Initial Data Base And Fncp

INITIAL DATABASE

www.nursingdepartment.blogspot.com

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

Sex

family member

Birthday

Age

Height

(mm/dd/yy)

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

Relationship to family Weight

Civil Status

Religion

Educational Attainment

Occupation

head

69.41kg

M

R/C

CG

GRCO

Head of the family

54.98kg

M

R/C

CUG

Housewife

Wife

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 Method of Disposal

Covered 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

KIT CHEN

CR

7 7

10

B.HEALTH STATUS GEONOGRAM OF PALIMA FAMILY

RP

LP

Hypertension, Diabetes DD P

ES

YS

None NP

MQP

PHYSICAL ASSESSMENT Name of Client: DDP Age: 29 years old MEASUREMENTS

RESULT Height

5’ 10’’

Weight

153 lbs (69.41kg)

NORMAL VALUES A medium frame man with a height of 5’10’’ should have a weight range of 151-163 lbs.

ANALYSIS Normal

VITAL SIGNS Temperature Pulse Rate Respiratory Rate Blood Pressure

36.5 degree celcius 63 20 110/80

36-37 degree celcius 60-100 bpm 16-20 bpm 120/80

Normal Normal Normal Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

ASESSED Skull

Symmetry

Symmetry

Scalp

Without flakes

Without flakes

Hair

Resilient hair

Resilient hair

Normal

Face

Symmetry

Symmetry

Eyebrows

Hair equal, intact

Hair equal, intact

Eyelashes

Intact, with curl

Intact, with curl

Eyelids

Aligned

Aligned

Lower palpebral

Pinkish

Pinkish

Sclera

White and clear

White and clear

Cornea

Transparent, shiny

Transparent, shiny

Pupils

Black, equal, round

Black, equal, round

Iris

Symmetry

Symmetry

Eye movement

Coordinated

Coordinated

Visual fields

Can see object in peripheral

Can see object in peripheral

Visual acuity

20/20 vision

20/20 vision

Ear canal

Uniform in color

Uniform in color

Hearing acuity

Normal voice can respond

Normal voice can respond

Internal nares

Symmetry

Symmetry

Septum

Symmetry

Symmetry

Normal and healthy

(conjunctiva)

Normal and healthy

Normal and healthy

Lips

Pinkish

Pinkish

Gums

Pinkish

Pinkish

Teeth

32, smooth, shiny

smooth, shiny

Tongue

Smooth

Smooth

Frenulum

Smooth

Smooth

Cheeks, buccal mucosa

Uniform in color

Uniform in color

Palate

Soft and glistering

Soft and glistering

Uvula

Light pink

Light pink

Tonsils

Pink and smooth

Pink and smooth

Voice

Can be heard

Can be heard

Muscular strength

Equal strength

Equal strength

Areola

Round or oval

Round or oval

Nipples

Round and equal

Round and equal

Abdomen

Unblemished skin, uniform in

Unblemished skin, uniform in

color

color

Normal and healthy

Normal and healthy

Normal and healthy

Name of Client: NP Age: 28 years old

MEASUREMENTS RESULT Height

5’ 2’’

Weight

119 lbs. (54.98 kg)

NORMAL VALUES A small frame man with a height of 5’2’’ should have a weight range of 115-130 lbs.

ANALYSIS Normal

VITAL SIGNS Temperature Pulse Rate Respiratory Rate Blood Pressure

37 degree celcius 70 19 100/80

36-37 degree celcius 60-100 bpm 16-20 bpm 120/80

Normal Normal Normal Normal

HEAD TO TOE ASSESSMENT AREAS TO BE ASESSED

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Skull

Symmetry

Symmetry

Scalp

Without flakes

Without flakes

Hair

Resilient hair

Resilient hair

Face

Symmetry

Symmetry

Eyebrows

Hair equal, intact

Hair equal, intact

Eyelashes

Intact, with curl

Intact, with curl

Eyelids

Aligned

Aligned

Lower palpebral

Pinkish

Pinkish

Sclera

White and clear

White and clear

Cornea

Transparent, shiny

Transparent, shiny

Pupils

Black, equal, round

Black, equal, round

Iris

Symmetry

Symmetry

Eye movement

Coordinated

Coordinated

Visual fields

Can see object in peripheral

Can see object in peripheral

Visual acuity

20/20 vision

20/20 vision

Normal

Normal and healthy

(conjunctiva)

Normal and healthy

Ear canal

Uniform in color

Uniform in color

Hearing acuity

Normal voice can respond

Normal voice can respond

Internal nares

Symmetry

Symmetry

Septum

Symmetry

Symmetry

Lips

Pinkish

Pinkish

Gums

Pinkish

Pinkish

Teeth

32, smooth, shiny

smooth, shiny

Tongue

Smooth

Smooth

Frenulum

Smooth

Smooth

Cheeks, buccal mucosa

Uniform in color

Uniform in color

Palate

Soft and glistering

Soft and glistering

Uvula

Light pink

Light pink

Tonsils

Pink and smooth

Pink and smooth

Voice

Can be heard

Can be heard

Muscular strength

Equal strength

Equal strength

Normal and healthy

Normal and healthy

Normal and healthy

Areola

Round or oval

Round or oval

Nipples

Round and equal

Round and equal

Abdomen

Unblemished skin, uniform in

Unblemished skin, uniform in

color

color

Name of Client: MQP Age: 6 ½ mos. old

Normal and healthy

MEASUREMENTS RESULT

NORMAL VALUES

Height

22 inches

An average weight of a 6

Weight

15.43 lbs (7 kg)

ANALYSIS Normal

months old infant is 16.53 lbs.

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

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

ASESSED Skull

Symmetry

Symmetry

Scalp

Without flakes

Without flakes

Hair

Resilient hair

Resilient hair

Face

Symmetry

Symmetry

Eyebrows

Hair equal, intact

Hair equal, intact

Eyelashes

Intact, with curl

Intact, with curl

Eyelids

Aligned

Aligned

Lower palpebral

Pinkish

Pinkish

Sclera

White and clear

White and clear

Cornea

Transparent, shiny

Transparent, shiny

Pupils

Black, equal, round

Black, equal, round

Iris

Symmetry

Symmetry

Eye movement

Coordinated

Coordinated

Normal

Normal and healthy

(conjunctiva)

Normal and healthy

Visual fields

Can see object in peripheral

Can see object in peripheral

Visual acuity

20/20 vision

20/20 vision

Ear canal

Uniform in color

Uniform in color

Hearing acuity

Normal voice can respond

Normal voice can respond

Internal nares

Symmetry

Symmetry

Septum

Symmetry

Symmetry

Lips

Pinkish

Pinkish

Gums

Pinkish

Pinkish

Teeth

32, smooth, shiny

smooth, shiny

Tongue

Smooth

Smooth

Frenulum

Smooth

Smooth

Cheeks, buccal mucosa

Uniform in color

Uniform in color

Palate

Soft and glistering

Soft and glistering

Uvula

Light pink

Light pink

Tonsils

Pink and smooth

Pink and smooth

Normal and healthy

Normal and healthy

Normal and healthy

Voice

Can be heard

Can be heard

Muscular strength

Equal strength

Equal strength

Areola

Round or oval

Round or oval

Nipples

Round and equal

Round and equal

Abdomen

Unblemished skin, uniform in

Unblemished skin, uniform in

color

color

ABNORMAL FINDING:

Normal and healthy

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

DDP

5’ 10’’

153lbs

22

Normal

NP

5’ 2’’

119lbs

22

Normal

22 inches

15.43 lbs

23

Normal

Member

MQP

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

N/A

N/A

n/a

MQP

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

A healthy child must be free from diseases or illnesses like

bagolumabas yang mga pula-pula niya sa fever cough and colds, rashes and the like. katawan.”

Subjective: “Ang daming ipis dito pag umaga, yung

A healthy home must be free from rodents and pest, it is clean,

pag binuksan mu yung ilaw, kanya

well ventilate and free from threats.

kanyang takbo na sila. Minsan din malangaw at may magnilan-ngilang daga na naghaharutan sa may kisame.”

Subjective: “Nakakatakot lang ditto yung bukas na

A healthy home must be free from rodents and pest, it is clean,

kanal dyan sa may labas. Lalo kapag

well ventilate and free from threats.

umuulan at bumabaha, baka kasi di mapansin malusbot dun”

III. CLUSTERED DATA Cues/Data

Family Health Care Plan

6 ½ mos old male infant with cough and rashes

A. Measles and as a Health Deficit

all over his body.

1. Inability to provide adequate nursing care to the dependent member with measles and cough due to:

“Nilagnat siya ng tatlong araw bagolumabas

•

Lack of knowledge on the nature and management of the

yang mga pula-pula niya sa katawan.”

health condition.

“Ang daming ipis dito pag umaga, yung pag binuksan mu yung ilaw, kanya kanyang takbo

B. Presence of Vectors and Rodents as Health Threat

na sila. Minsan din malangaw at may

1. Inability to recognize the health threat due to lack of

magnilan-ngilang daga na naghaharutan sa may kisame.”

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

“Nakakatakot lang ditto yung bukas na kanal dyan sa may labas. Lalo kapag umuulan at

are appropriate. 3. Inability to provide home conducive to health maintenance

bumabaha, baka kasi di mapansin malusbot

and personal development due to ignorance in preventive

dun”

measures.

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

COMPUTATION

SCORE

Nature of the problem

3/3 x 1

1

JUSTIFICATION It is a health deficit that requires immediate intervention.

Modifiability of the

2/2 x 1

1

problem

Resources needed are available. With the compliance in the given instructions of

Preventive potential

3/3 x 2

2

appropriate health providers, disease will be manageable. The family considers this as a problem that needs

Salience

2/2 x 1 TOTAL

2. Presence of Vectors and Rodents

1 5

immediate attention.

CRITERIA

COMPUTATION

SCORE

Nature of the problem

2/3 x 1

0.7

JUSTIFICATION It is a health threat that needs an immediate attention.

Modifiability of the

½x2

1

problem

The family has the necessary resources but does not utilize them properly.

Preventive potential

2/3 x 1

0.7

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

Salience TOTAL

3. Open Drainage

1/2 x 1 2.9

0.5

not think it needs an immediate attention.

CRITERIA

COMPUTATION

SCORE

Nature of the problem

2/3 x 1

0.7

JUSTIFICATION It is a health threat for it could damage the health of the family.

Modifiability of the

½x2

1

problem

It is partially modifiable for the family alone can’t solve the issue, referral to higher officials were still needed.

Preventive potential

2/3 x 1

0.7 Solving the problem lessen the risk of the family on acquiring infections brought about by an unpleasant environment

Salience

1/2 x 1

0.5 The family recognizes the problem but does not think it needs an immediate action.

TOTAL

2.9

PROBLEM PRIORITIZATION

Family Problems According to Priority

V.

1

Measles and cough

5

2

Presence of Rodents and Vectors

2.9

3

Open Drainage

2.9

FAMILY HEALTH CARE PLAN

INTERVENTION PLAN HEALTH

FAMILY

GOAL OF

OBJECTIVES OF

PROBLEM

NURSIN

CARE

CARE

G

METHOD OF NURSING

RESARCHER-

INTERVENTION

FAMILY

RESOURCES REQUIRED

CONTACT Measles and

Inability to

After nursing

After nursing

1. Establish rapport.

cough

manage

intervention,

intervention, the

2. Prepare the necessary

the

the family

family:

equipments needed.

condition

must be

due to the

equipped with

lack of

Home Visit

Material Resources: Visual Aids on Measles and cough.

3. Inform the family about

Human Resources:

-will be able

the visit.

Time and effort of both the

the necessary

identify the cause

4. Health education about

researchers and the family.

knowledge

knowledge

and effect of the

the diseases and its

regarding

they need in

disease.

management.

its

dealing with

manageme

the situation.

nt.

Financial Resources: Money for the researchers’

-Know the

transportation and food (if

appropriate

necessary).

intervention to make.

FAMILY HEALTHCARE TEACHING PLAN

NURSING INTERVENTION

METHOD OF

RESOURCES REQUIRED

RESARCHER-FAMILY CONTACT 1. Analyze with the family the

Home Visit

Material Resources:

problems measles and cough.

Visual Aids on Measles a cough.

2. Discuss with the family the

Human Resources:

appropriate courses of action.

Time and effort of both the researchers and the family.

3. Enumerate to the family the

Financial Resources:

danger signs they need to watch

Money for the researchers’ transportation and food (if necessary).

out for namely:  inability of the infant to drink or breastfeed  vomits everything  convulsions

 abnormally sleepy or difficulty to awaken

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.

www.nursingdepartment.blogspot.com