Initial Data Base and FNCP
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Transcript of Initial Data Base and FNCP
INITIAL DATABASE
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INITIAL DATA BASE
Our duty in the community started last September 29, 2008 and ended on September 30,
2008. Our clinical instructor in the area, Mrs. oriented us on what will be our assignments and
routines in our two days stay. The group was divided by pair and was instructed to choose a
client for family assessment. This family will be their chosen subject for study.
MQP, a client during that time, who happens to have rashes all over his body, which our
instructress identified to be measles, was our subject of study. According to the mother, the
child had a fever for three days before those rashes appear.
Given a subject, me and my partner formulated plans and designated task to done
individually. We ask permission to our client to be able to visit her at home. Upon the approval
of our request we set a date of visit. The next day, equipped with the necessary tools, we
proceeded in their home for our home visit.
A. FAMILY STRUCTURE AND DYNAMICS
No. Name of
family member
Sex Birthday
(mm/dd/yy)
Age Height
1 DDP M 12-07-78 29 y/o 5’ 10’’
2 NP F 05-11-80 28 y/o 5’ 2’’
3 MQP M 03-13-2008 6 ½ mos. 22 inches
Weight Civil Status Religion Educational
Attainment
Occupation
Relationship to family
head
69.41kg M R/C CG GRCO Head of the family
54.98kg M R/C CUG Wife
Housewife
7kg C R/C N/A N/A Sibling
Family’s head DDP is 29 years old, born on December 7, 1978, 5’10’’ in height and 153
lbs. in weight. He is a GRCO graduate, presently working in CC in Boni Avenue. His wife NP is
28 years old, born on May 11, 1980, 5’2’’ in height and weighs 119 lbs. She was an
undergraduate of the course Bachelor of Science in Business Administration. Presently, she
was a plain housewife to DDP and a mother to their child. NP was born in the Northern part of
Samar while her husband was from the Western part of it. Their three years of marriage was
blessed with a healthy baby boy named MQP. He is 61/2 mos.old, 22 inches long and weighs
15.43 lbs. All family members are Roman Catholic. To show their dedication they never fail to
go to church every Sunday to give thanks and praise for all the blessings God has given them.
Their family is nuclear in structure. According to them they owned the house but not the
land, for it is owned by the government. Common languages spoken were Waray and Tagalog.
In times of conflicts and problems they always depend on each other in solving it. For them
they can face any kind of hardships and problems as long as they are together.
B. SOCIO-ECONOMIC STATUS
Monthly Income: P10, 000-P15, 000
Weekly Budget: P2, 500
Amount Expenditure
P1500 Foods( Groceries)
P500 Bills: Electricity and water
P250 Transportation (Father)
P250 Savings
TOTAL: P2,500
Prioritization of Need
Rank Priorities
1 Food
2 Bills
3 Transportation
Majority of the family’s budget is allocated to their food needs. Second to this is their
budget to their billings like electricity and water. Based from the table above you can observe
that they give importance to their savings. This is for the preparation of their child’s future.
When it comes to their clothing you can observe it has not been indicated above for they
seldom spend money in clothing.
Financial difficulties of the family are solved by borrowing money from friends and
relatives, to be returned after the head of the family received his salary.
C.ENVIRONMENT
Home:
Ownership of the House Owned
Construction Materials Used Mixed
Space adequacy Adequate
Lighting Facility Electricity
Lighting Adequacy Adequate
Ventilation Adequate
Water Supply Level III (nawasa)
Drinking Water Nawasa
Food Storage Covered
Waste Disposal:
Garbage Container Covered
Method of Disposal Garbage Collection
Toilet Facility Level II (with poso negro not connected to
sewerage)
Drainage System:
Type of Drainage Open Drainage
Domestic Animals, Insects, Breeding Sites:
Pets/Animals None
Pests/Insects Rodents, Cockroaches, Mosquitoes, Flies
Way of Eradication Trapping, Using Insecticides
FLOOR PLAN MEASUREMENT
7
ROOM
SALA KITCHEN CR
77
10
B. HEALTH STATUS
GEONOGRAM OF PALIMA FAMILY
NPDD P
LP ES YSRP
NoneHypertension, Diabetes
PHYSICAL ASSESSMENT
Name of Client: DDP
Age: 29 years old
MEASUREMENTS
MQP
RESULT NORMAL VALUES ANALYSIS
Height 5’ 10’’A medium frame man with a height of 5’10’’ should have a weight range of 151-163 lbs.
Normal
Weight 153 lbs (69.41kg)
VITAL SIGNS
Temperature 36.5 degree celcius 36-37 degree celcius NormalPulse Rate 63 60-100 bpm NormalRespiratory Rate 20 16-20 bpm NormalBlood Pressure 110/80 120/80 Normal
HEAD TO TOE ASSESSMENT
AREAS TO BE
ASESSED
NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Skull
Scalp
Symmetry
Without flakes
Symmetry
Without flakes
Normal
Hair
Face
Eyebrows
Eyelashes
Eyelids
Lower palpebral
(conjunctiva)
Sclera
Cornea
Pupils
Iris
Eye movement
Visual fields
Visual acuity
Ear canal
Hearing acuity
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Coordinated
Can see object in
peripheral
20/20 vision
Uniform in color
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Coordinated
Can see object in
peripheral
20/20 vision
Uniform in color
Normal and
healthy
Normal and
healthy
Internal nares
Septum
Lips
Gums
Teeth
Tongue
Frenulum
Cheeks, buccal mucosa
Palate
Uvula
Tonsils
Voice
Muscular strength
Areola
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
32, smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Pink and smooth
Can be heard
Equal strength
Round or oval
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Pink and smooth
Can be heard
Equal strength
Round or oval
Normal and
healthy
Normal and
healthy
Normal and
Nipples
Abdomen Round and equal
Unblemished skin, uniform
in color
Round and equal
Unblemished skin,
uniform in color
healthy
Normal and
healthy
Name of Client: NP
Age: 28 years old
MEASUREMENTS
RESULT NORMAL VALUES ANALYSIS
Height 5’ 2’’A small frame man with a height of 5’2’’ should have a weight range of 115-130 lbs.
Normal
Weight 119 lbs. (54.98 kg)
VITAL SIGNS
Temperature 37 degree celcius 36-37 degree celcius NormalPulse Rate 70 60-100 bpm NormalRespiratory Rate 19 16-20 bpm NormalBlood Pressure 100/80 120/80 Normal
HEAD TO TOE ASSESSMENT
AREAS TO BE
ASESSED
NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Skull
Scalp
Hair
Face
Eyebrows
Eyelashes
Eyelids
Lower palpebral
(conjunctiva)
Sclera
Cornea
Pupils
Iris
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Normal
Normal and
healthy
Eye movement
Visual fields
Visual acuity
Ear canal
Hearing acuity
Internal nares
Septum
Lips
Gums
Teeth
Tongue
Frenulum
Cheeks, buccal mucosa
Palate
Uvula
Coordinated
Can see object in
peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
32, smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Coordinated
Can see object in
peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Normal and
healthy
Normal and
healthy
Normal and
healthy
Tonsils
Voice
Muscular strength
Areola
Nipples
Abdomen
Pink and smooth
Can be heard
Equal strength
Round or oval
Round and equal
Unblemished skin, uniform
in color
Pink and smooth
Can be heard
Equal strength
Round or oval
Round and equal
Unblemished skin,
uniform in color
Normal and
healthy
Normal and
healthy
Name of Client: MQP
Age: 6 ½ mos. old
MEASUREMENTS
RESULT NORMAL VALUES ANALYSIS
Height 22 inches An average weight of a
6 months old infant is
16.53 lbs.
Normal
Weight 15.43 lbs (7 kg)
VITAL SIGNS
Temperature 37.2 degree celcius 37.2 degree celcius Normal
Pulse Rate 113 bpm 120-140 bpm Normal
Respiratory Rate 48bpm 30-50 bpm Normal
HEAD TO TOE ASSESSMENT
AREAS TO BE
ASESSED
NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Skull
Scalp
Hair
Face
Eyebrows
Eyelashes
Eyelids
Lower palpebral
(conjunctiva)
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
Normal
Normal and
healthy
Sclera
Cornea
Pupils
Iris
Eye movement
Visual fields
Visual acuity
Ear canal
Hearing acuity
Internal nares
Septum
Lips
Gums
Teeth
Tongue
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Coordinated
Can see object in
peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
32, smooth, shiny
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Coordinated
Can see object in
peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
smooth, shiny
Normal and
healthy
Normal and
healthy
Frenulum
Cheeks, buccal mucosa
Palate
Uvula
Tonsils
Voice
Muscular strength
Areola
Nipples
Abdomen
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Pink and smooth
Can be heard
Equal strength
Round or oval
Round and equal
Unblemished skin, uniform
in color
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Pink and smooth
Can be heard
Equal strength
Round or oval
Round and equal
Unblemished skin,
uniform in color
Normal and
healthy
Normal and
healthy
Normal and
healthy
ABNORMAL FINDING:
Skin Smooth and
unblemished
Rashes all over the
body
Measles is an
infection
characterized by
fever rashes and
symptoms
referable to upper
respiratory tract,
the eruption is
preceded about 2
days coryza, during
which stage
grayish peck
(Koplik Spots) may
be found on the
inner surface of the
cheeks. A
morbilliform rash
appears on the 3rd
or 4rth day
affecting the face,
body and
extremities.
( Public Health
Nursing pp. 267)
Nutritional Status
Name of Family Height Weight BMI Interpretation
Member
DDP 5’ 10’’ 153lbs 22 Normal
NP 5’ 2’’ 119lbs 22 Normal
MQP 22 inches 15.43 lbs 23 Normal
All the family members have normal total body mass index because the ratio was 18.5-24.9.
Exercise Pattern
Name of Family
Member
Hours of Exercise Times per Week Normal
DDP 30 minutes 7 times a week 30 minutes/day
NP 30 minutes 7 times a week 30 minutes/day
MQP N/A N/A n/a
The father, DDP was not able to practice it everyday because of work. His wife on the other
has a daily routine exercise in a form of dancing. Their child on the other hand was still too
young to participate in the activity.
C. Values, Belief and Practices
Just like typical Filipinos they grow up to an environment wherein respect was being emphasized. The kind of environment they want their child to have and grow-up with. They do not want him to be stubborn or disrespectful in front of people older than him. They want him to believe and have faith in God just like them. For them what they plant to their child is what they will also earn in the future.
II. ORGANIZATIONAL DATA
Cues Normal Standards Based on Reference
Subjective:
“Nilagnat siya ng tatlong araw
bagolumabas yang mga pula-pula
niya sa katawan.”
A healthy child must be free from diseases or illnesses
like fever cough and colds, rashes and the like.
Subjective:
“Ang daming ipis dito pag umaga,
yung pag binuksan mu yung ilaw,
kanya kanyang takbo na sila. Minsan
din malangaw at may magnilan-
ngilang daga na naghaharutan sa
may kisame.”
A healthy home must be free from rodents and pest, it is
clean, well ventilate and free from threats.
Subjective:
“Nakakatakot lang ditto yung bukas
na kanal dyan sa may labas. Lalo
kapag umuulan at bumabaha, baka
kasi di mapansin malusbot dun”
A healthy home must be free from rodents and pest, it is
clean, well ventilate and free from threats.
III. CLUSTERED DATA
Cues/Data Family Health Care Plan
6 ½ mos old male infant with cough and
rashes all over his body.
“Nilagnat siya ng tatlong araw
bagolumabas yang mga pula-pula niya sa
katawan.”
“Ang daming ipis dito pag umaga, yung
pag binuksan mu yung ilaw, kanya
kanyang takbo na sila. Minsan din
malangaw at may magnilan-ngilang daga
na naghaharutan sa may kisame.”
“Nakakatakot lang ditto yung bukas na
kanal dyan sa may labas. Lalo kapag
umuulan at bumabaha, baka kasi di
A. Measles and as a Health Deficit
1. Inability to provide adequate nursing care to the
dependent member with measles and cough due to:
Lack of knowledge on the nature and management of
the health condition.
B. Presence of Vectors and Rodents as Health Threat
1. Inability to recognize the health threat due to lack of
knowledge about the condition.
2. Inability to make decisions with regards to the
management of the condition due to the failure on
identifying what measures are appropriate.
3. Inability to provide home conducive to health
maintenance and personal development due to
ignorance in preventive measures.
mapansin malusbot dun”
C.Open Drainage as Health Threat
1. Inability to make decisions with respect to taking
appropriate health actions due to lack of knowledge
about alternative solutions.
IV. PRIORITIZATION OF THE PROBLEM
1. Measles with cough
CRITERIA COMPUTATIO
N
SCORE JUSTIFICATION
Nature of the problem
Modifiability of the
problem
Preventive potential
Salience
3/3 x 1
2/2 x 1
3/3 x 2
2/2 x 1
1
1
2
1
It is a health deficit that requires immediate
intervention.
Resources needed are available.
With the compliance in the given instructions of
appropriate health providers, disease will be
manageable.
The family considers this as a problem that
needs immediate attention.
TOTAL 5
2. Presence of Vectors and Rodents
CRITERIA COMPUTATIO
N
SCORE JUSTIFICATION
Nature of the problem
Modifiability of the
problem
Preventive potential
Salience
2/3 x 1
½ x 2
2/3 x 1
1/2 x 1
0.7
1
0.7
0.5
It is a health threat that needs an immediate
attention.
The family has the necessary resources but does
not utilize them properly.
The susceptibility in acquiring other infections
can be prevented if the problem will be solved.
The problem was recognized by the family but
they do not think it needs an immediate
attention.
TOTAL 2.9
3. Open Drainage
CRITERIA COMPUTATIO
N
SCORE JUSTIFICATION
Nature of the problem
Modifiability of the
problem
Preventive potential
Salience
2/3 x 1
½ x 2
2/3 x 1
1/2 x 1
0.7
1
0.7
0.5
It is a health threat for it could damage the
health of the family.
It is partially modifiable for the family alone
can’t solve the issue, referral to higher officials
were still needed.
Solving the problem lessen the risk of the family
on acquiring infections brought about by an
unpleasant environment
The family recognizes the problem but does not
think it needs an immediate action.
TOTAL 2.9
PROBLEM PRIORITIZATION
Family Problems According to Priority
1 Measles and cough 5
2 Presence of Rodents and Vectors 2.9
3 Open Drainage 2.9
V. FAMILY HEALTH CARE PLAN
HEALTH
PROBLE
M
FAMILY
NURSIN
G
GOAL OF
CARE
OBJECTIVES
OF CARE
INTERVENTION PLAN
NURSING
INTERVENTION
METHOD OF
RESARCHER-
FAMILY
CONTACT
RESOURCES REQUIRED
Measles
and cough
Inability
to
manage
the
After
nursing
intervention,
the family
After nursing
intervention, the
family:
1. Establish rapport.
2. Prepare the
necessary equipments
needed.
Home Visit Material Resources:
Visual Aids on Measles and
cough.
condition
due to
the lack
of
knowledg
e
regardin
g its
managem
ent.
must be
equipped
with the
necessary
knowledge
they need in
dealing with
the
situation.
-will be able
identify the
cause and effect
of the disease.
-Know the
appropriate
intervention to
make.
3. Inform the family
about the visit.
4. Health education
about the diseases and
its management.
Human Resources:
Time and effort of both the
researchers and the family.
Financial Resources:
Money for the researchers’
transportation and food (if
necessary).
FAMILY HEALTHCARE TEACHING PLAN
NURSING
INTERVENTION
METHOD OF
RESARCHER-FAMILY
CONTACT
RESOURCES REQUIRED
1. Analyze with the family
the problems measles and
cough.
Home Visit Material Resources:
Visual Aids on Measles a cough.
2. Discuss with the family
the appropriate courses of
action.
3. Enumerate to the family
the danger signs they need
to watch out for namely:
inability of the infant
to drink or
breastfeed
vomits everything
convulsions
abnormally sleepy or
difficulty to awaken
Human Resources:
Time and effort of both the researchers and the family.
Financial Resources:
Money for the researchers’ transportation and food (if
necessary).
What to teach…
What is measles?
Measles is one of the most contagious viral diseases. It is caused by paramyxo virus and is the most unpleasant and the most dangerous of the children's diseases that result in a rash. This is due to the complications of the disease.
How is measles transmitted?
Droplets transfer the infections. Although the sick person may be in isolation, the disease may still spread from room to room.
Anybody who has not already had measles can be infected. Infants up to four months of age will not be infected if their mother has had measles herself
because they will be protected by her antibodies. The incubation period - the time between infection and the outbreak of the condition - is usually one
to two weeks. Patients are infectious from four days before the onset of the rash until five days after it appears.
What are the symptoms of measles?
After about 14 days the following symptoms start showing:
A fever at about 39ºC.
A cold. Coughing, possibly with a barking cough. Sore throat - the lymph nodes in the throat may swell. Reddish eyes. Sensitivity to light. Grayish spots, the size of grains of sand may appear in the mucous membrane of the mouth just
around the molar teeth. These are called Koplik's spots and can be seen before the rash appears. After three to four days the temperature may fall, although it can run high again when the rash
appears. The rash usually begins around the ears and spreads to the body and the legs within a day or two. At first the spots are very small - a couple of millimeters - but they double in size quickly and begin
to join together. The spots are a clear red color. The temperature, which may run as high as 40ºC, may stay that high for a couple of days. Then it
disappears together with the rash, which may leave some brown spots. After a week the child will be fit again.
How are measles treated?
The treatment is to stay in bed in a cool room without any bright lights. Medicines for coughing and reducing the temperature should only be given after consulting a GP.
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