FNCP 3rd Year 1st Sem

7/28/2019 FNCP 3rd Year 1st Sem

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DE LA SALLE HEALTH SCIENCES INSTITUTE

COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY

COMMUNITY HEALTH NURSING

FAMILY NURSING CARE PLAN

POBLACION HEALTH CENTER

PRESENTED TO: MS. JULIETA B. MONZON, RN, MAED

CLINICAL INSTRUCTOR

PRESENTED BY: JUSTIN ALECCA MARIE V. REYES

BSN 3 1 RLE GROUP 1


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DE LA SALLE HEALTH SCIENCES INSTITUTE

COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY

FAMILY NURSING CARE PLAN

HEAD OF THE FAMILY: Josephine NunezFAMILY MEMBER: 10 members_____________

ADDRESS: Plaridel, Imus, Cavite_____

FAMILY STRUCTURE: Extended____

PLACE OF ORIGIN: Imus, Cavite_____________

RELIGION: Roman Catholic________________

ETCHNIC GROUP: Caviteo__________________

I. Assessment of Family Structures and Dynamics / Socio Economic and Cultural Characteristics:A. Family Structure / Socio Economic

Family MemberRelation to

HeadSex

Birthdate

Civil Status

Highest

Education

Completed

OccupationMonthly

EarningRemarks

No. Name Month Year AgeType of

WorkPlace

1 Josephine NunezHead of

FamilyFemale April 1960

53 years

oldWidowed

high school

graduate

Sari-sari

store

owner

ImusNot

Disclosed

2 Jayzee N. Rapsing Eldest child Female August 198726 years

oldMarried

High School

Graduate

Direct

SellerImus

Not

Disclosed

3 Joey Rapsing Son-in-law Male April 197737 years

oldMarried

College

Undergradu

ate

Driver Imus

4 Jesus Nunez Jr. 2nd

child MaleSeptembe

r 198825 years

old Married

High School

Undergraduate

Constructio

n Worker

5 Myra Nunez Daughter- Female November 1988 25 years Married High School None


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in-law old Graduate

6 Jesher John Nunez 3rd child Male October 199022 years

oldSingle

Grade

School

Graduate

None

7 Renzel NunezYoungest

ChildMale March 1996

17 years

oldSingle

Grade school

Undergradu

ate

None

8 Brian Brix Rapsing Grandson Male March 20085 years

oldSingle

Kinder

StudentN/A

9 Jilliane Rapsing Grandson Male May 20094 years

oldSingle

Nursery

studentN/A

10 Lenny Jane NunezGranddaug

hterFemale November 2010

2 years

oldSingle N/A N/A

a.1 Dominant Family Member/s in terms of decision making especially on the aspect of health care: Mother ( Josephine Nunez)

a.2 Presence of any obvious / readily observable conflict between members of the family: ( ) Yes () No

a.3 Adequacy to meet basic necessities (foods, clothing, shelter, etc.): ()Yes ( ) No

a.4 Who makes decisions about money: Mother

a.5 Membership in an Organization: ( ) Yes () No

Name of the Organization: ______________________________________________________

Nature of Organization: ________________________________________________________

Position in the Organization: ____________________________________________________

B. Home and EnvironmentDate Assessed: July 24, 2013

1. Homea. Ownership: () Owned ( ) Rented ( )Rent Freeb. Construction Materials used: ( ) Light () Mixed ( )Strongc.

Number of rooms used for sleeping: 1 room only

d. Lighting Facilities: () Electricity ( ) Kerosene ( ) Others: Specify:e. Ventilation: ( ) Good () Poor


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f. General Sanitary Condition (Overall surroundings of house and environment): The house has poor ventilation and lighting. The place is clean,but clothes were scattered on the floor. The environmental area is clean, as well as the outside.

2. Drinking Water SupplySource: ( ) Private ( ) Public Potability: tap water from sink

Distance from house: Within the lot area

Storage: () None (Direct from faucet or pipe)

( ) Large covered container with faucet

( ) Large uncovered container without faucet

( ) Others: Specify:

3. KitchenCooking Facility: ( ) Electric Stove ( ) Gas Stove () Firewood / charcoal

Sanitary Condition: The kitchen is clean but it is located outside which may be a breeding site for microorganisms.

Drainage Facility: ( ) open drainage ( ) blind drainage ( ) none

4. Waste Disposala. Refuse and garbage

Container: () covered ( )open ( ) none

Method of disposal:( ) hog feeding ( ) composting

( ) open dumping ( ) open burning

( ) burial in pit () others. Specify: Weekly garbage collection

b. Toilet Type( ) none ( ) pail system

( ) overhang latrine ( ) Antipolo

( ) open pit privy () water-sealed latrine

( ) closed pit privy ( ) flushed type

( ) bore hole latrine

( ) others. Specify

Distance from house: Inside the house

Sanitary condition: The restroom is dirty and unsanitary.

5. Domesticated Animals No domestic animals


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Kind Number Where Kept

6. Nutritiona.Food Preferences (general/day)

() vegetables ( ) pork ( ) beef ( ) chicken () fish

Number of glasses consumed/day:

Juice: _Not taken daily_______

Water: 5-6 glasses__________

Softdrinks: 2-3 bottles daily___

Number of meals/day: 2x___

Number of snacks/day: 1x (sometimes none)__

b.Ways and means of food preparation (most of the time)() at house ( ) instant meals ( ) others __________________________

7. The Community in Generala.General sanitary condition: The community is clean, and there is no obvious danger that can be seen and observed.b.Housing congestion: () Yes ( ) Noc.Recreational Facilities: A playground is located near the house.d.Availability of healthcare services (Describe briefly): The family visits the Health center nearby.e.Distance of house from the nearest health care facility: The health center is near. Around 5-10 mins away.

8. Other informationa.Personal habits (15 years old and above)

Name: Josephine Nunez

( ) Smoking Number of packs/day:________________


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( ) Drinking alcoholic beverages

( ) Prohibited drugs

Name: Jayzee N. Rapsing

( ) Smoking Number of packs/day:_____1/2 pack_____



Name: Joey Rapsing




Name: Myra Nunez




Name: Jesher John Nunez


( ) Drinking alcoholic beverages( ) Prohibited drugs

Name: Renzel Nunez




b.Family Planning() Acceptor ( ) Defaulter ( ) Non acceptor Method: Pills

C. Health Status of Each Family Member (Only the present member)Josephine Nunez

i. Nursing history indicating:1. Present and past significant illnesses or beliefs and practices conducive to health and illness:


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The client has no present health problems.

2. Dietary History (quality & quantity of food intake per day):The client eats vegetables every day. She verbalized that she oftentimes skip meals.

3. Eating and feeding habits and practices:The client states that they eat vegetables all the time to keep themselves healthy.

ii. Developmental Assessment for infants, toddlers and preschooler (MMDST/s): N/Aiii. PYSICAL ASSESSMENT / RESULT OF LABORATORY / DIAGNOSTIC EXAM (Previous or Latest) OF ALL FAMILY MEMBERS:

SYSTEM REVIEW OF SYSTEMS PHYSICAL EXAM

General / Overall Health Status Ok naman kaso puyat ako parati.

Awake, conscious, coherent Good body posture

With good muscle strength

SHEENT minsan sinisipon lang ako

PERRLA Eyelids are moist and pink, eyelashes

short, evenly spaced and curled

outward.

Eyes are round shaped and equal

Reflection of light noted at the samelocation on both eyes.

(-) Earaches (-) Ear infection

(-)Ear lesions, masses Ears equal in size and symmetrical Skin smooth and without nodules

Auricle non-tender. (+) dark pink, moist nasal mucosa

(-) lesions (+) Symmetrical tongue, no lesions on

surface or sides.

(-) nodules, masses or pain reported onpalpation.

Non-tender sinuses.


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CHEST / LUNG Wala akong hika No unusual lump or nodules

(-) AsthmaCARDIO Wala namang problema sa puso ko

No history of heart problems No murmurs and gurgling and extra

heart sounds

ABDOMEN Wala, ok lang

No history of abdominal diseases orsurgery

.

GUTmahilig ako sa maalat pero wala naman aa

akong sakit sa bato PE NOT DONE

EXTREMITIES

Wala naman ako masyadong ugat sa kamay

lang konti at masakit din mga kalamnan

minsan pero nwawala din.

No varicosities or lesions No muscle weakness

Brian Brix Rapsing

i. Nursing history indicating:1. Present and past significant illnesses or beliefs and practices conducive to health and i llness:

The client has no past and present health problems.

2. Dietary History (quality & quantity of food intake per day):The client mostly eats vegetables and fish per day. The mother verbalized that he eats sufficient food every meal and sometimes not.

3. Eating and feeding habits and practices:N/A

ii. Developmental Assessment for infants, toddlers and preschooler (MMDST/s): SEE MMDST SCRAPBOOKiii. PHYSICAL ASSESSMENT / RESULT OF LABORATORY / DIAGNOSTIC EXAM (Previous or Latest) OF ALL FAMILY MEMBERS:

SYSTEM REVIEW OF SYSTEMS PHYSICAL EXAM

General / Overall Health Status N/A

No history of illness Body build is bilateral.

Adult appears to be statedchronological age

SHEENT N/A No blurring of vision


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PERRLA Eyelids are moist and pink, eyelashes

short, evenly spaced and curled outward.

Eyes are round shaped and equal Reflection of light noted at the same

location on both eyes.

(-) Earaches

(-) Ear infection (-)Ear lesions, masses

Ears equal in size and symmetrical Skin smooth and without nodules

Auricle non-tender. (+) dark pink, moist nasal mucosa

(-) lesions (+) Symmetrical tongue, no lesions on

surface or sides.

(-) nodules, masses or pain reported onpalpation.

Non-tender sinuses.CHEST / LUNG N/A

No unusual lump or nodules (-) Asthma

No wheezing (-) SOB

CARDIO N/A

No history of heart problems (-) Cyanosis, pallor

No murmurs and gurgling and extraheart sounds

ABDOMEN N/A

No history of abdominal diseases orsurgery

(-) Abdominal pain (-) Nausea and Vomiting

Abdomen is rounded and symmetrical.GUT N/A (-) Painful urination


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EXTREMITIES N/A

No muscle weakness No varicosities or lesions

Upper and lower extremities are warmD. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention

1. Immunization status of Family members:Name Age

Bacillus

Calmette

Gurin

Hepatitis B

Vaccine

OralPolio

Vaccine

DiphtheriaPertussis

Tetanus

Vitamin

A

MeaslesMumps

Rubella

Vaccine

Remarks

1 2 3 1 2 3 1 2 3

Josephine Nunez 53 years old

Jayzee N. Rapsing 26 years old

Joey Rapsing 37 years old

Jesus Nunez Jr. 25 years old

Myra Nunez 25 years old

Jesher John Nunez 22 years old

Renzel Nunez 17 years old

Brian Brix Rapsing 5 years old

Jilliane Rapsing 4 years old Lenny Jane Nunez 2 years old

2. Healthy Lifestyle Practices: ( ) Yes () NoSpecify:

3. Adequacy of rest and sleep: ( ) Yes ( ) No How many hours: 4-5hours4. Relaxation / stress management: () Yes ( ) No

Specify: watching television, talking with the neighbors

5. Use of protective measures:( ) mosquito net () footwear () protective clothing ( ) others. Specify:

II. PROBLEM SHEETHealth Condition and Problems Cues / Data Family Nursing Problems

Poor home condition Home is small for the number of membersresiding

Inability to provide an environment conduciveto health maintenance and personal


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Only one room is utilized for sleeping. The living room is sometimes made into a make-

shift bedroom

development due to inadequate family

resources, specifically limited physical

resources.

Poor drainage systems The drainage system is an open type. Drainage isnt being cleaned regularly Inability to provide an environment conduciveto health maintenance and personal

development due to inadequate knowledge of

preventive measures.

Poor food handling and preparation Kitchen is outside Kitchen is dirty and smelly. No covers are available for the leftover food.

Inability to provide an environment conduciveto health maintenance and personal

development due to inadequate knowledge of

importance of hygiene and sanitation.

III. PRIORITIZATION OF NURSING PROBLEMA. SCALE FOR RANKING HEALTH CONDITIONS AND PROBLEMS ACCORDING TO PRIORITIES


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SCALE FOR RANKING HEALTH CONDITIONS AND PROBLEMS ACCORDING TO PRIORITIES

CRITERIA WEIGHT

1. NATURE OF THE CONDITION OR PROBLEMPRESENTED

A.WELLNESS STATE

B. HEALTH DEFICIT

C. HEALTH THREATS

D. FORSEABLE CRISIS

3

3

2

1

1

2. MODIFIABILITY OF THE CONDITION OR PROBLEMA. EASILY MODIFIABLEB. PARTIALLY MODIFIABLEC. NOT MODIFIABLE

2

1

0

2

3. PREVENTIVE POTENTIALA. HIGHB. MODERATEC. LOW

3

2

1

1

4. SALIENCEA. A CONDITION OF THE PROBLEM NEEDING

IMMEDIATE ATTENTION.B. A CONDITION OF THE PROBLEM NOT

NEEDING IMMEDIATE ATTENTION

C. NOT PERCEIVED AS PROBLEM ORCONDITION NEEDING CHANGE

2

1

0

1

SCORING:

1. DECIDE ON A SCORE FOR EACH OF T HE CRITERIA.2. DIVIDE THE SCORE BY THE HIGHEST POSSIBLE SCORE AND MULTIPLY BY WEIGHT. (SCORE/

SCORE X WEIGHT)

3. SUM UP THE SCORE FOR ALL CRITERIA. T HE HIGHEST SCORE IS 5 EQUIVALENTS TO TOTALWEIGHT.

B. CASE ILLUSTRATION ON PRIORITY SETTING


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Problem: Inability to provide an environment conducive to health maintenance and personal development due to inadequate family resources,

specifically limited physical resources.

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

Nature of the problem

Modifiability of the problem

Preventive potential

Salience

2 / 3 x 1

1 / 2 x 2

2 / 3 x 1

0 / 2 x 1

.6

1

.6

0

Inability to provide homeenvironment conducive to health

maintenance due to financial

constraints The problem is partially

modifiable because the problem

cannot be easily solved due to

financial hardship that the family

experiences.

The problem is highly preventableby just fixing this problem with

little effort like cleaning.

The family does not perceive thisas problem of condition needing

change because they believe that

even if their house is crowded,

the important thing is they can

sleep and rest.

Total Score

2.2


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Problem: Inability to provide an environment conducive to health maintenance and personal development due to inadequate knowledge of preventive

measures..


Nature of the problem



Salience

2 / 3 x 1

2 / 2 x 2

3 / 3 x 1

1 / 2 x 1

.6

2

1

.5

The drainage is a breeding site formicroorganisms.

The drainage is ta concern of thebarangay officials, but they can do

measures to cover the drainage

temporarily.

The problem is highly preventableby just fixing this problem with

little effort like following health

care providers order.

The family perceives this problemas a condition not needing an

immediate attention because it

still hasnt brought diseases to the

family.

Total Score

Problem: Inability to provide an environment conducive to health maintenance and personal development due to inadequate knowledge of importance

of hygiene and sanitation.


Nature of the problem 2 / 3 x 1 .6 Inability to recognize the presence

4.1


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Salience

2 / 2 x 2

3 / 3 x 1

1 / 2 x 1

2

1

.5

of the situation and condition due

to inadequate knowledge

The family could easily transferand clean the equipment in their

kitchen.

\ The problem is highly preventable

by just making surethat the

kitchen is kept clean.

The family perceives this problemas not needing immediate

attention as long as they have ni

illness and theyre only threats and

not yet deficits.

Total Score

IV. FAMILY NURSING CARE PLANHEALTH PROBLEM

FAMILY NURSING

PROBLEMSOBJECTIVES OF CARE

PLAN OF INTERVENTION EVALUATION PLANURSING

INTERVENTIONSMETHODS OR TOOLS

RESOURCES

REQUIRED

OUTCOME CRITER

INDICATORS

4.1


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Inability to

provide an

environment

conducive to

health

maintenance and

personal

development dueto inadequate

knowledge of

importance of

hygiene and

sanitation.

Inability toprovide an

environment

Presence ofbreeding sites of

vector-borne

diseases and

contamination.

Neglectingcondition of the

dirty

surroundings

Risk fordevelopingdiseases such as

After 1-2 days ofhome visit, the

family will be able

to:

-become aware of

the threat that the

open drainage have.

- become more

conscious about the

open drainage and

make preventive

steps regarding the

matter.

After 1-2 days ofhome visit, the

ProvideHealth

teaching on

the

disadvantages

of the open

drainage

(presence of

breeding sites,

risk for

accidents)

Encourage thefamily to clean

the drainage

as much as

possible.

Emphasizeimportance of

clean and

healthyenvironment

Encouragefamily to

monitor and

check the

places that

are prone to

dust and dirt

ProvideHealth

Home visitLecture discussion

Home visitLecture discussion

Pen andpaper

Researchregarding

the matter

Time andeffort of the

student

nurse and

family

Visual Aids Time and

effort of the

student

The family wbe able to

verbalize th

the health

problem

imposes a

health threa

their family

The family wtake preven

measures b

cleaning,

covering an

reporting th

drainage to

barangay

officials..

The family be able realize

importance


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conducive to

health

maintenance and

personal

development due

to inadequate

knowledge of

importance ofhygiene and

sanitation.

Hepatitis and

Botulism.

family will be able

to:

-Recognize the

threat imposed to

the family in relation

to the unsanitary

handling of food.

-Take actionsregarding the matter

by

transferring/cleaning

the kitchen

appliances.

teaching

regarding the

different

diseases that

the family can

acquire when

food is

preparedunsanitary.

Emphasizeimportance of

proper food

handling.

Encourage thefamily to have

a container

and a cover

for kitchen

and eating

utensils Emphasize

importance of

knowing the

different

food-borne

and

transmissible

diseases.

nurse and

family

Pen andpaper

proper

handling

preparation

The famembers

should

willingness knowledge

understand

about good

healthy hab

V. SUMMARY OF LAST DAY OF HOME VISIT


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During the last day of the home visit, the head of the family is the only one in their home because the children are n school and the others are

somewhere else. I saw how little changes, such as the cleaner living room, and the place where they cook is cleaner than the first time I saw it. I was also able to do health

teachings regarding the problems I identified. Before I left, I was able to say thank you for their hospitality.

VI. PHOTO DOCUMENTATION

FNCP 3rd Year 1st Sem

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Transcript of FNCP 3rd Year 1st Sem