Family Case Study

I.
INTRODUCTION
A. Overview
Community health nursing is important, aside from being a specialized field of
nursing practice. Community health nursing is one of the two major fields of nursing in
the Philippines; the other is in the hospital. Community nursing practice means different
things to different nurses, that is, for many, it emphasize the setting of practice; which in
other term, it is a nursing practice outside the hospital.
Community health nurse has different clients and these include the individual,
family, population group and community itself. Family as one of the client the very
important social institution that performs two major functionsreproduction and
socialization. It is generally considered as the basic unit of care in the community health
nursing for many reasons. It may contribute knowingly or unknowingly to the
development of health and nursing problems of its members. It also performs health
promoting, health maintaining and disease-preventing activities. In many cases, it is the
family that provides unfailing nursing care particularly to the chronically-ill members.
Among the many family, it serves of prime importance is the role of the family
plays in providing emotional support and security to its members through love,
acceptance, concern and nurturing. This affective component holds families together,
gives family members a sense of belonging, and develops a sense of kinship. This is
accomplished by meeting the basic needs of its members: food, clothing, shelter and
provision of physically safe environment require skills, knowledge and economic
resources. In nursing profession, nurses consider the health of the family as a unit in
addition to the health of the individual family members.
FAMILY CARE STUDY BY: ANZELO AQUINO
Page 1
B. OBJECTIVES of the STUDY

This care study provides goals or objectives which serve as an instrument in
comprehensively assessing the patients health status and present condition. It also
focuses on the following aims:
Know the disease process
How the environment affects such problem that a family is experiencing
Promote health
Impart knowledge about health and wellness
Empower the family to maximize their abilities to achieve an optimum well being.
The interaction with the family has helped students to appreciate the essence of
community health nursing. They played a special part for students to become an
effective health care provider.
C. SCOPE and LIMITATION of the STUDY
On our community exposure at Zone 2, Baikingon, Cagayan de Oro City,
the students chose among those households of which they have assessed needs to be
prioritize for care. Home visits and family interactions were initiated to identify nursing
problems of the family.
This study analyzes the interplay of the different factors that affect the familys
health. However, the study is limited depending on the information being disclosed by
the family members and other sources and based on the objective aspects as the family
is being observed and monitored. Through constant interaction, the factors that affect
the family health were identified and appropriate interventions were done utilizing the
nursing process.
D. SIGNFICANCE of the STUDY
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The family care study was intended to provide information regarding the health
hazards, health deficits and health threats the family encountered. Through this study,
knowledge and information about maintenance that is being imparted to them may be
able to maximized and prevent elements that would threaten their health.
E. SPOT MAP
The Legaspi family resides in Zone 2, Baikingon, Cagayan de Oro City. It is
approximately 20 kilometers away from Liceo de Cagayan University. It can either be
reached by taking a private vehicle or by commuting/taking a Baikingon route jeepney
at jeepney-stop located at Cogon and it cost 35php per person. It will take about 30
minutes ride before reaching Baikingon if our point of reference is from Liceo de
Cagayan University. If we are going to commute from the school going to Legaspis
Residence, we are going to ride a hired-PUJ going to Baikingon which cost 65php
student fare back and forth. The road in going to Baikingon is moderately rocky and
sometimes its muddy and slippery during rainy season, but upon reaching the Zones in
Baikingon, it is already cemented. Once the Health Center is visible along the way, it is
obvious then that we already reached Zone 3. Another landmark that is in fronting the
residence of Maglangit Family is the Catholic Church that is few meters away from the
Health Center and upon reaching the Catholic Church, youll be able to passed a open
field basketball court.
Page 3
ASSEMBLY OF GOD
CHURCH
PETRON GASOLINE
STATION
Mr. and Mrs. Maglangit

Residence
JOLIBEE FASTFOOD
LICEO DE CAGAYAN
UNIVERSITY
BAIKINGON ELEMENTARY
SCHOOL
CATHOLIC CHURCH
RIC
BAIKINGON BRGY. OFFICE
SAINT PETER CHAPEL

IGLESIA FILIPINA
INPEDENTIE (IFI)
BRIDGE
BULUA ELEMENTARY
SCHOOL
MAKRO
MERCURY DRUG STORE

TOYOTA CDO CITY
BAIKINGON COVERED
BOUNDARY
SHELL G
CALTEX G
II.
HEALTH HISTORY
A. FAMILY PROFILE
Member 1
Name: Mr. Ike Legaspi
Role: Father/Husband
Age: 24 years old
Birthday: March 25, 1986
Birthplace: Baikingon, Cagayan de Oro City
Height: 54 inches
Weight: 54 kg
Educational Attainment: Elementary Graduate
Religion: Roman Catholic
Occupation: Farmer
Income: 1,500 per month
Food and Drug Allergies: No known food and drug allergies
Member 2
Name: Mrs. Razel Tuson
Role: Mother/Wife
Age: 18 years old
Birthday: February 27, 1993
Birthplace: Bulua Cagayan de Oro city
Height: 44 inches
Weight: 46 kg
Educational Attainment: Elementary Graduate
Occupation: Making sticks
Income: 800php per month
Food and Drug Allergies: No known and drug allergies
Member 3
BIKINGON HEALTH CENTER
MOTO
Name: Irah Legaspi

Role: Eldest Daughter
Age: 1 years old
Birthday: October 30, 2009
Birthplace: Baikingon
Height: 25 inches
Weight: 9 kg
Educational Attainment: Kindergarten
Occupation: N/A
Income: N/A
Member 4
Name: Ivory Claire Legaspi
Role: Youngest Daughter
Age: 5 months old
Birthdate: April 3, 2011
Birthplace: Baikingon
Height: 15 inches
Weight: 5 kg
Educational Attainment: N/A
Occupation: N/A
Income: N/A
B. FAMILY HEALTH HISTORY
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Name: Mr. Maglangit, N.

Mr. Maglangit, N. claimed that he is a cigarette smoker and alcoholic drinker since in
his younger years up to now. He had no known illness back then aside from fever,
cough and colds. He medicated himself with Tuseran forte 500mg 3x a day for 3
consecutive days during the episode of non-productive cough. No maternal and
paternal history of hereditary disease. He was hospitalized in 2007 and admitted to City
Hospital (currently known as JRB Hospital) due to sprain in his right hand because of
inevitable situation. He was at risk for infection back then but was given immediate
interventions and settle for home treatments.
Name: Mrs. Maglangit, E.
Mrs. Maglangit, E. claimed that she did not acquire any major illnesses aside
from minor symptoms such as headache, cough, fever and colds but was managed with
home medications back then. She has no known history of maternal and paternal
hereditary disease and never been hospitalized before.
Name: Maglangit, T.
Maglangit, T. according to her mother was admitted at Maria Reyna Hospital last
2008 due to presence of signs and symptoms of Dengue Fever like epistaxis, fever,
stomachache, presence of red spots on her skin. She was medicated with various drugs
but her mother cannot recall the ordered drugs. She develops allergies with dried fish
and pineapple that leads to redness in her face and small sores in her skin. Her
immunization was completed except Hepa B vaccines due to scarcity of supplies in the
Health Center.
Name: Maglangit, S.
Page 9
Maglangit, S. as claimed by her mother had previous cough and colds during her
5th month, Maglangit S. was brought by her mother to a certain clinic located at Cogon
and was examined by Dr. Serina. She was given Salbutamol Syrup 1ml 3x a day and
pediatric amoxicillin 1ml 3x a day. She was previously immunized with BCG, OPV, DPT
except Hepa and measles which will be administer this coming November.
Name: Maglangit, A.
Maglangit A. had previous episode of epigastric pain but he was medicated
immediately. He was brought by his son to a nearest clinic in the city for check up and
he was given medications. As for the present, he was claiming for joint pains specifically
in his knees and his elbows. He was also complaining of lack of energy and sometimes
he cant able to execute his daily activities. Maglangit A. cant recall any hereditary
disease from his folks. As observed, Maglangit A. cannot really hear when asked with
certain questions. He was never hospitalized as claimed by his son.
C. PRESENT HEALTH STATUS

Name: Mr. Maglangit N (Father)
Vital Signs
1st Visit
2nd Visit
3rd Visit
4th Visit
Temp.
July 11
*
July 18
*
Aug. 1
37.0 C
Aug. 5
36.8 C
Pulse
82 bpm
80 bpm
RR
20 cpm
18 cpm
BP
120/80mmHg
120/80mmHg
Complaint/s
None
Knee joint pain
*Went to City
Name: Mrs. Maglangit E (Mother)

Page 10
Vital Signs
1st Visit
2nd Visit
3rd Visit
4th Visit
Temp.
36. 7 C
36.5 C
36.7 C
Pulse
86 bpm
87 bpm
85 bpm
RR
20 cpm
19 cpm
20 cpm
BP
110/70mmHg
110/80mmHg
110/80mmHg
Complaint/s
None
None
None
*The mother went to City with her baby.
Name: Maglangit, T. (Eldest Daughter)

Vital Signs
1st Visit
2nd Visit
3rd Visit
4th Visit
Temp.
36. 5 C
36. 5 C
36.6 C
**
Pulse
90 bpm
94 bpm
90 bpm
**
RR
22 cpm
24 cpm
21 cpm
**
BP
**
Complaint/s
None
None
Cough, Colds
**
* No available pedia cuff

** At School
Name: Maglangit, S. (Youngest Daughter)

Vital Signs
1st Visit
2nd Visit
3rd Visit
4th Visit
Temp.
36. 8 C
**
36.7 C
36.8 C
HR
147 bpm
**
145bpm
151 bpm
RR
61cpm
**
60 cpm
62 cpm
BP
**
Complaint/s
None
**
None
Cough,Colds
Fontanels
Closed
Closed
Closed
* No available pedia cuff

**Baby was brought by her mother in City
Name: Maglangit, A. (Grandfather)

Page 11
Vital Signs
1st Visit
2nd Visit
3rd Visit
4th Visit
Temp.
36. 8 C
36. 9 C
36.5 C
36.9 C
Pulse
75 bpm
70 bpm
69 bpm
66 bpm
RR
16 cpm
18 cpm
19 cpm
19 cpm
BP
120/80mmHg
120/80mmHg
120/80mmHg
120/70mmHg
Complaint/s
Joint pain
Joint pain
Weakness, Joint Joint pain

Pain
IMMUNIZATION
Schedule
Maglangit, T.
Maglangit S.
BCG
HepB1
HepB2
HepB3
DPT1
DPT2
DPT3
OPV1
OPV2
OPV3
Measles
*To be schedule
Supporting Data
Page 12
FAMILY PLANNING
Name of Contraceptives used
Depomedroxy Progesterone Acetate(DMPA)
Pills
Date
2004-2006 / 2009
2006-2007
As stated by the wife, the first contraceptive she used was DMPA (Depo Medroxy
Progesterone Acetate). She used it for about 2 years before she decided to change its
contraceptive to Pills. She bought the pills from the health center. Just recently, the wife
decided to reuse DMPA as a contraceptive.
III.
DEVELOPMENTAL DATA
Robert Havighurst believes that learning is basic to life and that people
continue to learn throughout life. He describes growth and development as
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occurring during six stages, each associated with from six to ten tasks to be
learned.
Havighurst promoted the concepts of developmental tasks in the 1950's. A
developmental task is a task that arises at or about a certain period in the life of
an individual, successful achievement of which leads to his happiness and to
success with later tasks, while failure leads to unhappiness in the individual,
disapproval by society, and difficulty with the later tasks.
According to Havighurst, in the infancy and early childhood, the
developmental tasks of this level are: learning to walk, learning to take solid
foods, learning to talk, learning to control the elimination of body wastes, learning
sex differences and sexual modesty, achieving psychologic stability, forming
simple concepts of social and physical reality, learning to relate emotionally to
parents, siblings and other people, and learning to distinguish right from wrong
and developing a conscience.
According to Erickson, the developmental task for infant is trust versus mistrust
(other terms might be learning confidence or learning to love). Infants whose
needs are met and realized their discomforts are quickly removed. Infants, who
are cuddled, fondled, played with and talked to come to view the world as a safe
place and people as helpful and dependable. However, when the care is
inconsistent, inadequate, and rejecting, it fosters basic mistrust. Infants become
fearful and suspicious of the world and of people. They will carry this attitude
through later stages of development. Such children will be stuck emotionally at
this stage even though they continue to grow and develop in other ways.
Fortunately, because not all children achieved developmental task readily,
each task need not be resolved once and for all the first time it arises. The
problem of trust versus mistrust, for example, is not resolved forever during the
first year of life, but arises again at each successive stage of development.
Children who enter school with a sense of mistrust may come to trust a teacher
who takes the trouble to make him or her trustworthy. Given this second chance,
children who come through infancy with a vital sense of trust intact may still have
a sense of mistrust activated at a later stage if their parents are divorced or
separated under unpleasant circumstances.
Erickson envisions life as a sequence of levels of achievement. Each
stage signals a task that must be achieved. The resolution of the task can be
complete, partial, or unsuccessful. Erickson believes that the greater the task
achievement, the healthier the personality of the person, failure to achieve a task
influence the persons ability to achieve the next task. These developmental
tasks can be viewed as a series of crises, and successful resolution of these
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crises is supportive to the persons ego. Failure to resolve the crises is

damaging to the ego. After attaining one stage, the person may fall back and
need to approach it again. As nurses, we should be aware that environment is
highly influential in development. We can enhance people as well as infants
development by being aware of their development stage, by providing
opportunities. For the individual to resolve his or her developmental task, and by
helping the person develop coping skills relative to stresses experienced at a
certain level of growth and development particularly, the infant stage
FREUDS PSYCHOSEXUAL THEORY
To freud, persons whose ages 75 up fall to the Genital Stage on his

Psychosexual Stages Theory. People at this stage are expected to direct their energies
towards full sexual maturity and function and the development of skills needed to cope
up with the environment. As of client Maglangit case, all of his children have their own
respective families at present and some of them already died. According to him, he
enjoys her day by doing its house works especially in making brooms.
ROBERT HAVIGHURST DEVELOPMENTAL TASK THEORY
Since client Maglangit is already 84 years old, he belongs to the Late Maturity
Stage of Robert Havighursts Developmental Task Theory. Basing on our assessment
and interview with him, he has been adjusting well with his decreasing physical strength
and health. It is shown by him being a home buddy and in fact, he also house works. H
ERIK ERIKSONS DEVELOPMENTAL THEORY
Page 15
Client Maglangits age belongs to the Maturity Stage as Erik Eriksons Theory of
Stages of Development. The central task that she ought to resolve at this stage is to
resolve integrity versus despair. With his case, he verbalized that he is contented with
her life and living now, managing at home and is accustomed to this daily routine for
several years now. With this, he was able to accept ones own lifes uniqueness and
worth. Furthermore, he also said that he was happy to raise his children and watch
them grow with their respective family now.
JEAN PIAGETS COGNITIVE THEORY
Since client Maglangit is already 84 years old, he belongs to the Formal

Operational phase of Piagets Cognitive Development. People at this stage have
developed the uses of rational thinking and reasoning which is deductive and futuristic.
In relation, he still do his usual routine and makes broom and in doing the household
chores for him to develop specific flow of time management.
Page 16
IV. DESCRIPTION OF HOME AND ENVIRONMENT

FACTORS
Type of house
DESCRIPTION
Made of concrete
SIGNIFICANCE
Can be a source of accident
hazards
Source of electricity
Electrical Connection
It gives them light at night

and power connection to
other appliances such as TV
and Radio
Distance of source of
water
Common source of water is

from Poso approximately
250 meters away from the
house
Due to distance, the family

having difficulty on pitching
water
Type of water source
Distilled water for drinking

and water pump for dish
washing and cooking.
Prevents source of waterborne diseases
Distance/Location of
kitchen
Within the household
Can cause fire hazards
Way of cooking
Firewood
Can cause accidental

hazards
Ways of garbage
Open Burning
It may cause hazards to

children
Type of toilet
Water sealed
Favorable of bacterial growth

and breeding of insects
Drainage System
No drainage system
May cause vector borne

diseases because of
stagnant water
Domesticated Animals
Chicken, Pig and Dog
Can create environmental

disturbances
Distance of Health Center
Approximately 91.44 meters

away from the house
Accessible for emergency

and health management
Relationship to
neighborhood
Good
Harmonious relationship and

peaceful living
HOUSING
The roof was made of tin. The walls and the flooring are made of cement. In
terms of the layout of the house, the kitchen and the living room are situated without
divisions.
Page 18
KITCHEN
They used firewood for cooking. They have a sink but no proper drainage. From
their kitchen the water flows directly under their sink where there is spongy wetland
which may be possible for breeding place for mosquitoes.
Page 19
WATER SUPPLY
Water source comes from water pump, which is used for washing of clothes and
dish washing and also used for cooking. But the family used distilled bottle ordered from
the city as their main source for drinking. So far, the family didnt acquire any illnesses
related to water source.
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TOILET
The family shares the same water-sealed toilet which is located at the back of the
house. The sanitary condition is poor.
WASTE DISPOSAL
The family disposes and gets rid of their garbage by open burning.
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DRAINAGE SYSTEM
Drainage from the kitchen sink drains onto the area outside the house .This may
be a possible breeding place for mosquitoes.
DOMESTICATED ANIMALS
The family owns various animals such as pig, dog and chickens.
Page 22
ENVIRONMENT
There are various trees that surround the Maglangits House.
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COMMUNITY
The house of Maglangits Family was situated near with creational areas such as
open basketball field and volleyball court.
Page 24
Their House is in front with a Catholic Chapel.
The health center is accessible within 91.44 meters away from their house.
Page 25
V. FAMILY COPING INDEX

The purpose of the family coping index is to provide basis for estimating the
nursing needs of a particular family. It also helps nursing students to organize and plan
nursing care with precision so that care given is tailored to fit the particular family
situation.
Legend:
1- No competence
3- Moderate competence
5- Complete competence
AREA
Physical Independence
SCALE
3
JUSTIFICATION
Although the family can
take care of themselves,
not all family members are
Therapeutic Competence
physically fit.
The family was able to take
specific maintenance
medications but not at all
Knowledge of health
times.
The family knows their
condition
illnesses and ways on how

to minimize or prevent any
Application of principles
attacks.
There are times that the
of General Hygiene
family fails to apply general

principles in hygiene. The
lack of water supply causes
the family not to observe
Health Attitudes
hand hygiene all the time.

Knows the importance of
5
Page 26
having a good health. The

family displays a full effort
to recognize need for
Emotional Competence
medical care.
The family was able to deal
problems with courage. The

family does not let poverty
become the reason for
Family Living
them to give up.

They have a good
Physical Environment
relationship with each other.

The house is in poor
condition. The family has
inadequate living space.
Windows are not screened
and foods are not properly
Use of Community
kept and stored.

The family uses the
Facilities
community facilities and

knows appropriate person
to go to in terms of health
emergencies.
Page 27
VI. SCHEMATIC DIAGRAM OF THE FAMILY HEALTH PROBLEM
SOCIAL
ECONOMIC
The father
depend
his
financial
resources
in his
The
mother is
a plain
housewif
e
Five family members in the

family
Financially
unstable
Foreseeable crisis: The income of the

father is not enough to provide the basic
needs of the family.
POLITICAL
The health center

is accessible
about 91.44
meters away from
their house.
The mother visits the

health center as
needed
CULTURAL
Improper wasted
disposal
Unsafe water
source for cooking
BIOLOGICAL
GENETIC
PHYSICAL
No known
hereditary disease
(as claimed by
family)
No known other
Health Threat and
Health Deficit
ENVIRONMENTAL
Improper
garbage
disposal
No connection
of sink into the
drainage
No proper
drainage
Susceptible for transmission of
Health Threat: Improper

garbage disposal, no drainage,
presence of breeding grounds of
insects and flies that may cause
Page 30
Unsafe
water
source for
cooking
Unscreen
windows and
door
VII. ANATOMY AND PHYSIOLOGY
SYNOVIAL JOINTS
At any point in the body, where two bones meet, there will be a joint of sorts. The most
common joint is the Synovial joint. These joints are freely moving, and allow efficient
transfer of muscular force from one muscle to bone and to bone.
There are a number of different types of Synovial joint:
Ball and Socket: For example, at the femur-hip interface. This is where the head
of the bone fits into a socket on the other bone, allowing a wise range of motion,
in a number of axes.
Hinge joints: As their name indicates, these joints provide movement in one
plane, like a door hinge. Found at the join between humerous and ulna (loosely
speaking)
Pivot joints: These allow rotation of one bone around another, such as where the
radius and the ulna meet.
Condyliond: Also known as Ellipsoid joints, this is where curved facia meet,
offering movement in a number of planes. Found in the fingers.
Gliding joints: Found between two flat parts of bone, and allow little lateral
movement only. Found between the Carpals in the hands.
Saddle joints: These joints allow a greater range of movement than condyloid
joints, yet are similar in shape, the most well known example is at the base of the
thumb.
The ends of the bones in Synovial joints are shaped to fit each other in such a way
as to limit their movement in the directions required. Range and direction of movement
is aided and controlled by ligaments, that attach the bones together. On the surface of
the bone is the Articular cartilage, which aids movement, and reduces wear on the bone
face. Surrounding the whole joint is the Joint Capsule. This contributes to the control
and stability of the joint, along with the ligaments. It is attached to the periosteum,
tough and stretch resistant. Within this capsule is the Synovial membrane from which
the joint gets its name. this secretes Synovial fluid into the joint, which aids in reducing
friction. Between tendons and bone, in certain joints, little pads known as bursae can
be found. These offer a bridge for the tendon to move over, reducing friction and
wear between the tendon and the bone itself.
As was mentioned in the description of the structure of the joint, the shape of fit of
the bones and the tendons restrict mobility of the joint to within required constraints.
There are a number of other factors that also affect the range of motion, or ROM, of a
joint. The most obvious restrictions are structural, bony protrusions around the joint, like
where the point of the elbow fouls the humerous, limiting its movement. The joint
structure itself, with the ligaments, joint capsule and face of bones.
Temperature plays a major role in ROM. Quite simply, the warmer the joint is, the
greater its ROM will be, this places great emphasis on doing a proper warm-up before
exercise. Stretching is important to athletes. This is because as muscles become more
and more trained, they tend to shorten slightly, thus restricting mobility. However, good
muscle structure also add to the stability of many joints, like the knee. As we age, our
bodys ability to function decreases. this includes flexibility. Older people dont have the
same strength as the young.
PATHOPHYSIOLOGY
OSTEOARTHRITIS
Definition:
Osteoroarthritis is also known as degenerative joint disease, is the most common and
most frequently disabling of the joint disorders.
PREDISPOSING FACTORS
Increasing Age
Anatomic Deformity
Genetic Susceptability
PRECIPITATING FACTORS
Repetitive use
Previous joint damage
MANIFESTATION
Pain
Stiffness
Muscle spasm
Functional Impairment
Page 32
PATHOPHYSIOLOGY
Genetic and
Hormonal Factors
Other
Mechanical
Injury
Chondrocyte
response
Release of
cytokines
Stimulation, production
and release of proteolytic
enzymes,
metalloproteases,
collagenase
Resulting damage
predisposes to
more
Previous Joint
Damage
VIII. DRUG STUDY

Name: SALBUTAMOL
Dosage: 1ml 3x day
Classification: Bronchodilator
Action: Relaxes bronchial smooth muscle by stimulating beta 2 receptor
Indications: Cough
Contraindication: Hypersensitivity
Side Effects: Tremor, nervousness, dizziness, headache, tachycardia, palpitation,
nausea and vomiting, dyspnea
Precaution: patients with CV disorders, hyperthyroidism, or DM
Name: AMOXICILLIN
Dosage: 1ml 3x day
Classification: anti-infectives
Action: prevents bacterial cell wall synthesis during replication. Bactericidal.
Indication: Treats infections of the respiratory tract
Contraindication: hypersensitivity to penicillins and cephalosporins
Side Effects: dizziness, fatigue, insomnia, urticaria, skin rashes, anorexia, nausea and
vomiting
Precaution: cephalosporin-sensitive pts because of possible cross-allerginity.
.
IX.
NURSING SYSTEM REVIEW CHART
NAME: Maglangit, N
V/S
HR: 82 bpm
BP: 120/80mmHgTemp: 37C
DATE: August 1, 2009

RR:20cpm
Height:54 Weight: 54kg
An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location of
the problem in the figure using [X].
EEEENT:
[ ] 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
RERESP:
[ ] asymmetric [ ] tachypnea [ ] barrel chest
[ ] apnea [ ] rales [ ] cough
[ ] bradypnea [ ] shallow [ ] rhonchi
[x] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic
[ ] assess resp. rate, rhythm, pulse blood
[ ] breath sounds, comfort [ x ] no problem
CACARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ]numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] mur mur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[x] [ x ]no problem
GAGASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dyspagea [ ] rigidity [ ] pain
[ ] assess abdomen, bowel habits, swallowing
[ ] bowel sounds, comfort [x] no problem
GEGENITO URINARY AND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nucturia
[ ] assess urine frequency, control, color, odor, comfort
[ ] gyne bleeding [ ] discharge [x] no problem
NENEURO:
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors
[ ] confused [ ] vision [ ] grip
[ ] assess motor, function, sensation, LOC, strength
[ ] grip, gait, coordination, speech [x] no problem
MMUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechie
[x] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] flushed
[ ] wound [ x ] pain [ ] ecchymosis [ ] diaphoretic moist
[ ] assess mobility, motion gait, alignment, joint function
[ ] skin color, texture, turgor, integrity [ ] no problem
__________________
___________
__________________
__________________
__________________
__________________
__________________
_______________
_knee joint
pain_____________
_____________
__________________
__________________
__________________
______
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
B. Nursing
__________________
Assessment II
____
SUBJECTIVE
Communication:
[ ] hearing loss
Comments:
[ ] visual changes .wala man, as verbalized
[ x] denied
by the wife.
Oxygenation:
[ ] dyspnea
Comments:
Oo, gasigarilyo to siya; wala
[ x ] smoking history
naman(cough), as verbalized
1/2 pack per day.
by the wife.
[ ] cough
[ ] denied
Circulation:
[ ] chest pain
Comments:
wala man, as
[ ] leg pain
verbalized by the wife.
[ ] numbness of
extremities
[ x ] denied
Nutrition:
Diet: Diet as tolerated
[]N []V
Comments:
Character
wala man, dili man,
as verbalized by the
[ ] recent change in
wife
weight, appetite
[ ] swallowing
difficulty
[ x ] denied
Elimination:
Usual bowel pattern
[ ] urinary frequency
1-2xday
2-4x day
[ ] urgency
[ ] dysuria
[ ] hematuria
[ ] constipation
[ ] incontinence
remedy none
[ ] polyuria
Date of Last BM
[ ] foley in place
Aug.12,09
[x] denied
[ ] diarrhea character:none
MGT. OF HEALTH ILLNESS:
[x] alcohol
[ ] denied
(amount, frequency)
OBJECTIVE
[ ] glasses
[ ] languages
[ ] contact lens
[ ] hearing aid
R
L
Pupil Size: 2mm [ ] speech difficulties
Reaction: Pupils equally round and reacted to
light accommodation.
Resp.
[ x ] regular [ ] irregular
Describe: The patient has regular respiration of
16 cpm.
R : symmetrical lung expansion
L : symmetrical lung expansion
Heart Rhythm [ x ] regular [ ] irregular
Ankle Edema :
Pulse
Car. Rad. DP
Fem*
R
+
82bpm
+
L
+
82bpm
+
Comments: all pulses are palpable
*If applicable
[ ] dentures
[ x ] none
Upper
Full
[ ]
Partial
[ ]
with Patient
[ ]
Lower
[ ]
[ ]
[ ]
Comments:
The client has
normoactive
bowel sounds
Bowel Sounds:
Normoactive
Abdominal Distention
Present [ ] yes [x ] no
Urine* (color,
consistency, odor)
not in catheter
*if they are in place
Briefly describe the pt.s ability to follow

treatments (diet, meds, etc.) for chronic health
Page 38
gainom gihapon to siya, as verbalized by the

wife
[ ] SBE Last Pap Smear : N/ A
LMP: N/A
SKIN INTEGRITY:
[ ] dry
Comments:
wala man siya nangatol,
[ ] itching
as verbalized by the wife.
[ ] other
[ x ] denied
ACTIVITY/ SAFETY:
[ ] convulsion
Comments:
dili man, maayo man
[ ] dizziness
to iyang panglawas,
[ ]limited motion
of joints
wife.
Limitation in
Ability to
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
COMFORT/SLEEP/AWAKE:
[ ] pain
Comments:
(location, frequency, Wala man problema sa
remedies)
iyang pagtulog, as
[ ] nocturia
verbalized by the wife.
[ ] sleep difficulties
[ x ] denied
COPING:
Occupation: Retired army, Farmer
Members of Household: 5
Most Supportive Person: wife
problems (if present).

Patient was self medicating whenever he has
an illness.
[ ] dry
[ ] cold
[ ] pale
[ ] flushed
[ ] warm
[ ] moist
[ ] cyanotic
*rashes, ulcers, decubitus (describe size, location,
drainage)
No other alteration in skin integrity
[ ] LOC and orientation: Patient is oriented to
person, place, time and date.
Gait:
[ ] walker
[ ] cane
[ ] other
[ ] steady
[ ] unsteady
[ ] sensory and motor losses in face
or extremities N/A
[ ] ROM limitations: Patient can move all
extremities
[ ] facial grimace
[ ] guarding
[ ] other signs of pain:
N/A
[ ] siderail release form signed (60+ years)
N/A
Observed non-verbal behavior:
none
The person and his phone number that can be
reached any time: 09088849082
Page 39
IV.
NAME: Maglangit, E
V/S
HR:86bpm BP: 110/70 mmHg RR: 20cpm
DATE: July 11, 2009

Temp: 36.7 C Height: 46
Weight: 50kg
EEEENT:
RERESP:
[ ] apnea [ ] rales [ ] cough
[x] sputum [ ] diminished [ ] dyspnea
[ ] breath sounds, comfort [ x ] no problem
CACARDIOVASCULAR:
[x] [ x ]no problem
NENEURO:
MUMUSCULOSKELETAL and SKIN:
[ ] wound [ ] pain [ ] ecchymosis [ ] diaphoretic moist
[ ] skin
color, texture,
integrity
[ x ] no problem
FAMILY
CARE turgor,
STUDY
BY: ANZELO
AQUINO
__________________
___________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
_________
__________________
__________________
__________________
______
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
B. Nursing
____
Assessment II
Page 40
SUBJECTIVE
Communication:
[ ] hearing loss
Comments:
[ ] visual changes normal man as verbalized
[ x ] denied
by the patient.
Oxygenation:
[ ] dyspnea
Comments:
wala man, dili man q
[ ] smoking history
gasigarilyo, as verbalized by
none
the patient.
[ ] cough
[ x ] denied
Circulation:
[ ] chest pain
Comments:
dili man, as verbalized
[ ] leg pain
by the patient.
[ ] numbness of
extremities
[ x ] denied
Nutrition:
[]N []V
Comments:
Mao
man jud ni akong
Character
lawas, as verbalized
[ ] recent change in
by the patient.
weight, appetite
[ ] swallowing
difficulty
[ x ] denied
Elimination:
Usual bowel pattern
1-2xday
2-3xday
[ ] urgency
[ ] dysuria
[ ] hematuria
[ ] constipation
[ ] incontinence
remedy none
[ ] polyuria
Date of Last BM
[ ] foley in place
Aug.12,09
[ x] denied
[ ] diarrhea character: none
[ ] alcohol
[x ] denied
(amount, frequency)
OBJECTIVE
[ ] glasses
[ ] languages
[ ] contact lens
[ ] hearing aid
R
L
Resp.
[ ] regular [ ] irregular
Describe: The patient has irregular respiration
of 20 cpm.
Heart Rhythm [ ] regular [ ] irregular
Ankle Edema :
Pulse
Car. Rad. DP
Fem*
R
+
86bpm
+
L
+
86bpm
+
*If applicable
[ ] dentures
[ x ] none
Upper
Full
[ ]
Partial
[ ]
with Patient
[ ]
Lower
[ ]
[ ]
[ ]
Comments:
The patients
bowel sounds is
normoactive.
Bowel Sounds:
Normoactive
Urine* (color,
consistency, odor)
not in catheter

Page 41
dili ki gainom, as verbalized by the patient.

LMP: N/A
SKIN INTEGRITY:
[ ] dry
Comments:
Wala man, as verbalized
[ ] itching
by the patient.
[ ] other
[ x ] denied
ACTIVITY/ SAFETY:
[ ] convulsion
Comments:
dili man, kaya man
[ ] dizziness
nako maglihok-lihok,
[ ]limited motion
of joints
patient.
Limitation in
Ability to
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
[ ] pain
Comments:
(location, frequency, Normal man akong
remedies)
pagtulog, as verbalized
[ ] nocturia
by the patient.
[ x] denied
COPING:
Occupation: housewife
Most Supportive Person: husband

Patient dont have any chronic health problem.
[ ] dry
[ ] cold
[ ] pale
[ ] flushed
[ ] warm
[ ] moist
[ ] cyanotic
drainage)
Gait:
[ ] walker
[ ] cane
[ ] other
[ ] steady
[ ] unsteady
or extremities N/A
extremities
[ ] facial grimace
[ ] guarding
none
N/A
none
Page 42
IV.
NAME: Maglangit, T
V/S
HR: 90bpm
Temp: 36.5C
DATE: July 11, 2009

RR: 22cpm
Height: 34 Weight: 15kg
EEEENT:
RERESP:
[ ] apnea [ ] rales [ x ] cough
[x] [x]sputum [ ] diminished [ ] dyspnea
[ ] breath sounds, comfort [ ] no problem
CACARDIOVASCULAR:
[x] [ x ]no problem
NENEURO:
[ ] skin
color, texture,
integrity
[ x ] no problem
FAMILY
CARE turgor,
STUDY
BY: ANZELO
AQUINO
______________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
_________
__________________
__________________
___________cough,
productive_______
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
_____
B. Nursing
Assessment II
Page 43
SUBJECTIVE
Communication:
[ ] hearing loss
Comments:
[ ] visual changes dili man, as verbalized by
[ x ] denied
the mother.
Oxygenation:
[ ] dyspnea
Comments:
giubo man naa siya, uo, naa
[ ] smoking history
plemas, as verbalized by the
N/A
mother.
[ x] cough
[ ] denied
Circulation:
[ ] chest pain
Comments:
wala man siya sakit[ ] leg pain
sakit sa lawas, as
[ ] numbness of
verbalized by the mother.
extremities
[ x ] denied
Nutrition:
[]N []V
Comments:
wala
man, maayo man
Character
[ ] recent change in iyang pagkaon, as
weight, appetite verbalized by the mother.
[ ] swallowing
difficulty
[ x ] denied
Elimination:
Usual bowel pattern
1-2xday
2-3xday
[ ] urgency
[ ] dysuria
[ ] hematuria
[ ] constipation
[ ] incontinence
Remedy: none
[ ] polyuria
Date of Last BM
[ ] foley in place
Aug.12, 2009
[x] denied
[ ] alcohol
[x ] denied
(amount, frequency)
OBJECTIVE
[ ] glasses
[ ] languages
[ ] contact lens
[ ] hearing aid
R
L
Resp.
[ x] regular [ ] irregular
of 22 cpm.
Heart Rhythm [ x ] regular [ ] irregular
Ankle Edema :
Pulse
Car. Rad. DP
Fem*
R
+
90bpm
+
L
+
90bpm
+
*If applicable
[ ] dentures
[ x ] none
Upper
Full
[ ]
Partial
[ ]
with Patient
[ ]
Lower
[ ]
[ ]
[ ]
Comments:
The patients
bowel sounds is
normo active
Bowel Sounds:
Normoactive
Urine* (color,
consistency, odor)
not in foley catheter

Page 44
dili, as verbalized by the mother

LMP: N/A
SKIN INTEGRITY:
[ ] dry
Comments:
dili man siya gapangatol, as
[ ] itching
verbalized by the mother.
[ ] other
[ x ] denied
ACTIVITY/ SAFETY:
[ ] convulsion
Comments:
wala man, as
[ ] dizziness
verbalized by the
[ ]limited motion
mother.
of joints
Limitation in
Ability to
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
[ ] pain
Comments:
(location, frequency, Maayo man iyang
remedies)
pagtulog, as verbalized
[ ] nocturia
by the mother.
[ x ] denied
COPING:
Occupation: N/A
Most Supportive Person: Parents

Patient has cough and her mother self medicate
her.
[ ] dry
[ ] cold
[ ] pale
[ ] flushed
[ ] warm
[ ] moist
[ ] cyanotic
drainage)
Gait:
[ ] walker
[ ] cane
[ ] other
[ ] steady
[ ] unsteady
or extremities N/A
extremities
[ ] facial grimace
[ ] guarding
N/A
N/A
Active and alert
Page 45
IV.
NAME: Maglangit, S
V/S
HR: 147bpm
Temp: 36.C
DATE: July 11, 2009

RR: 61cpm
Height: 19 Weight: 8kg
EEEENT:
RERESP:
[ ] apnea [ ] rales [ x ] cough [x]colds
[x] [x]sputum [ ] diminished [ ] dyspnea
CACARDIOVASCULAR:
[x] [ x ]no problem
NENEURO:
[ ] skin
color, texture,
integrity
[ x ] no problem
FAMILY
CARE turgor,
STUDY
BY: ANZELO
AQUINO
_________________
colds_________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
_________
__________________
__________________
____________coug
h,________product
ive_______________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
B. Nursing
______
IV.
Assessment
NURSING SYSTEM
REVIEW CHART
NAME:
Name: Maglangit, A
DATE: July 11, 2009
Page 46
V/S
HR: 75bpm
BP: 120/80mmHg
Temp:36.8C
RR: 16cpm Height: 54 Weight: 48kg
_________________
blurred
vision__________
EEEENT:
[ ] [x] impaired vision [ ] blind
[ ] assess eyes[x] ears nose
[ ] throat for abnormality [ ] no problem
RERESP:
[ ] apnea [ ] rales [ ] cough [ ]colds
[x] [ ]sputum [ ] diminished [ ] dyspnea
CACARDIOVASCULAR:
[ ] diminished pulses [ ] edema [ x ] fatigue
[x] [ ]no problem
NENEURO:
[ ] wound [ x ] pain [ ] ecchymosis [ ] diaphoretic moist
SUBJECTIVE
[ ] skin color, texture, turgor,
integrity [ ] no problem
________________fa
tigue________mal
nutrition______dry
skin_____________
__________________
_______________kn
ee joint
pain___________
__________________
impaired______he
aring________
__________________
__________________
_________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
B. Nursing
__________________
Assessment II
__________________
__________________
____
OBJECTIVE
Page 47
Communication:
[ x ] hearing loss
Comments:
[ x ] visual changes
.bungol na raba na siya, medjo
[ ] denied
halap pajud, as verbalized by
his son.
Oxygenation:
[ ] dyspnea
Comments:
dili man, wala pud siya
[ ] smoking history
giubo, as verbalized by his
none
son
[ ] cough
[ ] denied
Circulation:
[ ] chest pain
Comments:
sakit and akong tuhod,
[ x ] leg pain
gabinhod iyang tiil, as
[ x ] numbness of
verbalized by the patient.
extremities
[ ] denied
Nutrition:
[]N []V
Comments:
Character
uo, dili naman gud naa
[ x] recent change in siya ganahan mukaon,
weight, appetite as verbalized by his son.
[ ] swallowing
difficulty
[ ] denied
Elimination:
Usual bowel pattern
1-2xday
2-3xday
[ ] urgency
[ ] dysuria
[ ] hematuria
[ ] constipation
[ ] incontinence
remedy --none
[ ] polyuria
Date of Last BM
[ ] foley in place
Aug.12, 2009
[x] denied
[x] alcohol
[ ] denied
(amount, frequency)
cige naa siya gainom ug fighter, as verbalized
[ ] glasses
[ ] languages
[ ] contact lens
[ ] hearing aid
R
L
Resp.
[ x] regular [ ] irregular
of 75 cpm.
Heart Rhythm [ ] regular [ ] irregular
Ankle Edema :
Pulse
Car. Rad. DP
Fem*
R
+
75bpm
+
L
+
75bpm
+
*If applicable
[ ] dentures
[ x ] none
Upper
Full
[ ]
Partial
[ ]
with Patient
[ ]
Lower
[ ]
[ ]
[ ]
Comments:
The patient has
hypoactive
bowel sounds
Bowel Sounds:
hypoactive
Urine* (color,
consistency, odor)
not in catheter

Page 48
by his son.
LMP: N/A
SKIN INTEGRITY:
[ x ] dry
Comments:
dili man siya gapangatol
[ ] itching
as verrbalized by his son.
[ ] other
[ ] denied
ACTIVITY/ SAFETY:
[ ] convulsion
Comments:
kakaya paman siya
[ ] dizziness
pero gareklamo lang
[ ]limited motion
siya ua sakit sa iyang
of joints
tuhod ug tiil, as
verbalized by his son.
Limitation in
Ability to
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
[ ] pain
Comments:
(location, frequency,
Dili man pud, as
remedies)
verbalizeed by his
[ ] nocturia
son.
[ x ] denied
COPING:
Occupation: broom maker
Most Supportive Person: son
Patient was just using efficascent for his knee

joint pain
[ x ] dry
[ ] cold
[ ] pale
[ ] flushed
[ ] warm
[ ] moist
[ ] cyanotic
drainage)
Gait:
[ ] walker
[ ] cane
[ ] other
[ ] steady
[ ] unsteady
or extremities N/A
extremities
[ ] facial grimace
[ ] guarding
N/A
N/A
Self-focused, restless
Page 49
CUES
Si Trishia dili
pa kumpleto
yang
immunization
as verbalized by
the mother.
HEALTH
PROBLEM
Lack of
Immunizatio
n/
Inadequate
immunizatio
n status
specially of
children as a
health threat
FAMLY
NURSING
PROBLEMS
1. Inability to
make decisions
with respect to
taking
appropriate
health action due
to:
a. lack of
knowledge
b. failure to
comprehend the
nature of the
problem
2. Failure to
utilize community
resources for
health care due
to:
GOAL OF
CARE
OBJECTIVES
OF CARE
At the end of
After nursing
the nursing
intervention,
intervention the family
, the family
will:
will start
a. go to the
availing of
health
the
center to
immunizatio
avail of the
n services.
immunizati
on
b. know of the
importance
of a
complete
immunizati
on.
INTERVENTION
MEASURES
1. Discuss:
a. the importance
of having a
complete
immunization
b. the side effects
that may occur if
immunization is
given
2. Discuss with the

family the
advantages and
disadvantages of
having a complete
immunization.
METHOD OF
NURSEFAMILY
CONTACT
Home-visit
RESOURCES
REQUIRED
Material
resourses
such as visual
aids,
equipments
for
demonstratio
n
Time and
effort of the
students and
family
members
Expenses for
teaching and
transportation
a. lack of
knowledge
b. failure to
perceive the
benefits of health
services
c. Inadequate
family resources.
X. NURSING MANAGEMENT (FAMILY HEALTH PLAN)
Page 52
CUES
The family
has a stray
dog. The
house is
only 15 sq.
meters. and
5 people are
living in it.
They dont
have food
storage
facilities
They dont
have a
drainage
system
Poor lighting
HEALTH
PROBLEM
Poor home
or
environmen
t condition
as a health
threat
FAMLY
NURSING
PROBLEMS
Inability to
provide a
home
environment
conducive to
health
maintenance
and personal
development
due to:
a.
inadequate
family
resources
b. lack of
knowledge of
importance of
proper
sanitation
GOAL OF
CARE
OBJECTIVE
S OF CARE
At the end
After nursing
of the
intervention,
nursing
the family
interventi will:
on, the
family will a. be able to
budget the
provide
familys
an
income to
environm
include
ent
improvemen
conducive
t of the
for health
home and
of the
environment
family.
b. know the
importance
of proper
sanitation
and
preventive
INTERVENTION
MEASURES
1. Discuss with the
family:
a. ways of
budgeting the
familys income
b. other possible
resources for
improvement of
home and
environment
2. Discuss with the

family the
importance of a
home with good
sanitation.
METHOD
OF NURSEFAMILY
CONTACT
Home-visit
RESOURCE
S
REQUIRED
Material
resourses
such as
visual aids,
equipments
for
demonstratio
n
Time and
effort of the
students and
family
members
Expenses for
teaching and
transportatio
Family
income
depends on
the pension
of the
husband.
c. lack of
knowledge of
preventive
measures
measures.
n
3. Discuss with the
family the
different ways to
improve home or
environment
conditions
Page 54
CUES
1.
Inco
me
depends
on the
husband
s
pension
as a
retired
soldier
2.
the
family
has 5
members
.
HEALTH
PROBLE
M
FAMLY
NURSING
PROBLEMS
Family size
beyond
what
family
resources
can
adequatel
y provide
as a
health
threat
1. Inability to
recognize the
presence of the
condition due
to
attitude/philoso
phy in life
which hinders
recognition and
acceptance of a
problem
2. Inability to
make decisions
with respect to
taking
appropriate
health action
due to lack of
knowledge as
to alternative
courses of
action open to
the family
GOAL OF
CARE
OBJECTIV
ES OF
CARE
At the end
of the
nursing
intervention
, the family:
After
nursing
intervention
, the
couple:
1. will
recognize
the
presence
of the
condition.
a.
Can
explain
what
planning
the
family is
about
b.
Can
enumerat
e the
various
ways of
maintaini
ng family
size
c.
Will select
a method
most
appropria
te for
them
2. will
decide on
appropriat
e actions
to
maintain
family size
based on a
sense of
responsibil
ity for love
and life
INTERVENTION
MEASURES
1. Analyze with the

couple critical
issues related
with marital
relationship and
the parents
responsibility for
love and life s a
basis for
maintaining
family size.
2. Discuss with the

couple alternative
courses of action.
3. Analyze with the

couple the
advantages and
disadvantages of
each
alternative/metho
d to encourage
better decisionmaking on the
METHOD
OF
NURSEFAMILY
CONTACT
Home-visit
RESOURC
ES
REQUIRED
Material
resourses
such as
visual aids,
equipments
for
demonstrati
on
Time and
effort of the
students and
family
members
Expenses for
teaching and
transportatio
n
best option.
CUES
Dirty
kitchen
and they
cook
inside
the
house.
The
receiving
room
serves as
dining
room
and
kitchen.
HEALTH
PROBLEM
FAMLY NURSING
PROBLEMS
GOAL OF
CARE
OBJECTIVE
S OF CARE
INTERVENTION
MEASURES
Risk for
accident
hazards as
a health
threat
Inability to
provide a home
environment
conducive to
health
maintenance
and personal
development
due to:
a. inadequate
family
resources
b. lack of
knowledge of
importance of
proper
sanitation
c. lack of
knowledge of
At the end
of the
nursing
intervention
, the family
will provide
an
environmen
t conducive
for health of
the family.
After
nursing
intervention
, the family
will:
1. Discuss with the

family:
Page 56
a. be able
to budget
the familys
income to
include
improveme
nt of the
home and
environmen
t
a. ways of
budgeting the
familys income
b. other possible
resources for
improvement of
home and
environment
2. Discuss with the

family the
importance of a
METHOD
OF NURSEFAMILY
CONTACT
RESOURCE
S
REQUIRED
Home-visit
Material
resourses
such as
visual aids,
equipments
for
demonstrati
on
Time and
effort of the
students and
family
members
preventive
measures
b. know the
importance
of having a
safe and
accident
hazard free
home
environmen
t.
Page 57
home with a safe

and sound
environment.
3. Discuss with the

family the
different ways to
remove accident
and fire hazards.
Expenses for
teaching and
transportatio
n
NURSING CARE PLAN
Grandfather:
Gabinhod akong tiil, sakit akong tuhod, as verbalized by the patient.
-guarding behavior
-facial grimace
-self-focusing
-massaging lower extremities
Restlessness
A
Chronic pain related to inflammatory reaction
Short term: At the end of 8 hours of community duty, the patient will be able to
verbalize methods of pain relief.
Long term: At the end of the community duty, the patient will be able to
demonstrate use of relaxation skills and diversional activities.
Independent:
1. Perform pain assessment each time pain occurs. Note and investigate
changes from previous reports
-to rule out worsening of underlying condition/ development of complication
2. use of non pharmacologic methods of pain control like massage
-to alleviate pain
3. assist client to learn breathing techniques
-to assist in muscle and generalized relaxation
4. Teach and use pain management technique like heat and cold, joint
protection and rest
-to relieve pain
5. Educate client regarding long-term pain management like exercise regimen
for maintaining joint mobility
-to help alleviate pain
At the end of 8 hours of community duty, the patient was able to verbalized
behavior modification of lifestyle and appropriate use of therapeutic
interventions.
S
O
A
P
kapoy akong lawas,kapoy ilihok-lihok", as verbalized by the patient.

-weakness
Fatigue related to pain and adequate nutrition
Short term: At the end of 8 hours of duty, the patient will be able to identify
basis of fatigue and individual areas of control.
Long term: At the end of the community duty, the patient will be able to report
improved sense of energy.
Page 60
Independent:
1.Discuss lifestyle changes/ limitations imposed by fatigue state
-to improve level of activity
2. Establish realistic activity goals with client
-enhances commitment to promoting optimal outcomes
3. Encourage client to do whatever possible to optimal outcomes
-increase activity level as tolerated
4. Provide diversional activities. Avoid over stimulating/ under-stimulation
-impaired concentration can limit ability to block competing stimuli/
distractions
5. Encourage daily exercise and activities
-to maintain/ increase strength and muscle tone and enhance sense of wellbeing
6. Encourage client to use naps and night time sleep
-to provide rest of system
7. sleep-inducing routine and comfort measures
-may help improve quality of sleep
At the end of 8 hours of duty, the patient was able to participate in

recommended treatment program.
S
O
A
P
bulad akong kaonon, as verbalized by the patient

-weakness
-poor muscle tone
-wt-48kg
Nutrition imbalanced: less than requirements related to inadequate food
intake.
Short term: At the end of 8 hours of community duty, the patient will be able
to verbalize understanding of necessary interventions.
Long term: At the end of the community exposure, the patient will be able to
demonstrate behavior changes to regain appropriate weight.
Page 61
Independent:
1.Discuss eating habits, including food preferences, intolerance/ aversions
-to appeal to clients likes/dislikes
Encourage diet modification:
2.increase protein, carbohydrates
-to increase energy and muscle strength
3. small feedings with snacks
-for adequate nutritional intake
4. promote pleasant, relaxing environment including socialization when
possible
-to enhance intake
5. prevent/ minimize unpleasant odor/sight
-may have negative effect on appetite/eating
6. Encourage oral care before and after meals
-to increase appetite
7. Promote adequate fluid intake
-limiting fluids 1 hour prior meal decreases possibility or early satiety
8. Emphasize importance of well-being, nutritrious intake. Provide
informations regarding individual nutritional needs and ways to meet these
needs within financial constraits
-to promote wellness

At the end of 8 hours of community duty, the patient was able to verbalize
understanding in ways to gain appropriate weight.
S
O
wala man pud naa siya tambal ga-imnon, as verbalized by his son.
-lack of attention to illness
-acceleration of illness
A
P
-inappropriate family activities for meeting goals of treatment

Ineffective therapeutic regimen management related to economic difficulties.
Short: At the end of 8 hours of community duty, the patient will be able to
verbalize acceptance of need/ desire to change actions to achieve goals of
treatment.
Long: At the end of the community duty, the patient will be able to
Page 62
demonstrate behaviors/ change in lifestyle necessary to maintain therapeutic

I
regimen.
Independent:
1. Provide information to aid family in understanding the value of treatment
program
-to assist family to develop strategies to improve management of therapeutic
regimen
2. Identify community resources as needed using the three strategies of
education, problem solving and resource linking
-to address specific deficits
3. Determine understanding of and value of treatment regimen to the family
-to identify precipitating factors
4. Identify availability and use of resources
-for proper interventions
5. Help family identify criteria to promote ongoing self-evaluation of situation/
effectiveness and family process
-provides opportunity to be proactive in meeting needs

At the end of 8 hours of community duty, the patient was able to participate
in solving of factors.
Question: Lo, mag BP mi sa imo karon. Answer: akonh tiil ug tuhod, as
verbalized by the patient.

-inappropriate answers when asked
-blurred vision
A
P
-loss of hearing
Impaired communication related to auditory and visual deficit
Short: At the end of 8 hours of duty, the patient will be able to participate in
therapeutic communication
demonstrate congruent verbal and non verbal communication

Independent:
1. Establish relationship with patient, listening carefully and attending to
Page 63
clients verbal and non-verbal expression

- to assist client to establish means of communication
2 maintain eye contact
-for therapeutic communication
3. keep communication simple, using all modes of accessing information:
visual, auditory
-to gain proper information and understanding
4. determine meaning of words used by client and congruency of
communication and non-verbal message
-for proper communication
5. Validate meaning of nonverbal communication; do not make assumptions.
Be honest: if you do not understand, seek assistance from others
E
-for therapeutic communication

At the end of 8 hours of duty, the patient was able to establish method of
communication in which needs can be expressed.
Page 64
Son:
gacomplain lage na siya kay sakit daw iyang tuhod, as verbalized by the
wife.
-restlessness
-guarded behavior
A
P
-grimace
Acute pain related to inflammation of the joint
Short: At the end of 8 hours of duty, the patient will be able to verbalize
methods that provide pain relief
Long: At the end of the community duty, the patient will be able to report pain
is relieved/ controlled.
Independent:
1. Encourage verbalization of feelings about pain
-to assist client in controlling pain
2. Provide quiet environment, calm activities
-to alleviate pain
3. provide comfort measures like change in position, use of cold/heat
compress
-to provide non-pharmacologic pain management
4. Instruct/ encourage use of relaxation exercise such as focused breathing
-for non-pharmacologic pain management
5. Encourage diversional activities like TV, socialization with others
-to divert attention
6. Encourage adequate rest periods
-to prevent fatigue
: At the end of 8 hours of duty, the patient was able to demonstrate use of
relaxation skills and diversional activities.
Page 65
S
O
A
P
Children:
Naa plemas iyang pag-ubo, as verbalized by the mother.

-cough, productive
Ineffective airway clearance related to increase production of secretions.
Short term: At the end of 8 hours of community duty, the patient will be able
to verbalize understanding on therapeutic management regimen.
Long term: At the end of the community exposure, the patient will be able to
maintain airway patency.

Independent:
1.Position head midline with flexion
-to open or maintain open airway
2. Elevate head of bed/ change position every 2 hours and PRN.
-to take advantage of gravity decreasing pressure on the diaphragm and
enhancing drainage/ ventilation
3. encourage deep-breathing and coughing exercise
-for lung expansion
4. Increase fluid intake to at least 2000 ml/day
-to help liquefy secretions
5. demonstrate and encourage pursed-lip or diaphragmatic breathing
techniques
-for proper lung expansion
6. provide opportunities for rest; limit activities to level of respiratory
tolerance
-prevents/lessens fatigue
7. monitor infant/child feeding intolerance
-may compromise airway
Dependent:
8. Administer salbutamol syrup 1ml 3xday, as prescribed by the doctor upon
check-up
-to mobilize secretions
9. Administer amoxicillin 1ml 3xday as prescribed
-to treat infections of respiratory tract.
At the end of 8 hours of community duty, the patient was able to expectorate
secretions readily.
Page 66
S
O
Hinay siya mo totoy, as verbalized by the mother

-poor sucking reflex
-sucks slowly
A
P
-un continuous sucking/ breastfeeding

Ineffective breastfeeding related to poor infant sucking reflex
Short: At the end of 8 hours of nursing duty, the patient will be able to
demonstrate techniques to improve/ enhance breastfeeding
Long: At the end of the community duty, the patient will be able to assume
responsibility of effective breastfeeding

Independent:
1. Assess client knowledge about breastfeeding
-to identify maternal causative factor
2. Note previous unsatisfactory experience(including self and others
-because it may be affecting current situation
3. Review feeding schedule
-to note increased demand for feeding. ( At least 8 times per day, taking both
breast at each feeding for more than 15 mins on each side)
4. Determine whether baby is content after feeding, or exhibits puffiness and
crying within the 1st hour after breastfeeding
-suggesting unsatisfactory breastfeeding process
5. Encourage frequent rest periods, sharing household/ child care duties
-to limit fatigue and facilitate relaxation at feeding times
6. Engorgement: heat/cool applicators to the breast, massage from chest
wall down to the nipple
-to enhance let down reflex
7. Increase skin to skin contact
-to condition infant to breastfeed
8. Recommend monitoring number of infants wet diaper
- at least 6 wet diapers in 24 hours suggest adequate hydration

: At the end of 8 hours of nursing duty, the patient was able to verbalize
understanding of causative/ contributing factors.
Page 67
S
O
A
P
complete na iyang immunization except sa hepa B,

Risk for infection related to incomplete immunization
verbalize understanding of individual causative factor
demonstrate techniques to promote safe environment
Independent:
1.Stress proper handwashing techniques

- A first line of defense against nosocomial infections
2. Prevent contact with people infected with Hepa B
-to prevent transmission of infection
3.Instruct not to share equipments with infected people
-to prevent infection
4. Instruct in techniques to protect integrity of skin
- to promote wellness
5. Promote childhood immunization program . Encourage adults to update
immunizations as appropriate
-to promote wellness
6. Involve in appropriate community education programs
-to increase awareness of spread/ prevention of communicable diseases.
At the end of 8 hours of nursing duty, the patient was able to identify
interventions to prevent risk of infection.
S
O
A
P
Dili, gahatagan gihapon nako ug gatas, as verbalized by the mother

Knowledge deficit related to importance of strict breastfeeding
verbalize understanding on the importance of breastfeeding
Page 68
Long: At the end of the community duty, the patient will be able to do strict
I
breastfeeding
Independent:
1.Determine patients method of accessing information and include in
teaching plan
- To facilitate learning
2.provide active role for client in learning process
- promotes sense of control over situation
3. Provide information relevant to the situation
-to assess clients motivation
4. Provide information on the effects of strict breastfeeding to the emotional
and intellectual capacities of the infant
-to enhance knowledge

At the end of 8 hours of nursing duty, the patient was able to participate in
learning process.
Page 69
XI. ACTUAL IMPLEMENTATION

Day 1 (July 11, 2009)
During the first day of home visit in the community, we had a hard time finding
and choosing a family that will fit the criteria needed in making a family care study. As
noticed, it was seldom to find old men and women in the community probably they were
inside their houses. So what we did, we knocked every household that we passed by
just to ask if they had a family member who is 65 years old or above and a child of 0 to
5 years old. Unfortunately, their grandparents were not able to live with them. As we go
along, we saw an old man sitting in one corner of the store, we immediately run onto
him and ask him several questions and that is the time when he brought us to his home
where we were able to interview his daughter in law. We immediately assessed the
family members including the baby and unfortunately, the father went to City and were
not able to assess him but we indentified some problems.
Day 2 (July 18, 2009)
During the second day of visit, we werent able to assess the father, the mother
and her baby because they went to the City. So what we did, we assessed the
grandfather and his granddaughter. We provide interventions that alleviate the
complaints of the elderly with gerontologic considerations. We tried to indentify anymore
problem that needs immediate interventions. We were able to assess their home where
we were able to document the structure of their house, the environment and some other
factors that leads to health threat, of course with the permission from the grandfather.
And those problems that we indentified will be our focus of health teachings to uplift the
health status of the family and maintenance to prevent any occurrence of illness.
Day 3 (August 1, 2009)
During the third day of home visit, we were thankful that all the family members
were present; we were able to assess the father since it was our first time to meet him.
And this day, we were able to impart health teachings that weve prepared which is
suitable for their condition. The family openly accepted the things that we have
discussed to them particularly on the improvement of their environmental sanitation

which is basically more on the promotion of health and prevention of illness to minimize
possible expenses for hospitalization.
Day 4 (August 5, 2009)
This is the fourth day of our home visit and probably the last, so we grab the time
that we had by imparting more health teachings. We encouraged the family to
segregate the garbage properly and maintained clean surroundings all the time, and
with regards to their health especially to the grandfather, we encouraged him to have
adequate rest periods and eat proper food, we also encouraged proper compliance of
medications. We also encouraged them to contact and be in their Health Center in case
of emergency.
XII. EVALUATION
After four days of home visits, the group was able to give prompt interventions by
providing health teachings and education to promote understanding and inspire the
family to modify areas that can be modified in order to promote health and prevent any
disease.
We observed that some of our health teachings and interventions were followed
and applied, but some were also disregarded because we have noticed that changes
did not show in their environmental sanitation. But at least they were able to grasp
information which expands their knowledge.
We were able to know the disease process and gave care to our client especially
the elderly with proper care and we were able to observed the health of the baby which
is in good condition during our visits despite the presence of cough and colds during the
last visit but the mother complied with various medications which is prescribed for baby.
We were thankful to the family since they accepted us without any hesitations
and they entertained us. They answered our questions and they listen for discussion
with regards to imparting of information which really matters to them.
Page 72
BIBLIOGRAPHY
Smeltzer, Suzanne. Medical-Surgical Nursing. 11th edition. Pp. 1914-1915
Kozier, Barbara et. Al. Fundamental of Nursing. 7 th edition. Pp. 190-192
Orong, Dennis et al. Compilation of Health Care 2 Related Learning experience
Input. Pp. 12-17
Reyala, Jean P. et. Al. Community Health Nursing Services in the Philippines. 9 th
edition, pp. 52-54
Webliography
http://www.unilab.com.ph/consumer/products_details.asp?eee=361
http://www.brianmac.co.uk/physiol.htm
http://en.wikipedia.org/wiki/Human_musculoskeletal_system
Page 73
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Family Case Study

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I.

FAMILY CARE STUDY BY: ANZELO AQUINO

B. OBJECTIVES of the STUDY

D. SIGNFICANCE of the STUDY

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

Mr. and Mrs. Maglangit

SAINT PETER CHAPEL

MERCURY DRUG STORE

BIKINGON HEALTH CENTER

Name: Irah Legaspi

Name: Mr. Maglangit, N.

FAMILY CARE STUDY BY: ANZELO AQUINO

C. PRESENT HEALTH STATUS

Knee joint pain

Name: Mrs. Maglangit E (Mother)

*The mother went to City with her baby.

Name: Maglangit, T. (Eldest Daughter)

* No available pedia cuff

Name: Maglangit, S. (Youngest Daughter)

* No available pedia cuff

Name: Maglangit, A. (Grandfather)

Weakness, Joint Joint pain

crises is supportive to the persons ego. Failure to resolve the crises is

FREUDS PSYCHOSEXUAL THEORY

To freud, persons whose ages 75 up fall to the Genital Stage on his

ROBERT HAVIGHURST DEVELOPMENTAL TASK THEORY

ERIK ERIKSONS DEVELOPMENTAL THEORY

FAMILY CARE STUDY BY: ANZELO AQUINO

JEAN PIAGETS COGNITIVE THEORY

Since client Maglangit is already 84 years old, he belongs to the Formal

FAMILY CARE STUDY BY: ANZELO AQUINO

IV. DESCRIPTION OF HOME AND ENVIRONMENT

It gives them light at night

Common source of water is

Due to distance, the family

Type of water source

Distilled water for drinking

Prevents source of waterborne diseases

Within the household

Can cause fire hazards

Can cause accidental

It may cause hazards to

Favorable of bacterial growth

May cause vector borne

Chicken, Pig and Dog

Can create environmental

Distance of Health Center

Approximately 91.44 meters

Accessible for emergency

Harmonious relationship and

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

FAMILY CARE STUDY BY: ANZELO AQUINO

Their House is in front with a Catholic Chapel.

FAMILY CARE STUDY BY: ANZELO AQUINO

V. FAMILY COPING INDEX

illnesses and ways on how

family fails to apply general

hand hygiene all the time.