contaminated by insects or pests. In addition to that, they should also cover their food

storage.

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y The family should also be advised to not wait for the ailment to become severe before

seeking medical help.

y The family must also be educated and follow the proper preparation of herbal medicines as

it was presented during the mothers class.

y The family should persevere to perform proper waste segregation and disposal of their

garbage as it was presented during the mothers class.

y The family should be aware that organizations in the community are open and present for

their problems to be addressed properly.

yThey should be encouraged to verbalize their concerns with regard to the community so

that resolutions can be made.

XI. EVALUATION

Although some short comings were not thoroughly anticipated during the care of the

family as well as referral was not very successful due lacks of time, still were able to care to the

concerned family.

There were no difficulties encountered as to the family members attitude because they

were participative and accommodating throughout the care rendered to them. In the client care

process, several interventions were done as well as health teachings. This includes the

appropriate care for the disease conditioned, information drive or further research and

education which concerns of health care and health related conditions. As well as other health

tips were emphasized to the concerned family, these were discussed as to anticipate the care of

the individual and the family as a whole.

During the termination phase, the family said their thanks for the health teachings that

were imparted to them. The objectives of this study was met, related factors that affected the

familys health was identified. Referral and appropriate interventions was provided to the family.

The objectives of the study were successfully met; health promotion and prevention of disease

was implemented as part of this study. As part of the implementation Proper referral and

interventions were done.

Poverty exists everywhere and although there are a lot of factors to consider, the

attitude of a person is really important. Poverty pushes these people to live into that type of

life status. The lack of income and financial constraints puts health as the lowest priority in

their day to day living exposing them to risk to different kinds of diseases.

It was total different experience on my part to be exposed in the Community and all its

actuality and candidness, learning the intricacies of community health nursing was more

worthwhile and full of appreciation. Previously we have one-sided view about nursing care, but

everything was changed soon after we grasped the idea of community nursing. This fact made

us realized that although the period covered for our exposure is inadequate if we truly want to

render effective health service, yet we could evaluate everything that transpired as within

satisfactory. We admit that the client who is subject of our study made all things possible for

us to learn what we need to know and what we supposed to gain in the field of community

nursing.

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XII. BIBLIOGRAPHY

Maglaya, Araceli(2004). Nursing Practice in the Community. 4th edition. Argonauta

CorporationMarikina City

IMCI (Integrated Management of Childhood Illness) Chart Booklet. 2009 edition.

Sr. Jimenez, Carmen (2008). Community Organizing Participatory Action Research

(COPAR) for

Community Health Development. C& E Publishing, Inc. Quezon City

Cuevas, Frances Prescilla (2007). Public Heath Nursing in the Philippines. 10th

edition. C& E Publishing, Inc. Quezon City

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XIII. APPENDICES

FAMILY HEALTH PLAN

y Inadequate living space

Criteria Computation Actual score Justification

Nature of theProblem

2 / 3 X 1 0.67 It is health threat that does notdemand immediate action

Modifiability of theProblem

0/ 2 X 2 0 Increasing the living space will requirequite a financial expenditure. Thefamilys resources are presently notadequate considering the other

problems.PreventivePotential

3 / 3 X 1 1 Increasing the living space willy reduce possibility of transferability

communicable disease, e.g(scabies)

y provide privacy to membersy provide bigger space to allow

adequate movements whenperforming housework

Salience of the

Problem

1 / 2 X 1 0.5 The family recognizes this as a health

threat but not needing an immediateaction

Total score 2.17

y Improper Garbage Disposal


Nature of the

Problem2 / 3 X 1 0.67 It is health threat that requires

immediate action.


2 / 2 X 2 2 The problem is easily modifiablebecause the student nurse can help the

family understand and explore wayshow to properly dispose their garbagewastes to keep environment clean.

PreventivePotential

3 / 3 X 1 1 This problem can easily be prevented ifthe family will be encouraged andmade them realized the importance ofproper garbage disposal.

Salience of theProblem

0 / 2X 1 0 The family does not recognize theexistence of the problem

Total score 3.67

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y Family size beyond what family resources can adequately



2 / 3 X 1 0.67 It is a health threat


2 / 2 X 2 2 Current knowledge, interventions andresources are available to solve theproblem.

PreventivePotential

3 / 3 X 1 1 The possibility of increasing the familysize is reduced; the available familyresources can be utilized to encouragegrowth promoting experiences formembers.

Salience of the

Problem

1 / 2 X 1 0.5 The family perceives it as a serious

problem needing attention to ensurethat the last pregnancy will be the lastone.

Total score 4.17

y Unsafe Drinking Water


Nature of the

Problem



2 / 2 X 2 2 Current knowledge, interventions andresources are available to solve theproblem.

PreventivePotential

3 / 3 X 1 1 The problem can be easily prevented ifthe family will be reminded with thesterilization method.


0/ 2 X 1 0 The family does not recognize theexistence of the problem

Total score 3.67

y Inadequate water supply





2/ 2 X 2 2 The family does not have adequateresources to solve the problem.Inadequacy of water supply is a barrierto achievement of good personal

hygiene which is very important.PreventivePotential

3 / 3 X 1 1 The problem can be highly prevented ifthe family will exert more effort ingetting for water resources that isreadily available near their house.


0/ 2 X 1 0.5 The family perceives it as a problembut does not see the problem asneeding immediate action.

Total score 4.17 The family does not recognize the

existence of the problem

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