Initial Data Base For Family Nursing Practice

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE A. Family Structure, Characteristics, and Dynamics Member of the household

Relationship to the head of the family Father/ husband wife

Leland N. de Leon Marciana S. de Leon Mark Leland S. Son de Leon Elaine S. de daughter Leon Member of the household

Place of residence of each member of the family Leland N. de Living Leon independently Marciana S. de Living Leon independently Mark Leland S. Living with de Leon parents Elaine S. de Living with Leon parents

age

sex

Civil status

Position in the family

45

Male

Married

Father/husband

44

Female

Married

Mother/wife

19

Male

Single

Eldest child/son/brother

18

Female

Single

Youngest child/daughter/sister

Type of family structure

Dominant family members in terms of decision making

Patriarchal/ nuclear Patriarchal/ nuclear Patriarchal/ nuclear Patriarchal/ nuclear

Short temper/ easily irritated Good listener Joker Easily irritated

B. Socio-economic and Cultural Characteristics Member of Income and expenses the occupation Place of Income of household work each working member Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon

General family relationship or dynamics

Production manager Landlady

Bulacan

Adequacy to meet basic necessities P15,000.00/mo Adequate

Manila

P4,000.00/mo

BTM student

PUP

BSN student

UERMMMC

Adequate

Who makes decisions about money

C. Home and Environment The de Leon Family’s House is made of concrete and has three bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. Every member of the family has their own bedrooms. Mr. and Mrs. de Leon share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and roaches present in de Leon family’s house. Their foods are stored in closed door cabinets and the refrigerator. The de Leon’s’ water supply comes from deep well and not from NAWASA. They use water septic tank for their water supply. The water coming from the septic tank is used for washing, cleaning, and bathing and not for drinking purposes. The de Leon family buys distilled water from water refilling stations. The de Leon family has their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by Mrs. de Leon and sometimes the siblings. Their garbage is taken out everyday and collected by garbage trucks everyday. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Mr. de Leon built a poso negro near the laundry area and is been cleaned every once in a while to check for clogs. Their neighborhood is not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility. D. Health Status of Each Member Member of the household

Medical and nursing history

Nutritional assessment Dietary history 4x a day

Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon

Rheumatic heart disease

Elaine S. de Leon

dengue

2x a day 4x a day 3x a day

Eating habits and practices Meat, fruits and vegetables Sea foods Meat, fish, fruits and vegetables meat, fruits, less vegetables and fish

Risk factor assessment Cigarette and tobacco smoking obesity stress

E. Value, Habits, Practices on Health Promotion, Maintenance and Disease Prevention Member of the Immunization Healthy lifestyle Practices household status of family members Leland N. de Leon

complete

Biking everyday

Marciana S. de Leon

complete

Stretching and eating fruits

Mark Leland S. de Leon

complete

Basketball (occasionally)

Elaine S. de Leon

complete

Badminton, Walking and eating fruits

Adequacy of : Member of the household

Rest/ sleep

Exercises/ activities

Use of protective measures

Relaxation and other stress management activities

Leland N. de Leon Marciana S. de Leon

9 hours 8 hours

10-20 minutes 5-10 minutes

Uses jacket

Rest or watch TV or listen to jazz music Rest and watch TV

Mark Leland S. de Leon

6-8 hours

1 hour

Use pads

Rest or eat

Elaine S. de Leon

6 hours

1 hour

Use umbrella when raining, and handkerchiefs

Rest and watch TV or surf the internet

Uses slippers in and out the house and umbrella

FIRST LEVEL ASSESSMENT SMOKING Structured Questions: 1. Why do you smoke? •

I smoke because it relieves my stress and it’s already been a habit and a part of my everyday practice.

2. Do you know the consequences of smoking? •

3.

I know that smoking is dreadful for the health especially for the lungs but smoking has already been a habit for me.

Did you try to stop smoking? • I did not try to stop smoking.

STRESS Structured Questions: 1. Why are you always stressed out? •

There are a lot of things I have to do so I sleep late and have to wake up early to go to school.

2. Do you have enough rest or sleep? •

No, because now that I’m in college. I usually sleep only for about 5 or 6 hours.

3. How do you relieve stress? •

Whenever I came home from school, I tried to rest for an hour or just lay back and watch TV

RHEUMATIC HEART DISEASE Structured Questions: 1. What do you do to improve your health? •

I drink my medicine on time and eat right amount of food.

2. Do you have regular check-ups with your doctor? •

I usually go to heart center on the date that the doctor asked me to come back

3. Do you take in alternative medicines or other herbal medicines you think that will improve you current health? •

I intake herbal drink and herbal supplements from recommendations from friends and relatives. I also drink multivitamins and vitamin C tablets.

PRIORITIZATION SMOKING Criteria Computation 1. Nature of the 2/3 x 1 Problem

2. Modifiability of the Problem 3. Preventive Potential 4. Salience of the Problem

Actual Score 0.66

2/2 x 2

2

3/3 x 1

1

1/2 x 1

0.5

TOTAL SCORE

Justification It is a health threat that does not demand immediate action Resources are available and interventions are feasible Smoking can be reduced or minimized The family recognizes it as a problem. It does not seem the problem as needing immediate action.

4.16

2. STRESS Criteria Computation 1. Nature of the 2/3 x 1 Problem

2. Modifiability of the Problem 3. Preventive Potential

Actual Score 0.66

2/2 x 2

2

3/3 x 1

1

Justification It is a health threat that does not demand immediate action Resources are available and interventions are feasible. Stress can be reduced or minimized

4. Salience of the Problem

1/2 x 1

TOTAL SCORE

0.5

The family recognizes it as a problem but does not required immediate action

4.16

3. RHEUMATIC HEART DISEASE Criteria Computation 1. Nature of the 3/3 x 1 Problem

Actual Score 1

1/2 x 2

2

3. Preventive Potential

3/3 x 1

1

4. Salience of the Problem

2/2 x 1

1

2. Modifiability of the Problem

TOTAL SCORE

Justification It is a health deficit that requires immediate attention and adequate management. Current knowledge, interventions and resources are available to solve the problem Disease can be prevented. The family perceives it as a serious problem needing attention.

5

THE PRIORITIZED HEALTH PROBLEMS:

RANK 1 RANK 2 RANK 3

RHEUMATIC HEART DISEASE SMOKING STRESS

5 4.16 4.16

FAMILY NURSING DIAGNOSIS forget HEALTH GOAL OF PROBLEM CARE FAMILY DIAGNOSIS Smoking To improve the 1. inability condition of to the client recogniz e the presence of the condition or problem due to: attitude/p hilosoph y in life which hinders recogniti on/accep tance of a problem 2. inability to make decisions with respect to taking appropri ate health action due to: failure to compreh end the nature, magnitud e and scope of

OBJECTIVES

General: To eliminate or minimized smoking habits. Specific: 1. to educate about the cause and effects of smoking. 2. to provide activities that will disregard from smoking. 3. to give appropriate medication and counseling for the client

NURSING INTERVENT ION

EVALUATI ON

1. the client will be able to recogniz e the bad effects of 1. Health smoking. Teaching 2. the patient will be able to eliminate 2. Guide the or family as minimize motivation d al strategy. smoking. 3. discus with the family the cause and effects of smoking and how does it affects one’s health

the problem 3. Inability to provide adequate nursing care to the sick, disabled, depende nt or vulnerabl e/at-risk member of the family due to: lack of knowled ge about the health condition 4. inability to provide a home environ ment conduciv e to health maintena nce and personal develop ment due to; negative attitude / philosop hy in life which is not conduciv

e to health maintena nce and personal develop ment 5. Failure to utilize communi ty resources for health care due to: lack of inadequa te knowled ge of communi ty resources for health care HEALTH PROBLEM FAMILY DIAGNOSIS Stress 1. inability to recognize the presence of the condition or problem due to: lack of or inadequate knowledge 2. inability to make decisions with respect to taking

GOAL OF CARE

OBJECTIVES

EVALUATION

appropriate health action due to: failure to comprehend the nature/magnitu de of the problem/condi tion 3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/atrisk member of the family due to: 4. inability to provide a home environment conducive to health maintenance and personal development due to; 5. Failure to utilize community resources for health care due to: HEALTH PROBLEM FAMILY DIAGNOSIS Rheumatic Heart Disease 1. inability to recognize the presence of the

GOAL OF OBJECTIV CARE ES

NURSING INTERVENTI ON

EVALUATION

2.

3.

4.

5.

condition or problem due to: inability to make decisions with respect to taking appropriate health action due to: Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/atrisk member of the family due to: inability to provide a home environment conducive to health maintenance and personal development due to; Failure to utilize community resources for health care due to: