Family Case Presentation

BSN-II
Family Case
Presentation
Introduction
The health of the family is viewed as a whole
involving all its member and not individually. The
family is a basic unit of society and its members
should be empowered to maintain a healthy
status and lifestyle.
Each family is unique in way of recognizing
and meeting the needs of each member. The
family is the principal integer of health care
and/or a pillar in furnishing physical, spiritual,
emotional, social and financial supports for its
members. It is also the primary factor for the
growth and development of the members. The
health of each family member is very significant
and the way they live simply reflects their health
Nursing practice in the community means

different things to different nurses. During the
implementation phase, the nurse encounters the
realities in family nursing practice which can
motivate her to try out creative innovations or
overwhelm her to frustration or interaction. As
the nurse practitioner works with the clients she
experiences varying degrees of demands on her
resources. A dynamic attitude on personal and
professional development is, therefore, necessary
if she has to face up to challenges of nursing
practice.
We chose this family for our family case study
because, it is the poorest family in the
community and by that statement, we come to
perceive this as reinforcement for a strong
restoration and maintenance of health for the
prevention of illnesses and promotion and the
Objectives
General:
At the end of family case presentation,

the presenters will be able to gain
knowledge, enhance fundamental
skills and exhibit desirable attitudes
with the application of nursing process
to promote health and prevent
diseases in nursing a family.
Specifically it aims to:
Identify family structures and types.

Asses the health status of the Family.
Determine the function of each family
member.
Identify and prioritize any existing health
problems.
Formulate family nursing diagnosis.
Plan and implement suitable nursing
intervention.
Evaluate for efficiency and effectiveness of
family nursing intervention.
CHAPTER I:
FAMILY
ASSESSMENT
Family Structure
and
Characteristics
and Dynamics
.1. Demographic Data of the Family

Name
Mr. E.V.
Age Sex
33
Date of
Birth
M 06/12/1979 Married
Occupation
Father
Grade II
Construction
Worker
04/11/1984 Married Mother
Grade II
N/A
Grade III
N/A
Mrs. G.V 30
Mr. G.V
M 10/15/2005
Civil
Status
Position
in the Educational
Family Attainment
Single
1st
Child
A.2. Family
Structure
The family belongs to a nuclear

type of family which is composed of
father, mother and 4 children. The
father is considered as the head of
the family and is responsible for
providing the needs of the family.
The mother who is responsible for
taking good care of the four children
and management of their home in
terms of doing household chores.
The eldest son, G.V. is currently

studying and now is in Grade III, the
second son, J.V. is in Grade I, the
third son, F.V. is in kindergarten, and
the youngest, C. V., which is the only
girl among siblings and is not yet
studying.
A.3. General Family

Relationship and
Dynamics
Criteria
Status
Additional Information
Observable conflict
between family members
As stated by the mother, the 3

children dont fight very often.
Characteristics of
Communication
The parents communicate between

children very well and vice versa.
Where:
(+) Positive/Good, observable, can
be seen
(-) Negative, inexistence, cannot
be seen
A.4. Decision-making
The father is responsible for
decision-making but he stills asks his
wife for the approval of his decisions.
With regards to health matters, the
mother is less responsible for
treating immediately the illness of
her children.
A.5. Dietary Habit

Breakfast rice, egg, noodles, coffee
Lunch rice, vegetables, fish (once a week)
Dinner rice, fish, meat (especially when the father

has his salary)
B.Socio-economic &
Cultural Factors
B.1 Income & Expenses
The family V get their income for their

daily expenses from the salary of Mr. E
for working as a construction worker. The
family earns money of approximately Php
200 per day, and a total of Php 5,600 per
month. The family V is also a member of
4Ps (Pantawid Pamilyang Pilipino
Program) and they receive Php 1,600
every two months.
Allocations
Basic Needs of the

Family
Estimated Expenses
per day
Estimated Expenses
per Month
Food
Php 60.00
Php 1, 800.00
Drinking Water
Php 2.00 per gallon (3x)
Php 24.00
Allowance of the 3
children
Php 21.00
Php 420.00
Others (grocery)
Php 250.00
Cigarettes of Mr. E.
Php 20.00
Php 560.00
TOTAL:
Php 107
Php 3,054
B.2. Educational
Attainment
Both parents are elementary

undergraduate and studied only
up to 2nd Grade. Their 3 sons are
still studying, the 1st child is in
grade 3, the 2nd child is in grade
1 and the 3rd child is in
kindergarten.
B.3. Ethic Background

& Religion Affiliation
The family Vs religion is Roman
Catholic. Nagasimba kami kada 1st
Saturday of the month iya sa
Camanci Sur ag kung Domingo mata
hay sa Kalibo kami gasimba. Maliban
sang asawa nga gatrabaho hay indi
imaw kasunod kamun stated by the
mother. Mrs. V, is a native of
Buruaga and his husband, Mr. V, is a
native of Camanci Sur, Numancia.
B.4. Awareness of
Community
Organization
The family is under the
program of 4Ps (Patawid
Pamilyang Pilipino Program) and
actively joins assemblies under
it. They are aware of other
community organization like
Igkampuran Community but
barely participate to it.
C. Home and
Environment
C.1. Description of the House
Their house is located in Camanci Sur,
Numancia, Aklan and placed approximately
50 meters away from the main road. It
surrounded by different trees and grasses.
The house is very open and only their
bedroom has covers. There is no front door.
The house is a combination of woods, metal
roof and other diverse materials such as
sacks blanket and tarpaulin.
The roof is made of galvanized iron. The
foundation of the house is made of wood
There is a stairs leading to the upper floor

or to the bedroom of the house. It is made
of bamboo and has no handrails. The
structure of the house is slightly swayed
because of poor foundation. They have no
window and their floor is unpaved.
Its upper floor is made of combination of
scrapped plywood put together and
bamboo slates but has spaces and undone
nailing. There is two mat located in the left
and right side of the bedroom and they
use a blanket as a covering for the room.
The sidewalls are made of old and dirty
blanket, sacks and streamers put together
and tied.
Next to the bedroom on the left side, is

a storage room where their other
clothes and personal things are placed.
Under the bedroom of the house is
where some wastes are placed. There
is also ducks and chickens.
They have a tent made of tarpaulin
that serves as their kitchen and living
area.
House Plan
C.2. Adequacy of
Living Space
Upon arrival to the house, you will see
there small space for their bedroom
with approximately 224 cm x 296 cm in
measurement and this also serves as
their dining area. The clean and dirty
clothes are scattered everywhere and
they have no proper place and storage
for all it. They have no proper kitchen,
living room as well as bathrooms.
C.3. Sleeping
Arrangement
They only have 1 bedroom, where the
couple together with their 4 children sleep.
Crowding Index
Formula:
Crowding index =
=6 Ratio or 6:1 room (6 person/1 room)
Result: 6 persons in 1 bedroom
Ideal: 2 persons in one room (2:1)
C.4. Adequacy of
Appliances and
Furniture
They dont have any electrical
appliances. They have 1
monoblocked chair and small
table where their water
containers and other kitchen
utensils are placed.
C.5. Presence of
Accident Hazards
The upper floor that is made of bamboo
slates has gaps that can lead to fall of
the children. Their ladder has no
handrails that can also lead to
accidentally fall. Their knife and other
sharps objects are just placed inside the
bedroom and can be easily reached by
the children. The swaying of the house
may lead to accidentally falling.
C.6. Presence of Insect

and Rodents
When roaming around the house there
are presence of cockroaches and flies
especially under their house where the
chicken and ducks are located. In their
yard, there are flies, worms and
cockroaches found where the wastes are
placed. The presences of mosquitoes are
much possible during nighttime since the
walls of the house are made of
improvised sacks, blanket and streamers.
C.7. Food Storage and

Cooking Facilities
They do not have a food cover for
their left over foods. Most of the time
and they left their food just on the
floor. They use casserole for cooking,
kettle for boiling of water and uses
fire woods as fuel for cooking. They
have a tray for their eating utensils
but it is unclean.
C.8. Water Supply and

Storage
The family gets their water for
laundering and dishwashing from
their neighbors pump
approximately 150 meters from
their house and their drinking water
from a faucet (NAWASA) at their
neighbor. They use plastic
container to collect water.
C.9. Toilet Facility

The type of toilet the Family V has
is Bored-Hole Latrine where they
just dig soil to serve as their toilet
and if its already full they just
cover it with soil and dig again
another hole. Its location is 10
meters away from their house.
C.10. Garbage Disposal

They dispose their garbage
outside their house for about 5
m away from the house.
Sometimes they leave it
scattered. They dont perform
garbage segregation.
C.11. Drainage System

The mother does the laundry
and dishwashing in their nonfunctioning water pump. They
dont have good drainage
system. After washing, the water
flows to a man made hole which
small and shallow and the water
stays there for couple of days.
C.12. Household Pets

The animals that are
present in the house are 2
chickens and 2 ducks located
under the house which are
owned by the family.
C. 13. Presence of
Electricity
They just tap on their neighborhood for
the source of their electricity.
C.14. Kinds of Neighborhood

According to Mrs. V, even though they are a
little distant from the neighborhood, they still
have a good relationship with them. Their
neighbors are kind and helpful especially
when the family V, needs help.
C.15 Social and Health

Facilities
There is a public
elementary school and day
care center located in the
Camanci Sur, Numancia,
Aklan and no barangay health
station.
The family avails free health

services such as free
immunizations and consultations
from the barangay health station
located at Brgy. Bulwang,
Numancia, Aklan. The mother
take every free previlages
offered by the barangay health
station. She seeks health care
immediately and sees to it she
doesnt miss the immunization
C.16 Communication
and Transportation
The mother owns a
cellphone which is used for
communication and
emergencies. They use
tricycle for transportation
CHAPTER
II: REVIEW
OF SYSTEM
A.1 Family Health

Status/History
Name: Mr. E.V. (FATHER)

PAST MEDICAL HISTORY
He verbalizes that he didnt knew if he
was fully immunized when he was a
child and never been hospitalized
however, he experienced common
fever, cough, and runny nose.
PRESENT MEDICAL HISTORY
He doesnt have any complain to his
health.
VITAL SIGNS:
Temperature: 36.9C/ax
Pulse Rate: 72 beats per minute
Respiratory Rate: 18 breaths per
minute
Weight: 61 kg
Height: 55 FT.
BMI: 22.34 (NORMAL)
Name: Mrs. G.V. (MOTHER)

She stated that she has not been
hospitalized because of any illness though
she had been delivered 4 children in the
health center. She also said that she
experienced usual illness such as fever,
cough and runny nose but it didnt lead to
further complication that needs
hospitalization.
She has open wounds such as bites, cuts,
and abrasions due to left dirt in her legs
and dont have any treatment. Other than
OBSTETRIC/GYNECOLOGIC HISTORY
Gravida4 Term4 Preterm0 Abortion0

Living Birth4
G1-G.V., October 15, 2005, BHC, 3.083 kg.
G2- J.V., Feb 08, 2007, BHC, 2.974 kg.
G3- F.V., June 28. 2008, BHC, 3.345 kg
G4- M.C.J.V., April 04, 2013, BHC, 3.81 kg
VITAL SIGNS
minute
Blood Pressure: 120/80 mmHg
Weight: 44 kg
Height: 410
BMI: 20.28 (NORMAL)
Name: Mr. G.V. (First Child)

PAST MEDICAL HISTORY:
He had never been hospitalized and
diagnosed with illness other than the
usual like low grade fever, cough,
and stomach aches and her mother
seeks help at the center and buy a
medication. He delivered via normal
spontaneous vaginal delivery.
Has observable open wounds and
abrasion in both legs due to
scratching and dirt but other than
VITAL SIGNS:
minute
Weight: 19 kg
Height: 119 cm
BMI: 13.38 (SEVERE UNDERWEIGHT)
NAME: Mr. J.V. (SECOND CHILD)

He had never been admitted to the
hospital but experienced common
illness such as fever, cough, and
runny nose. He was delivered via
normal vaginal delivery at the health
center.
No other complain but he has an open
wounds in his both legs due to
scratching and accidentally fall when
he was playing.
VITAL SIGNS:
Temperature: 36.7c/ax
minute
Weight: 17 kg
Height: 114 cm
NAME: Mr. F.V. (THIRD CHILD)

His mother stated that F.V. had never
been hospitalized though
experienced usual sickness such as
fever, cough, runny nose,
headaches, and stomach aches and
she just buy over the counter drugs
for the treatment.
F.V. has no current complains aside
from observable open wounds on
both of his lower legs due to fall from
VITAL SIGNS:
minute
Weight: 10 kg
Height: 98cm
NAME: (M.C.J.V) (FOURTH CHILD)

PAST MEDICAL HISTORY:
According to her mother, M.C.J.V. didnt
experience severe illness yet aside from
usual cough, colds and low grade fever
and it didnt lead to further complication
that needs to be hospitalize. She was
delivered by normal spontaneous vaginal
delivery.
Upon assessment during our first visit,
M.C.J.V. has been experiencing runny nose
and skin rashes on her neck and
extremities for three days. No medications
has been given as stated by the mother.
VITAL
SIGNS:
minute
Weight: 7 kg
Height: 71 cm
BMI: 14 (SEVERE UNDERWEIGHT)
A.2 Physical
Assessment
Date of Assessment: August 20, 2014

Name: Mr. E.V. (FATHER)
GENERAL SURVEY
His age is appropriate to his physical
appearance, 55 in height and 61 kg in
weight. Alert and oriented, often smiles
and has a good posture. His skin is light
brown in color and has a short black hair,
wearing loose, slightly dirty shirt and
short.
INTEGUMENT
Skin
He has intact skin, has scars in legs and
hands, skin texture is rough and dry, warm
in temperature and no presence of moist.
Skin color is light brown and in skin turgor,
skin go back to its original shape in not
less than 2-3 seconds.
He uses soap for his skin care and take a
bath everyday.
Hair
He has dry, thick, black hair, evenly
distributed.
Scalp is intact and no scaling and lesions.
Nail
He has untrimmed and dirty nails, hard and no
clubbing observed.
Firmly attach to the nail bed.
Capillary refill not less than 2-3 seconds, and
cuts his nails once a week.
Head
Head is symmetrically at midline, still and erect.
Facial expressions are voluntary, often smiles,
eyebrows can raise, can close eyes tightly and no
lesions observed.
The heads range of motion is not limited and has
no complains regarding the head except for the
common/ usual headaches experienced if very
tired and stressed.
Eyes
Has rounded brown eyes and are
symmetrical, aligned from the tip of the
ears and are regular in shape.
Eyebrows are evenly distributed.
Eye movements are normal, eyelids are
equal in size, and covers approximately
both the eyeballs and symmetry in
blinking.
Eyelashes are curled up, bony orbits are
round and no lesions and are symmetrical,
eyeballs are equal in size, non-tender and
firm, both sclera are clear and moist, iris
are equal in shape with brown color
without vascularity.
Ears
Ears are light brown in color, no lesions,
uniform in shape and in line with the
canthus of the eyes.
Auricles are firm, smooth, non-tender, and
pinna recoils after folded. No presence of
nodules, swelling and pain upon palpation.
In external auditory canal, there is a
presence of wet, yellowish, small amount
of cerumen observed.
He clean his ear once a week with
cottonbuds.
Nose and Sinuses

Nose color is same as the face, mucosa
lining is smooth, intact, deep-pink and
non-deviated septum.
During palpation, nose is non-tender, no
discharges and dont experience runny
nose.
He has a patent airway and no difficulty
of breathing.
Mouth
Lips are intact, free in lesions, dark brown
in color and slightly moist, no cracks,
swelling and cyanosis.
Mucosa and gums are moist, pink, intact
and no lesion, teeth are complete but with
decay and debris are present in the right
molar tooth.
Tongue has normal size, pink, moist and
intact.
Oral brushing is done at least once a
week.
Neck
Neck is brown in color, no lesions and
masses.
RESPIRATORY
Has the respiratory rate of 18 breathes per
minute, chest is symmetrical and do not
use accessory muscle upon breathing.
No nasal flaring noted.Upon auscultation,
no significant deviation is heard.
CARDIOVASCULAR
Upon inspection, no jugular vein distention
is observed.
No thrills, no murmurs and bruits are
heard and have a cardiac rate of 72 beats
per minute.
GASTROINTESTINAL
Abdomen is big in size and is round, skin is
intact and no lesions, rashes, scars.
Bowel sounds are normal, umbilicus is
inverted and in the midline with no bluish
discoloration and inflammations observed.
No bulges, tenderness, pain and enlarged
organs during palpation.
Usual bowel pattern is every day and
complains no unusual abnormalities felt
with brownish, formed a stool.
GENITOURINARY
He voids for about 5-6 times a day and no pain felt upon
urination.
He refused to assessed his GU system.
His sexual pattern is done once a week.
MUSCULOSKELETAL
His posture is erect, head is in the midline, and
body alignment is normal.
No presence of any spinal deformities and
gaits is normal.
Upon Romberg test, there is a slight swaying
of the body.
No involuntary movement is observed and has
no record of fall and trauma.
NEUROLOGIC
Behaviour is normal and facial expressions
are voluntarily.
He is alert, oriented, and memory is
normal, usually dont forget the past
things that happened.
He is alert and well oriented during the
visit and cooperates well to assessments.
All cranial nerves are active and intact
and he had no history of seizures,
paralysis, and other neurologic disorders.
ENDOCRINE
No history of endocrine disorder.
HEMAPOETIC
No bruises or hematoma noted to his
body and he claimed that he dont
have any history of bleeding
disorder.
LYMPHATIC
Upon palpation, no swollen of lymph
nodes are present.
Name: Mrs. G.V. (MOTHER)

GENERAL SURVEY
She is coherent, conscious and often
smiles. Her skin is dark brown in
color, and have a long black hair,
evenly distributed in the scalp and
tied up. She speaks appropriately
and both legs have open wounds and
often left dirty. She is wearing dirty
loose shirt and short.
INTEGUMENT
Skin
Skin is dark brown in color, intact, no
lesions noted, skin has a slightly rough
and dry texture with warm temperature
and has abrasions in both legs from
scratching of insect bites.
No presence of edema, and upon
assessing the skin turgor, skin go back to
its original shape in not less than 2-3
seconds.
Dont have any removed lesion, tattoos
and other skin disorders.
He uses soap for her skin care, and has no
access to any skin moisturizers but take a
Hair
She has dry, long black hair, evenly
distributed, scalp is intact and no scaling.
No signs of pediculosis.
Often uses
Nails
She has untrimmed and dirty nails, hard
and no clubbing observed, firmly attach to
the nail bed.
Capillary refill not less than 2-3 seconds.
Nail care is seldom done at least once in
two weeks.
Head
She has rounded head, still and upright in
position.
Facial expressions are voluntary, often
smiles, eyebrows can raise, can close her
eyes tightly and no lesions observed.
Upon assessing range of motion,
movements are not limited and no
complains aside from usual/common
headaches when stressed and tired.
Eyes
Eyes are symmetrical and canthus are aligned
from the tip of the ears, eyebrows are evenly
distributed, eyelids are equal in size, and covers
approximately both the eyeballs and symmetry
in blinking, her eyelashes are curled up.
Bony orbits are round and no lesions and are
symmetrical, eyeballs are equal in size, nontender and firm, both sclera are clear and moist,
iris are equal in shape with brown color without
vascularity.
She can read letters 2-3 ft far from her.
Ears
Ears have the same colour with the rest of
the body, no lesions, uniform in shape and
in line with the canthus of the eyes.
pinna recoils after folded no presence of
swollen lymph nodes, swelling and pain
upon palpation.
presence of dirt outside the pinna.
Ears are cleaned only for about twice a
month.
Nose and Sinuses

Upon inspection, mucosa lining is smooth,
intact, deep-pink and non-deviated
septum.
During palpation, nose is non-tender, no
discharges and dont experience runny
nose.
She has a patent airway and no difficulty
of breathing and nasal flaring.
Mouth
Lips are dry, but free of lesions, dark
brown in color and are cracked, mucosa
and gums are moist, pink, intact, and no
lesion.
Teeth are incomplete having one missing
tooth in the right molar and debris or
decay are present in her both left and
right molar tooth.
Tongue has normal size, pink, moist and
intact with papillae present.
Oral brushing is done only when necessary
(if about to go somewhere).
Neck
Brown in color, symmetrical, no lesions
and masses, full range of motion, and
neck is slightly long in size, proportional in
head and shoulder.
Trachea is in the midline and non-tender,
lymph nodes are non-palpable.
Breast
Skin in the breast area is smooth,
undimpled and has same color in the rest
of the skin.
Right breast is larger than the left breast,
no edema, lesions and masses.
Nodes are non-palpable, no other
discharges in the nipples, areola are dark
brown in color.
She breastfed her baby every 3hours or
depending on her babys demand.
RESPIRATORY
Upon observation, her respiratory rate is 21
breaths per minute, chest is symmetrical and
do not use of accessory muscle upon
breathing, no presence of masses and lesions.
Posture is good, chest skin is intact. No nasal
flaring, no barrel chest and spinal deformities.
She is a thoracic breather, trachea is in the
midline, no crepitus and other significant
deviation.
CARDIOVASCULAR
No abnormal findings noted, sounds are
timing in cardiac cycle with the cardiac
rate of 70 beats per minute.
GASTROINTESTINAL
Abdominal skin is intact, flat and no
tenderness, masses, scars or lesions
observed.
Umbilicus is in the midline and inverted
and has no signs of discoloration.
She has stated no complaints regarding
her gastrointestinal system.
Bowel movement is about every other day
with formed dark brown stool as stated.
GENITOURINARY
She refused to be assessed on the
reproductive area.
Has no complains of pain upon micturation
and has regular voiding movement.
Her sexual pattern is once a week.
MUSCULOSKELETAL
Head is in midline, and observed no spinal
deformities and has erect posture.
Has no observed involuntary movements
and has the full Range of Motion.
Has no problem or past history of
musculoskeletal dislocations and disorder.
NEUROLOGIC
She is alert and oriented upon
assessment, and respond to questions and
assessment measures though easily
destructed with her surroundings.
All cranial nerves are still active
ENDOCRINE
She claimed that she dont have any
history of endocrine disorder.
HEMAPOETIC
Upon inspection, there is no bruises or
hematoma noted to her body and dont
have any history of bleeding disorder.
LYMPHATIC
No swollen lymph nodes palpated.
OBSTETRIC RECORD
According to her obstetric record, she has
4 Gravida, 4 Para, 4 Term, 0 Preterm, 0
Abortion, 4 Live children and got married
last May 2014 at the age of 30 and she
was able to bear 4 children in the years
2005, 2007, 2008, and 2013.
She had her menarche when she was 14
years old and currently have a regular
menstrual period.
She delivered all her children via Normal
Spontaneous Vaginal Delivery at the
health center with a midwife.
Currently, she had her Depo Provera
injection as their family planning method
Name: G.V. (First Child)

GENERAL SURVEY
He is wearing dirty t-shirt and short. Alert
and oriented and always smiles. He is
playful but sometimes shameful towards
others.
INTEGUMENT:
Skin
With visible intact skin in his upper body
but has observable skin lesion such as
scars, scales and abrasions from the lower
legs to his sole.
Skin has a slightly rough and warm in
turgor, skin go back to its original shape in not

less than 3-4 seconds.
Skin in lower legs is found dirty and has wounds
(bites and abrasions), no swollen lymph nodes.
He uses soap for his skin care, and has no
access to any skin moisturizers
Hair
He has dry black hair, evenly distributed, scalp
is intact and no scaling.
Uses only shampoos for his hair care if
available.
Nails
He has untrimmed and dirty nails, hard
and no clubbing observed, firmly attach to
the nail bed.
Capillary refill not less than 2-3 seconds.
His mother cuts his nails every two weeks
or if necessary.
Head
He has rounded head still, and upright in
position.
Facial expressions are voluntary, always
smiles, eyebrows can raise, can close eyes
tightly and no lesions observed.
The heads range of motion is not limited
Eyes
Eyes are symmetrically aligned from the
tip of the ears, eyebrows are evenly
distributed, eyelids are equal in size, and
covers approximately both the eyeballs
and symmetrically blink eyelashes are
long and curled up.
Bony orbits are round and no lesions and
are symmetrical eyeballs are equal in size,
non-tender and firm, both sclera are clear
and moist, iris are equal in shape with
brown color without vascularity.
He can read letters 2-3 ft far from him.
Ears
Ears have the same colour with the rest of the
body, no lesions, uniform in shape and in line
with the canthus of the eyes, auricles are firm,
smooth, non-tender, and pinna recoils after
folded.
No presence of nodules, swelling and pain
upon palpation.
In external auditory canal, presence of white
scaling of the skin and dirt outside the pinna
are observed.
His mother cleans his with cotton buds only
for about twice to thrice a month.
Nose
The color is same as the face, mucosa lining
is smooth, intact, deep-pink and non-deviated
septum.
Upon palpation, nose is non-tender, no
discharges and dont experience runny nose.
He has a patent airway and claims no clogged
upon breathing.
Mouth
Lips are smooth, intact, and free of lesions,
pink in color and slightly moist. No cracks
swelling and cyanosis, mucosa and gums are
moist, pink, intact, and no lesion, deciduous
teeth are incomplete and debris or decay are
present in both molar tooth, tongue has
Neck
Brown in color, no lesions and masses, full
range of motion, and neck is short in size,
proportional in head and shoulder.
Trachea is in the midline and non-tender
Lymph nodes are non-palpable and has no
complains regarding his neck.
RESPIRATORY
minute.
Upon auscultation, normal lung sounds are
heard.
Chest symmetrically moves, do not use
accessory muscles upon breathing and no
nasal flaring is observed.
CARDIOVASCULAR
Upon inspection, no jugular vein distention
is observed and pulsations are note in the
neck vessels and other pulsation, no thrills
and heaves present, no murmurs and
bruits are heard.
Sounds are timing in cardiac cycle and
has 66 beats per minute as cardiac rate
recorded.
GASTROINTESTINAL
Abdomen is big and protruding with intact
skin and no lesions, rashes, scars
observed. Bowel sounds are normal.
Umbilicus is inverted and in the midline
with no bluish discoloration and
inflammations observed.
No bulges, tenderness, and enlarged
organs palpated and complain no pain felt
upon assessment.
Usual bowel pattern is done every other
day and complains no unusual
abnormalities felt and with formed light
brown stool.
GENITO URINARY
He voids for about 6-7 times a day.
He refused to assessed his GU system,
but claims that he never experience pain
and severe itchiness in his genital area.
MUSCULOSKELETAL
Posture is erect , head is in the midline,
and body alignment is normal.
No history of falls, no spinal deformities,
gait is normal, no complains of pain upon
movement and has no observable
involuntary movements.
NEUROLOGIC
are voluntarily, he is alert, oriented and
playful.
All cranial nerves are active and intact
upon assessment.
ENDOCRINE
He claimed that she dont have any
HEMAPOETIC
hematoma noted to his body and dont
LYMPHATIC
NAME: (J.V) (SECOND CHILD)

GENERAL SURVEY:
He was oriented and alert but is ashamed
towards other person. Has a good posture and
he was wearing loose dirty shirt and short. He
often smiles and playful.
INTEGUMENT
Skin
He has intact skin, brown in color and has dirty
hands and feet, skin is slightly rough and dry
texture and has wounds such as scars,
abrasions and bites.
Skin is warm in temperature and extremities
are non-edematous, and upon skin turgor test,
skin goes back in original shape in not less than
2-3 seconds.
Hair
He has dry black hair, evenly distributed, scalp
is intact and no scaling.
Uses only shampoo if available.
Nails
His nails are observably untrimmed and dirty
but firmly attached to the nail bed.
Capillary refill is not less than 2-3 seconds.
His mother cuts his nails every two weeks or if
needs to be checked on school.
Head
Has symmetrically round head, upright and
erect, facial skin is intact and free from lesions.
Upon assessing range of motion, movement are
not limited and has no complains of head
Eyes
Eyes are symmetrical and canthus are
aligned from the tip of the ears, eyebrows
are evenly distributed, eyelids are equal in
size, and covers approximately both the
eyeballs and symmetry in blinking,
eyelashes are curled up.
Bony orbits are round and no lesions and
are symmetrical, eyeballs are equal in
size, non-tender and firm, both sclera are
clear and moist, iris are equal in shape
with brown color without vascularity.
He can read letters 2-3 ft far from him.
Ears
Ears have the same colour with the rest of
the body, no lesions, uniform in shape and
in line with the canthus of the eyes.
pinna recoils after folded, no presence of
swollen lymph nodes, swelling and pain
upon palpation.
presence of dirt outside the pinna. his
mother cleanse his ears only when
necessary, itchy or at least once in two
weeks..
Nose
The color is same as the face, mucosa lining is smooth,
intact, deep-pink and non-deviated septum.
During palpation, nose is non-tender, no discharges and
dont experience runny nose.
No nasal flaring observed and has patent airway.
Mouth
Lips is intact, smooth and free from lesions, oink in color and
slightly moist, no cracks, swelling, and cyanosis.
Teeth are incomplete (deciduous) and debris or decay are
present in both right and left molar teeth with moist, pink,
intact and no lesion in the mucosa and gums.
Tongue has normal size, pink, moist and intact.
Oral brushing is done only when necessary or needs to be
checked in school.
Neck
Neck is brown in color, no lesions and
masses and lymph nodes palpated.
Has full range of motion and is
proportional to his head and shoulder.
Trachea is in midline and complains no
pain upon assessment.
RESPIRATORY
minute.
Chest symmetrically expand and do not
use accessory muscle upon breathing.
Upon auscultation, normal lung sound is
CARDIOVASCULAR
He is observably not cyanotic which
is an evidence of good blood
circulation.
No jugular distention is observed and
normal pulsations are noted.
He has a cardiac rate of 73 beats per
minute.
GASTROINTESTINAL
Abdomen is round and protruding with no
lesions, scars and rash.
Bowel sounds are normal, umbilicus is
inverted and at the midline with no bluish
discoloration.
No bulges, tenderness and pain upon
palpation.
Usual bowel movement is every other day
with no complains of abnormalities felt
and with brownish, formed stool.
GENITO URINARY
He voids 6-7 times in a day and no pain
felt upon urination.
MUSCULOSKELETAL
Body is well aligned, where extremities are
symmetrical in length, head is in midline
and gait is normal.
No spinal deformities and involuntary
movement is observed.
NEUROLOGIC
are voluntarily.
He is alert, oriented and playful.
Cranial nerves are all intact and active.
ENDOCRINE
He claimed that she dont have any
HEMAPOETIC
hematoma noted to his body and dont
LYMPHATIC
No swollen lymph nodes palpated.
NAME: (F.V) (THIRD CHILD)

GENERAL SURVEY:
He is playful and smiles if approached. His
alert but destructed to new faces seeing
around him but respond to questions and
cooperate during the assessment. He was
wearing loose, dirty shirt and short and a
dirty slippers for his footwear.
INTEGUMENT
Skin
Has a dark brown skin color with warm
temperature
. No any other complaints aside from
observable skin lesions such as bites,
scars, and abrasion.
Has good skin turgor and has no tattoes
observed.
Takes a bath everyday and uses only soap.
Head
Has proportional size of the head to his body with
erect and still position, has good range of motion
and facial muscles are voluntary.
Has no complain regarding with the head except
from the usual/common headaches which are
tolerable.
Eyes
Eyes are both aligned, symmetrically blink, lashes
are curled up and show no abnormal findings
upon assessment, eyeballs are equal, non-tender
and firm.
Nose and Sinuses
Nose is smooth and intact with patent airways
and non-deviated septum, no discharges
observed and no nasal flaring.
Has no complains of pain and clogged in area of
Mouth
Has pink and moist lips with deep-pink
mucosa, tongue is voluntarily moved and
moist.
Has incomplete deciduous teeth and
decay in his both left and right molar
teeth.
Oral cleaning is done only if necessary or
if dental checked is to be done at school.
Neck
Has the same skin tone with the rest of
the body, trachea is in midline, and no
masses, lesions, and distentions palpated.
RESPIRATORY
He breaths 27 breaths per minute without the use
of accessory muscles and breathes in her chest
symmetrically.
Breathe normally without any other significant
sounds heard.
CARDIOVASCULAR
Pulsated 80 beats per minute without distention,
bruit, or hum.
GASTROINTESTINAL
Abdomen is round, big and protruding with
umbilicus in the midline and no signs of
discoloration.
Abdomen is non-tender, no masses and lesions
palpated.
Bowel movement is done every other with light
GENITO URINARY
Voids 5-7 times a day without pain felt, but
refuse for GU assessment.
MUSCULOSKELETAL
Has no spinal deformities with still and
erect posture.
Head is in the midline and has no history
of severe falls and musculoskeletal
problem, extremities are symmetrically
and non-edematous.
NEUROLOGIC
Respond actively to questions and
cooperate well.
Shows awareness of whats happening
during the entire visits.
NAME: (M.C.J.V) (FOURTH CHILD)

GENERAL SURVEY:
She is very playful and active. Often dont
obey instructions and prefer to play.
Weight and height are appropriate to
developmental age. She was wearing dirty
dress and has observable skin rashes in
the face and in the body.
INTEGUMENT
Skin
Has rough and dry skin with warm
temperature and has light skin color, skin
rash and abrasion from scratching of
insect bites are observed in both upper
and lower extremities.
Hair
Observed dry and brownish hair with
intact and no scaling scalp, found no
pediculosis.
Nails
Has untrimmed dirty nails with pinkish
color and no clubbing is observed.
Has good capillary refill and her mother
cuts and cleans nails seldom, usually done
once in two weeks.
Head
Head is symmetrically erect and still at
midline, full range of motion and
appropriate for developmental stage and
Eyes
Eyes are symmetrically aligned,
conjunctiva are pink, sclera and cornea
appears smooth, clear and moist, iris is
uniform in brownish color and in size,
pupils constrict and react to light.
Bony orbits are firm, non-tender and have
equal size, eyebrows are even and curled
up, both eyelids cover the eyeball,
symmetrically blink, no swelling and
tenderness palpated.
Ears
Ears are symmetrically aligned to the
outer cantus of the eye, auricles have
uniform shape and color without lesions
and masses. Ears recoil upon folding and
with whitish dry ear discharge. M.C.J.V.
reacts in sounds heard, evidence of good
hearing, the mother claims that she cleans
her childs ears for only twice-thrice a
month or if cotton balls is available.
Nose
Nose is in the midline and has same color
with the skin, both nares are patent upon
thorough assessment and had nondeviated septum.
Has clear watery discharge on first visit no
more other signs of significant deviations.
Mouth
Has a proportional lips in relation to the
head with pink, smooth, and slightly moist
lips.
Tongue is voluntary movable and
deciduous teeth are not yet complete.
She has not been brought to dental clinics
Neck
Proportional to the head and body, but has
skin rashes mocule.
No masses and distention palpated.
RESPIRATORY
Starting to breath using chest
symmetrically with respiratory rate of 34
breathes per minute.
No abnormal sound heard upon
auscultation, and observed no difficulty of
breathing.
CARDIOVASCULAR
Pulsated cardiac rate of 93 beats per
minute without any distentions, bruits, and
GASTROINTESTINAL
Has a round, symmetric but protruding
abdomen without skin lesions, masses and
tenderness, skin is intact and shows no claimed
abdominal pain.
Bowel movement is regular every morning with
loose bright stool.
GENITO URINARY
Is been using 2-3 diapers and voids for about 79 times a day, and observed light pink rash
(macules) in the genital area.
MUSCULOSKELETAL
Shows no deformities and able to move body
freely with her head still and erect in the
midline, extremities and voluntarily movable
NEUROLOGIC
Respond to sounds and playfully
communicate with others.
ENDOCRINE
She claimed that she dont have any
HEMAPOETIC
Upon inspection, there are no bruises or
hematoma noted to her body and dont
LYMPHATIC
No swollen lymph nodes palpated
A.3 Gordons Health

Pattern
1. HEALTH PERCEPTION- HEALTH

MANAGEMENT
According to Mrs. V, they dont believe on

herbal medicines. They usually take over-thecounter drugs as remedies and treatment like
Paracetamol syrup for the fever of her
children.Ga adto mata kami sa center kung
may gamasakit. Gapangayo man kami igto it
mga bueong. The mother also verbalized.
2. NUTRITIONAL-METABOLIC PATTERN
According to Mrs. G.V., They eat three times

a day. Their daily meal is composed of rice,
fish and vegetables. She also stated that
twice a week, they buy pork especially when
the father has his salary. All members of the
family have no food preferences. The
children are not picky to the food and just eat
what their mother had prepared for them.
3. ELIMINATION PATTERN
The
family usually void 5-7 times a

day. The father, mother and the 3
sons defecate usually every other
day, whereas the youngest child, C.V.
defecates every morning and
consumes 2-3 diapers per day.
4. ACTIVITY-EXERCISE PATTERN
Tanan man siguro kita hay ga

ihersisyo taga agahon as
verbalized by the mother. She also
verbalized that when she was
pregnant, she exercises everyday.
She walks every morning around
their yard.
5. SLEEP-REST PATTERN
The mother wakes up at 4:00 in the
morning. She starts cook their breakfast
then when the other family members woke
up they will eat their breakfast together.
Exactly 6:00 in the morning the 3 sons and
the father are ready to leave the home. At
11:00 A.M. the mother finished cooking
their lunch and waits for the three sons to
come home. They eat dinner at 6:00 in the
evening. Usually they go to sleep at
exactly 8:00 P.M.
6. COGNITIVE- PERCEPTUAL PATTERN
The father and mother are alert and

conscious during the entire home visit. They
were oriented to time and place. They
exhibit appropriate facial expressions. They
respond to questions and instructions
accordingly. The children also understand
and follow instructions very well.
7. SELF-PERCEPTION, SELF-CONCEPT
PATTERN
Mrs. V, is aware of the various health

problems faces by their family. She showed
understanding and concern to these
problems.
8. ROLE-RELATIONSHIP PATTERN
Roles of each member
Mrs. G.V, the mother does all household
chores such as cleaning the house,
cooking, and doing the laundry. Most of
the time Mr. E. V is not at home because of
his occupation as construction worker but
then, he is responsible for marketing and
buying their foods. The eldest son is
responsible in taking good care of his
younger siblings, while the other children
dont have any responsibility in the family.
Relationship of the family
The family gets along well. The mother

verbalized that her children are not
quarrelling. They play together and has a
very close relationship with each other.
The mother and father argue sometimes
but not very often.
9. SEXUAL-REPRODUCTIVE PATTERN
Mr. V and Mrs. V are still both sexually

active. They use contraceptives like DepoPovera for Family Planning.
10. COPING STRESS TOLERANCE

PATTERN
Mrs. V, has a very close relationship with
his husbands mother. She stated that
when she has a problem, she always goes
to her to discuss it and asks some advice.
11. VALUES, HABITS AND PRACTICES
The Family V is Roman Catholic and is

strong believer of God. The mother is an
active Charismatic Community member
and always goes to church every Sunday
together with her children. The family
doesnt believe in any superstition.
B. Habits and
Practice on Health
Maintenance
and Disease
Promotion
Prevention
1. Common Illness Encountered in the

last 6 months and Treatment Applied
According to the mother, the family only
experienced usual illness this past 6
months. Mrs.G.V stated Kung amat nga
gina sip-on ag gina ubo hay ginapabay an
malang namun hay gakaduea man.
According to her, she gives Paracetamol
syrup if her children experience fever, and
take no medications upon experience
2. Immunization Status of the Family

All children of the family are fully
immunized and both the parents dont
have the idea if they were immunized.
Adequacy of Rest/Sleep
Actual Hours of Sleep of the Family
Family
Members
Bedtime
Arise
Rest
Total
hours of
Sleep
Father
8:00 P.M.
4:00 A.M.
8 hrs
Mother
8:00 P.M.
4:00 A.M.
1-4 P.M.
8hrs
Children
8:00 P.M.
4:00 A.M.
11-4 P.M.
8hrs
Appropriate Hours of Sleep for Specific Age

Age Group
Required Hours of Sleep
Infant (1 month- 1 yr. old)
16-18 hours
Children (5-12 yrs. old)
8-10 hours
Adolescent (13-18)
6-8 hours
Adult (45-70)
4-6 hours
4. Use of Promotive-Preventive Health

Services
Consult person for health related problems
The family consults a doctor, but most
often on the midwife in the health center.
Medical Care financial
As verbalized by the mother, the only
source of medical care financial is Pantawid
Pamilyang Pilipino Program (4 Ps) for
children ages 0-5 years old.
Prenatal Care
The mother had regular prenatal care in
BHU for all her pregnancies.
Postnatal Care
Her postnatal care was rendered in
BHU.
Dental Health
Both parents and the youngest child did
not undergone dental check-up. The three
sons have undergone dental check-up
because of government program
implemented in school.
5. Infant Feeding Practice
As verbalized by the mother, all her

sons were breastfeed during their infant
days. Now, C.V., the youngest child is still
being breastfeed by the mother.
CHAPTER
III:
Computing and
Justifying Scores of
Health Problems
Criteria
1. Nature of the Condition or Problem Presented
Wellness State
Health Deficit
Health Threat
Foreseeable Crisis
2. Modifiability of the Condition or Problem
Easily Modifiable
Partially Modifiable
Not Modifiable
3. Preventive Potential
High
Moderate
Low
4. Salience
Scale:
A condition or problem, needing immediate attention
A condition or problem, not needing immediate attention
Not perceive as a problem or condition needing change.
Weight
3
3
2
1
2
1
0
3
2
1
1
2
1
0
Malnutrition
Criteria
Nature of the
problem
Health Deficit
Modifiability of the
problem
Easily Modifiable
Preventive potential
High
Salience of the
problem
Not a problem
Computation
Actual score
3/3x1
2/2x2
3/3x1
0/2x1
Total Score:
Justification
It is a health deficit that
requires immediate
management to eliminate
any untoward
consequences.
The problem is easily
modifiable if further
teaching will be provided
to the mother.
Susceptibility to other
diseases can be prevent if
malnutrition is eliminated.
It is not felt as a problem.

The mother neglect it and
leave untreated.
Walking barefooted
Criteria
Nature of the
problem
Health Threat
problem
Easily Modifiable
High
Salience of the
problem
Not a problem
Computation
2/3x1
2/2x2
Actual score
Justification
.67
It is a health threat because it

can lead to some diseases and
illness specifically parasitism.
3/3x1
0/2x1
TOTAL SCORE: 3. 67

modifiable if adequate
information about the
importance of wearing
footwear is provided to the
mother.
Illness, diseases, and
parasitism can be prevented if
wearing slippers will be
observed at all times,
It is not felt as a problem
because the mother is less
concern whether her children
are wearing their slipper or
not.
Improper Waste Disposal

Criteria
Nature of the problem
Health Threat
problem
Easily modifiable
High
Salience of the problem

Not a problem
Computation
Actual score
2/3x1
.67
2/2x2
3/3x1a
0/2x1
TOTAL SCORE: 3. 67
Justification
It is a health threat. The
family will easily acquire
disease.
modifiable because the
family resources are
available and interventions
are feasible.
Occurrence of
communicable diseases can
be reduced or minimize if
cleaning the surroundings
is implemented at all times.
It is not felt as a problem,

they just leave the garbage
scattering anywhere.
Improper Drainage System

Criteria
Health Threat
problem
Easily Modifiable
High

Not a problem
Computation
2/3x1
Actual score
.67
2/2x2
3/3x1
0/2x1
Total Score: 3.67
Justification
It is a health threat because it is
conducive to breeding and
habitation of vectors of diseases.
(eg mosquitos)
It is easily modifiable, the
resources and intervention
needed to solve the problem are
available to the family.
The possibility of acquiring
disease can be prevented if the
family ensure a proper drainage
system.
It is not felt as problem. The
family is not concern about their
drainage system as long as they
have a place to pour out their
used water, it is alright to them.
Fire Hazards
Criteria
Health Threat
problem
Easily Modifiable
High
Not a problem
Computation
Actual score
2/3x1
.67
2/2x2
3/3x1
0/2x1
Total Score: 3.67
Justification
It is a health threat because
it can lead to death of
family members.
It is easily modifiable
through relocation of their
cooking area from their
house.
Fire can be prevented if

proper area for cooking is
build.
It is not a problem because
they find it more
accessible if their cooking
area is just under their
house.
Accidental Hazards: Fall

hazard
Criteria
Computation
Health Threat
problem
Easily Modifiable
High
Salience of the
problem
Not a problem
2/3x1
Actual score
.67
2/2x2
3/3x1
0/2x1
Total Score: 3.67
Justification
it can lead to accidents
such as falling and cuts.
modifiable, intervention
can be attainable through
filling the gaps on bamboo
floor, hammer the nails,
and secure stairs.
Accidents can be reduced
or minimize if hazards are
eliminated.
It is not felt as a problem
because the father is
always on his work and the
mother focus on the house
hold chores.
Smoking (father)
Criteria
Health Threat
problem
Easily Modifiable
High

Not a problem
Computation
Actual score
2/3x1
.67
2/2x2
3/3x1
0/2x1
Total Score: 3.67
Justification
severe smoking can lead to
lung cancer and other
disease.
Through proper health
teachings to the father,
educating the father about
the risk of smoking and the
strategy to eliminate the
habits.
Occurrence of respiratory
disease can be prevented if
smoking habits is lessen
and eliminated.
Because the didnt want to
be warn and still insist of
smoking.
Lack of Toileting Facility

Criteria
Health Threat
problem
High

Does not need immediate
attention
Computation
Actual score
2/3x1
.67
1/2x2
3/3x1
1/2x1
.5
Total Score: 3.17
Justification
It is a health threat because the
family is risk of other
complications from suppressing
the urge to defecate.
It is partially modifiable. The
family easily dug a pit for their
defecation but had hard time to
find tarps to serve as wall.
Susceptibility to other
complications if there will be
toileting facilities for their
regular bowel movement.
The problem does not need
immediate attention. The family
planned to have proper toileting
facilities but failed to
implement it.
Ineffective breastfeeding
Criteria
Health deficit
problem
High

Not a problem
Computation
3/3x1
1/2x2
3/3x1
0/2x1
Actual score
1
Total Score : 3
Justification
It is health deficit because of
inability to initiate proper breast
feeding causing the breast to have
unequal size.
It is partially modifiable though the
mother dont have enough
knowledge regarding the problem,
she can continue and initiate breast
feeding in the smaller breast.
Prevention of further complication

will be done if the mother will be
able to breastfeed with both breast.
Not a problem because the mother is
not concern of her body image and
the risk of having unequal size of
the breast.
Rashes
Criteria
Nature of the
problem
Health Deficit
problem
High
Salience of the
problem
Not a problem
Computation
3/3x1
1/2x2
3/3x1
0/2x1
Actual score
Justification
It is a health deficit because of

failure to maintain good skin
condition.
1
0
Total Score: 3
The family does not have adequate

resources to solve the problem.
Inadequacy of living space and
water supply are barriers to
achieve good personal hygiene
which is important in management
and prevention of rashes.
Skin rashes can be prevented if
proper care is implemented.
It is not felt as a problem. The
mother neglect it and leave it
untreated because she prioritize
their basic needs rather than
buying medication for the rashes.
Prioritized Problems in the Family

Rank
1
2
3
4
5
6
7
8
9
Identified
Problems
Malnutrition
Walking Barefooted
Improper Waste
Disposal
Improper Drainage
System
Fire Hazard
Fall Hazard
Smoking (father)
Lack of toileting
Facility
Ineffective
Score
4
3.67
3.67
3.67
3.67
3.67
3.67
3.17
3
CHAPTER
FAMILY
IV:
NURSING
CARE PLAN
Health Problem No.1: Malnutrition

Family Nursing Problem
Inability of the family to recognize the
presence of malnutrition in a dependent
member:
Inability to provide adequate nursing care
to a member suffering from malnutrition
due to:
Lack of knowledge about the health
condition.
Lack of knowledge on nature and extent of
nursing care needed.
Goal of care
After 3 weeks of nursing intervention the
family will be able to:
Improve their nutritional status.
Know the importance of nutritious food
and have a balance diet.
Nursing Intervention:
Discuss the importance of nutritious foods
and proper way of preparing nutritious
foods.
Discuss how to attain balance diet.
Discuss the possible complications of the
signs and symptoms of malnutrition.
Evaluation:
Goals met. The family will be able to
prepare food properly.
Methods of Family-Nurse Contact:
Home Visit
Resources Required
Time and effort of both family and nursing
students.
Expenses for the transportation of the
nursing students.
Health Problem No.2: Walking barefooted

Failure to utilize resources for health care due
to:
Failure to perceive the benefits of wearing
slippers.
Lack of knowledge about the possible
occurrence of diseases such as parasitism.
Goal of care
Recognize the benefits of wearing slippers.
Wear slippers at all times.
Nursing Interventions
Discuss briefly the benefits of wearing
slippers and disadvantages of not wearing
the slippers.
Provide clean footwear.
Evaluation:
Goals met. The family is able to identify
the importance of wearing slippers and
correctly perform wearing of slippers
provided to them.
Methods of Family-Nurse Contact

Home Visit
Resources Required
Financial assistance for the nursing
students expenses for transportation.
Time and effort of both the family and
Health Problem No.3: Improper Waste

Disposal
Inability of the family to recognize the
condition due to:
Lack of knowledge about the importance
of clean environment.
Inadequate resources for cleaning the
environment.
Inadequate knowledge about the benefits
of having proper segregation and garbage
Goal of care
Maintain the cleanliness of their
surroundings.
Have adequate knowledge about the risk
of developing diseases brought by dirty
surroundings.
Discuss the pros and cons of dirty
surroundings.
Demonstrate the proper way of cleaning
the surroundings.
Evaluation:
Goals met. The family is able to identify
factors that can affect the health off family
members if poor environmental sanitation
is not eliminated.
Methods of Family-Nurse Contact:
Home Visit
Resources Required
Time and effort of both family and nursing
students to clean the environment.
Barangays pail, broom and shovel.
Money of nursing students for
transportation
Health Problem No. 4 : Improper

Drainage System
Family Nursing Problem:
Inability to provide a home environment
conducive to health maintenance due to:
Inadequate family resources specifically
limited physical resources or lack of space
to construct facility
Failure to see benefits of proper drainage
system.
Lack of skill in carrying out measures to
improve home environment.
Goal of Care:
After 3wks, the family will be able to:

enhance the capability to provide home
environment conducive to Health
maintenance.
know the benefits of having proper
drainage system.
maintain good drainage system.
Discuss the proper drainage system.
Help the family to enhance their drainage
system by digging deep.
Teach the family about maintaining of
good drainage system once a week they
should dig.
Educate the family about the benefits of
drainage system.
Evaluation:
Goals met: The family absorbed the
teachings and following the
recommendation of the nursing students
about the maintenance of drainage
system.
Method of Nurse-Family Contact
Home Visit
Resources Required
Time and effort of nursing students and
family members.
Shovel of the Barangay
Broom and dust pans
Health Problem No. 5 : Accidental Hazard

(Fire)
Inability of the family to recognize the problem
due to:
Knowledge deficit about safety cooking area.
Goal of Care:
After 3 weeks of intervention the family
will be able to:
Relocate their cooking area to a safe
place.
Educate the family to relocate their
cooking area.
Discuss safety precautions.
Nursing Intervention
Discuss the risks of cooking area near/
under the house.
Educate the family to relocate their
cooking area.
Evaluation:
Goals unmet: The father is stubborn and
didnt want to be told. He still insists to
smoke because he doesnt feel any
complications in his body.
Method of Family Contact
Home Visit
Resources Required
Time and effort of the nursing student and
family members.
Expenses for the student nurse.
Health Problem No.6: Accidental Hazard

(Fall Hazard)
Inability of the family to determine the
presence of accidental hazards due to:
Insufficient knowledge about the possible
accidents brought by missing bamboo
slots.
Lack of resources
Goal of care
Recognize the presence of hazard
Enumerate ways how to eliminate the
hazard.
Have sufficient resources to eliminate
hazards specifically falling.
Discuss to the family the possible effects
of the problems and enumerate ways on
how to eliminate it.
Provide resources such as bamboo, nails,
tarpaulin and box.
Evaluation:
Goals met. The family learned how to
construct and modify needed facilities to
eliminate health threat.
Methods of Family-Nurse Contact

Home Visit
Resources Required
nursing students.
Financial assistance for the nursing
students expenses for materials needed
and transportation.
Health Problem No. 7: Cigarette Smoking

(father)
Unhealthful lifestyle & personal practices:
Cigarette/Tobacco Smoking
Goal of Care
father will be able to:
Lessen his smoking habits.
Know the risks of cigarette smoking.
Know the importance of health and have a
healthy lifestyle.
Discuss the risk and diseases brought by
smoking.
Teach the father how to lessen the
smoking.
Advise the father to engage in activities
that will make him stop to smoke.
Discuss to the father the effects of his
smoking habits to the children.
Evaluation:
Goals unmet. The father is stubborn and
didnt want to be told. He still insist to
smoke because he doesnt feel any
Method of nurse-family contact

Home visit
Resources Required
Time & effort of the nursing student &
family members.
Expenses for the transportation of student
nurses.
Health Problem No.8: Lack of Toileting

Facilities
Inability to provide a home environment
conducive to health maintenance due to:
Failure to see benefits of having toileting
facilities
Inadequate family resources specifically
financial constraints
Goal of care:
After three weeks of nursing intervention,
the family will be able to:
know the importance and advantages of
having toileting facilities.
Build and improvise toilet
Help the family dig a pit and build the
foundation of the toilet
Discuss the importance of having good
toileting facilities
Provide information about the
maintenance of toiletry
Evaluation
Goals met. The family is able to build and
maintain toilet facility.
Method of nurse-family contact

Home visit
Resources required:
Time and effort of both student nurse and
family
Nursing students expenses for
transportation
Barangays shovel and bamboo for
foundation.
Health Problem No. 9 : Ineffective

Breastfeeding
Unsatisfactory feeding process due to:
Knowledge deficit about the proper
breastfeeding technique.
Maternal breast anomaly.
Goal of Care:
After 3 weeks of nursing intervention, the
mother will be able to:
Have a knowledge about the benefits of
breastfeeding.
Demonstrate the proper breastfeeding
technique.
Explain the benefits of breastfeeding , the
mechanisms include in lactation, the
proper breast care and most especially the
proper breastfeeding position.
Discuss the importance of adequate
nutrition during lactation.
Assist the breastfeeding process as
needed.
Evaluation
Goal was met: The mother understands
the importance and benefits of
breastfeeding and unable to demonstrate
proper breastfeeding technique.
Method of Family-Nurse Contact
Home Visit
Resources Required
The time and effort of both the mother,
their daughter and the nursing students.
Money of the nursing students for
transportation.
Health Problem No. 10 : Rashes

Inability to provide nursing care to the risk
member of the family due to:
Inadequate knowledge about the nature of
the problem.
Lack of necessary facilities and supplies
for care.
Goal of Care:
After 3 weeks of nursing intervention, the
Recognize the importance of good
hygiene.
Enumerate ways to reduce the spread of
rashes..
Instructed the family to wash the rashes
with antibacterial soap.
Teach the family how to perform proper
hygiene to reduce the spread of
Evaluation
Goals partially met. The rashes was
reduced and the family is able to take care
of each members.
Method of Family-Nurse Contact

Home Visit
Resources Required
nursing students.
Material resource: Antibacterial soap.
CHAPTER V:
GENERAL HEALTH
TEACHING
Advice the family to:

Eat nutritious food as often as possible.
Rationale: To enhance the nutrition of the
family and maintain a healthy body.
Observe proper hygiene.
Rationale: To prevent the susceptibility to
certain diseases.
Do hand washing before and after meal
Rationale: To reduce microorganism.
Encourage the family especially the child
to always wear slippers.
Rationale: To avoid accumulation of
parasites to human body that may cause
diseases.
Educate the family about the importance

of cleanliness and encourage them to
improve and maintain a clean and safe
home and environment.
Rationale: Prevent habitation of vectors
and breeding sites which leads to other
disease.
Advice the father to eliminate smoking
habits.
Rationale: To prevent lung problems and
prevent susceptibility to other
complications.
Encourage the mother to continue
breastfeeding on both breasts.
Rationale: To meet the needs of the
CHAPTER VI:
CONCLUSION
Family V has lots of problems regarding

to their environment and health and they
dont have any idea about how to solve
their problems. Their problems involve
poor
environmental
sanitation,
poor
personal hygiene, fall hazards, fire
hazards, lack of toilet facility, ineffective
breastfeeding, lack of knowledge about
the importance of health so we did actions
needed to reduce their risk in their family
problems.
After our nursing intervention, family V

can able to realize their problem especially
their
health
problem
and
showed
awareness about the potential risk.
Although at first health teaching, the
mother showed uneasiness when we
tackled about their problem but at last,
she and her family accepted the problem.
We, together with the family cooperated
when we do our nursing intervention so
we did it easily and because of that,
therefore we conclude, that we partially
achieved our goals because of our nursing
actions and health educations that
improved
their
knowledge
and
RECOMMENDATION
Family
V should maintain their

cleanliness to their environment and
should be aware about the potential
risk.
They also need to keep their nails
and hands clean especially the
children.
They must keep their cooking place
slightly away from their house to
prevent fire hazard.
They should have adequate toilet
Mr.
and Mrs. V should be aware

about the health of the family
especially their children to prevent
possible complications on their
nutritional status.
The mother should breastfeed the
baby in both breast to promote milk
let down and to avoid enlargement of
the other breast.
Mr. V should limit his alcohol drinking
and smoking to avoid further
problem to his problem.
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BSN-II

Nursing practice in the community means

At the end of family case presentation,

Specifically it aims to:

Identify family structures and types.

.1. Demographic Data of the Family

04/11/1984 Married Mother

The family belongs to a nuclear

The eldest son, G.V. is currently

A.3. General Family

As stated by the mother, the 3

The parents communicate between

A.5. Dietary Habit

Lunch rice, vegetables, fish (once a week)

Dinner rice, fish, meat (especially when the father

B.1 Income & Expenses

The family V get their income for their

Basic Needs of the

Php 2.00 per gallon (3x)

Both parents are elementary

B.3. Ethic Background

There is a stairs leading to the upper floor

Next to the bedroom on the left side, is

C.6. Presence of Insect

C.7. Food Storage and

C.8. Water Supply and

C.9. Toilet Facility

C.10. Garbage Disposal

C.11. Drainage System

C.12. Household Pets

C.14. Kinds of Neighborhood

C.15 Social and Health

The family avails free health

A.1 Family Health

Name: Mr. E.V. (FATHER)

Name: Mrs. G.V. (MOTHER)

Gravida4 Term4 Preterm0 Abortion0

Name: Mr. G.V. (First Child)

NAME: Mr. J.V. (SECOND CHILD)

NAME: Mr. F.V. (THIRD CHILD)

NAME: (M.C.J.V) (FOURTH CHILD)

Date of Assessment: August 20, 2014

Nose and Sinuses

Name: Mrs. G.V. (MOTHER)

Nose and Sinuses

Name: G.V. (First Child)

turgor, skin go back to its original shape in not

NAME: (J.V) (SECOND CHILD)

NAME: (F.V) (THIRD CHILD)

NAME: (M.C.J.V) (FOURTH CHILD)

A.3 Gordons Health

1. HEALTH PERCEPTION- HEALTH

According to Mrs. V, they dont believe on

According to Mrs. G.V., They eat three times

family usually void 5-7 times a

Tanan man siguro kita hay ga

6. COGNITIVE- PERCEPTUAL PATTERN

The father and mother are alert and

Mrs. V, is aware of the various health

Relationship of the family

The family gets along well. The mother

Mr. V and Mrs. V are still both sexually

10. COPING STRESS TOLERANCE

11. VALUES, HABITS AND PRACTICES