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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 family member Sex Birthday (mm/dd/yy) Age Height 1 DDP M 12-07-78 29 y/o 5� 10�� 2 NP F 05-11-80 28 y/o 5� 2�� 3 MQP M 03-13-2008 6 � mos. 22 inches Weight Civil Status Religion Educational Attainment Occupation Relationship to family head 69.41kg M R/C CG GRCO Head of the family 54.98kg M R/C CUG 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 Covered Method of Disposal Garbage Collection

Toilet Facility Level II (with poso negro not connected to sewerage) Drainage System: Type of Drainage Open Drainage Domestic Animals, Insects, Breeding Sites: Pets/Animals None Pests/Insects Rodents, Cockroaches, Mosquitoes, Flies Way of Eradication Trapping, Using Insecticides FLOOR PLAN MEASUREMENT 7SALAKITCHENCR

7 7 10 B.HEALTH STATUS GEONOGRAM OF PALIMA FAMILY DD P NP RP LP ES YS Hypertension, None Diabetes

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

RESULT NORMAL VALUES ANALYSIS Height 5� 10�� A medium frame man with a height of 5�10�� should have a weight range of 151-163 lbs. Normal Weight 153 lbs (69.41kg) VITAL SIGNS Temperature 36.5 degree celcius 36-37 degree celcius Normal Pulse Rate 63 60-100 bpm Normal Respiratory Rate 20 16-20 bpm Normal Blood Pressure 110/80 120/80 Normal HEAD TO TOE ASSESSMENT AREAS TO BE ASESSED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS Skull Scalp Hair Symmetry Without flakes Resilient hair Symmetry Without flakes Resilient hair Normal

Face Eyebrows Eyelashes Eyelids Lower palpebral (conjunctiva) Sclera Cornea Pupils Iris Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry Normal and healthy Eye movement Visual fields Visual acuity Ear canal Hearing acuity Internal nares Septum Coordinated Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry Coordinated Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry Normal and healthy Normal and healthy

Lips Gums Teeth Tongue Frenulum Cheeks, buccal mucosa Palate Uvula Pinkish Pinkish 32, smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Pinkish Pinkish smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Normal and healthy Tonsils Voice Muscular strength Areola Nipples Abdomen Pink and smooth Can be heard Equal strength Round or oval Round and equal Unblemished skin, uniform in color Pink and smooth Can be heard Equal strength Round or oval Round and equal Unblemished skin, uniform in color Normal and healthy Normal and healthy

Name of Client: NP Age: 28 years old MEASUREMENTS RESULT NORMAL VALUES ANALYSIS Height 5� 2�� A small frame man with a height of 5�2�� should have a weight range of 115-130 lbs. Normal Weight 119 lbs. (54.98 kg)

VITAL SIGNS Temperature 37 degree celcius 36-37 degree celcius Normal Pulse Rate 70 60-100 bpm Normal Respiratory Rate 19 16-20 bpm Normal Blood Pressure 100/80 120/80 Normal HEAD TO TOE ASSESSMENT AREAS TO BE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS ASESSED

Skull Scalp Hair Face Eyebrows Eyelashes Eyelids Lower palpebral (conjunctiva) Sclera Cornea Pupils Iris Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry Normal Normal and healthy Eye movement Visual fields Visual acuity Coordinated Can see object in peripheral 20/20 vision Coordinated Can see object in peripheral 20/20 vision Normal and healthy

Ear canal Hearing acuity Internal nares Septum Lips Gums Teeth Tongue Frenulum Cheeks, buccal mucosa Palate Uvula Uniform in color Normal voice can respond Symmetry Symmetry Pinkish Pinkish 32, smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Uniform in color Normal voice can respond Symmetry Symmetry Pinkish Pinkish smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Normal and healthy Normal and healthy Tonsils Voice Muscular strength Pink and smooth Can be heard Equal strength Pink and smooth Can be heard Equal strength Normal and healthy

Areola Round or oval Round or oval Nipples Round and equal Round and equal Normal and healthy Abdomen Unblemished skin, uniform in Unblemished skin, uniform in color color Name of Client: MQP Age: 6 � mos. old

MEASUREMENTS RESULT NORMAL VALUES ANALYSIS Height 22 inches An average weight of a 6 months old infant is 16.53 lbs. Normal Weight 15.43 lbs (7 kg) VITAL SIGNS Temperature 37.2 degree celcius 37.2 degree celcius Normal Pulse Rate 113 bpm 120-140 bpm Normal Respiratory Rate 48bpm 30-50 bpm Normal HEAD TO TOE ASSESSMENT

AREAS TO BE ASESSED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS Skull Scalp Hair Face Eyebrows Eyelashes Eyelids Lower palpebral (conjunctiva) Sclera Cornea Pupils Iris Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry Normal Normal and healthy Eye movement Coordinated Coordinated Normal and healthy

Visual fields Visual acuity Ear canal Hearing acuity Internal nares Septum Lips Gums Teeth Tongue Frenulum Cheeks, buccal mucosa Palate Uvula Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry Pinkish Pinkish 32, smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry Pinkish Pinkish smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Normal and healthy Normal and healthy Tonsils Pink and smooth Pink and smooth 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 Normal and healthy Abdomen Unblemished skin, uniform in Unblemished skin, uniform in color color ABNORMAL FINDING:

Skin Smooth and unblemished Rashes all over the body Measles is an infection characterized by fever rashes and symptoms referable to upper respiratory tract, the eruption is preceded about 2 days coryza, during which stage grayish peck (Koplik Spots) may be found on the inner surface of the cheeks. A morbilliform rash appears on the 3rd or 4rth day affecting the face, body and extremities. ( Public Health Nursing pp. 267) Nutritional Status

Name of Family Member Height Weight BMI Interpretation DDP 5� 10�� 153lbs 22 Normal NP 5� 2�� 119lbs 22 Normal MQP 22 inches 15.43 lbs 23 Normal All the family members have normal total body mass index because the ratio was 18.5-24.9. Exercise Pattern Name of Family Member Hours of Exercise Times per Week Normal DDP 30 minutes 7 times a week 30 minutes/day NP 30 minutes 7 times a week 30 minutes/day MQP N/A N/A n/a The father, DDP was not able to practice it everyday because of work. His wife on the other has a daily routine exercise in a form of dancing. Their child on the other hand was still too young to participate in the activity. C.Values, Belief and Practices Just like typical Filipinos they grow up to an environment wherein respect was being emphasized. The kind of environment they want their child to have and grow-up with. They do not want him to be

stubborn or disrespectful in front of people older than him. They want him to believe and have faith in God just like them. For them what they plant to their child is what they will also earn in the future. II. ORGANIZATIONAL DATA Cues Normal Standards Based on Reference Subjective: �Nilagnat siya ng tatlong araw bagolumabas yang mga pula-pula niya sa katawan.� A healthy child must be free from diseases or illnesses like fever cough and colds, rashes and the like. Subjective: �Ang daming ipis dito pag umaga, yung pag binuksan mu yung ilaw, kanya kanyang takbo na sila. Minsan din malangaw at may magnilan-ngilang daga na naghaharutan sa may kisame.� A healthy home must be free from rodents and pest, it is clean, well ventilate and free from threats.

Subjective: �Nakakatakot lang ditto yung bukas na 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 � mos old male infant with cough and rashes all over his body. �Nilagnat siya ng tatlong araw bagolumabas A. Measles and as a Health Deficit 1. Inability to provide adequate nursing care to the dependent member with measles and cough due to: � Lack of knowledge on the nature and management of the

yang mga pula-pula niya sa katawan.� health condition. �Ang daming ipis dito pag umaga, yung pag binuksan mu yung ilaw, kanya kanyang takbo na sila. Minsan din malangaw at may magnilan-ngilang daga na naghaharutan sa may kisame.� �Nakakatakot lang ditto yung bukas na kanal dyan sa may labas. Lalo kapag umuulan at bumabaha, baka kasi di mapansin malusbot dun� B. Presence of Vectors and Rodents as Health Threat 1. Inability to recognize the health threat due to lack of knowledge about the condition. 2. Inability to make decisions with regards to the management of the condition due to the failure on identifying what measures are appropriate. 3. Inability to provide home conducive to health maintenance and personal development due to ignorance in preventive measures. 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 JUSTIFICATION Nature of the problem Modifiability of the problem Preventive potential Salience 3/3 x 1 2/2 x 1 3/3 x 2 2/2 x 1 1 1 2 1 It is a health deficit that requires immediate intervention. Resources needed are available. With the compliance in the given instructions of appropriate health providers, disease will be manageable. The family considers this as a problem that needs immediate attention. TOTAL 5 2. Presence of Vectors and Rodents

CRITERIA COMPUTATION SCORE JUSTIFICATION Nature of the problem Modifiability of the problem Preventive potential Salience 2/3 x 1 � x 2 2/3 x 1 1/2 x 1 0.7 1 0.7 0.5 It is a health threat that needs an immediate attention. The family has the necessary resources but does not utilize them properly. The susceptibility in acquiring other infections can be prevented if the problem will be solved. The problem was recognized by the family but they do not think it needs an immediate attention. TOTAL 2.9 3. Open Drainage

CRITERIA COMPUTATION SCORE JUSTIFICATION Nature of the problem 2/3 x 1 0.7 It is a health threat for it could damage the health of the family. Modifiability of the problem � x 2 1 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 1 Measles and cough 5 2 Presence of Rodents and Vectors 2.9 3 Open Drainage 2.9 V. FAMILY HEALTH CARE PLAN

HEALTH PROBLEM FAMILY NURSIN G GOAL OF CARE OBJECTIVES OF CARE INTERVENTION PLAN NURSING INTERVENTION METHOD OF RESARCHERFAMILY CONTACT RESOURCES REQUIRED Measles and cough Inability to manage the condition due to the lack of knowledge regarding its manageme nt. After nursing intervention, the family must be equipped with the necessary knowledge they need in dealing with the situation. After nursing intervention, the family: -will be able identify the cause and effect of the disease. -Know the appropriate intervention to make. 1. Establish rapport. 2. Prepare the necessary equipments needed. 3. Inform the family about the visit. 4. Health education about the diseases and its

management. Home Visit Material Resources: Visual Aids on Measles and cough. Human Resources: Time and effort of both the researchers and the family. Financial Resources: Money for the researchers� transportation and food (if necessary). FAMILY HEALTHCARE TEACHING PLAN

NURSING INTERVENTION METHOD OF RESARCHER-FAMILY CONTACT RESOURCES REQUIRED 1. Analyze with the family the problems measles and cough. 2. Discuss with the family the appropriate courses of action. 3. Enumerate to the family the danger signs they need to watch out for namely: . inability of the infant to drink or breastfeed . vomits everything . convulsions . abnormally sleepy or difficulty to awaken Home Visit Material Resources: Visual Aids on Measles a cough. Human Resources: Time and effort of both the researchers and the family. Financial Resources: Money for the researchers� transportation and food (if necessary). What to teach� What is measles?

Measles is one of the most contagious viral diseases. It is caused by paramyxo virus and is the most unpleasant and the most dangerous of the children's diseases that result in a rash. This is due to the complications of the disease. How is measles transmitted? � Droplets transfer the infections. Although the sick person may be in isolation, the disease may still spread from room to room. � Anybody who has not already had measles can be infected. � Infants up to four months of age will not be infected if their mother has had measles herself because they will be protected by her antibodies. � The incubation period - the time between infection and the outbreak of the condition - is usually one to two weeks. � Patients are infectious from four days before the onset of the rash until five days after it appears. What are the symptoms of measles? After about 14 days the following symptoms start showing: � A fever at about 39�C. � 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 40�C, 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