INITIAL DA DAT TA BASE FOR FO R FAMILY FAMILY NURSING PRACTICE A. Famil Family y Structure Structure,, Characteris Characteristics, tics, and and Dynamics Dynamics Member of the household Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon
Relationship to the head of the family Father/ husband wife
age
sex
Civil status
Position in the family
45
Male
Married
Father/husband
44
Female
Married
Mother/wife
Son
19
Male
Single
Eldest child/son/brother
daughter
18
Female
Single
Youngest child/daughter/sister
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
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 Socio-econom -economic ic and Cultur Cultural al Charact Characterist eristics ics Member of Income and expenses the occupation Place of 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. Ho Home me and and Envi Enviro ronm nmen entt 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 fa mily 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. refrigerator. The de Leon’s’ water supply comes from deep well and not no t from NAW 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. everyday. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, 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 family has their own cell 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, Habits, Practices Practices on Health Promoti Promotion, on, Maintenance Maintenance and Disease 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 Why do you you smo smoke ke?? •
I smoke because it relieves my stress and it’s already been a habit and a part of my everyday practice.
2. Do you you know know the the conseq consequenc uences es of smokin smoking? g? •
3.
I know that smoking is dreadful for the health especially for the lungs but smoking has already been a habit for me.
Did Did you you try to sto stop p smok smokin ing? g? I did not try to stop smoking. •
STRESS Structured Questions:
1. Why are you always always stress stressed ed out? 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 you have have enoug enough h rest rest or slee sleep? p?
•
No, because now that I’m in college. I usually sleep only for about 5 or 6 hours.
3. How How do you you rel relie ieve ve str stres ess? s?
•
Whenever I came home from school, schoo l, I tried to rest for an hour or just lay back and watch TV
RHEUMATIC HEART DISEASE Structured Questions:
1. What What do you do to to impro improve ve your your healt health? h? •
I drink my medicine on time and eat right amount of food.
2. Do you you have regula regularr check-u check-ups ps with with your your doctor 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. Natu Naturre of the 2/3 x 1 Problem
2. Modi odifiab fiabil iliity of the Problem 3. Preventi ntive Potential
4. Sali alience of 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. Natu Naturre of the 2/3 x 1 Problem
2. Modi odifiab fiabil iliity of the Problem 3. Preventi ntive 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. Sali alience of 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. Natu Naturre of the 3/3 x 1 Problem
Actual Score 1
1/2 x 2
2
3. Preventi ntive Potential
3/3 x 1
1
4. Sali alience of of the Problem
2/2 x 1
1
2. Modi odifiab fiabil iliity 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 HEAL HEALTH TH PROBLEMS:
RANK 1 RANK 2 RANK 3
RHEUMATIC 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 ed educate about the cause and effects of smoking. 2. to pr provide activities that will disregard from smoking. 3. to give appropriate medication and counseling for the client
NURSING INTERVENT ION
EVALUATI ON
1. the cl 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. inabi nabillity ity to recognize the presence of the condition or problem due to: lack of or inadequate knowledge 2. inabi nabillity ity 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. Inabi nabillity ity to provide adequate nursing care to the sick, disabled, dependent or vulnerable/atrisk member of the family due to: 4. inabi nabillity ity to provide a home environment conducive to health maintenance and personal development due to; 5. Failure to to utilize community resources for health care due to: HEALTH PROBLEM FAMILY DIAGNOSIS Rheumatic Heart Disease 1. inab inabil iliity to recognize the presence of the
GOAL OF CARE
OBJECTIV ES
NURSING INTERVENTI ON
EVALUATION
2.
3.
4.
5.
condition or problem due to: inab inabil ilit ity y to make make decisions with respect to taking appropriate health action due to: Inab Inabil iliity to provide adequate nursing care to the sick, disabled, dependent or vulnerable/atrisk member of the family due to: inab inabil iliity to provide a home environment conducive to health maintenance and personal development due to; Fail Failur uree to uti utili lize ze community resources for health care due to:
