Republic of the Philippines

CAVITE STATE UNIVERSITY (CvSU)

DON SEVERINO DE LAS ALS CAMPUS Indang, Cavite

College of Nursing

FAMILY NURSING CARE PLAN

In Partial Fulfillment of the Requirement in NURS 50 Maternal and Child care Nursing

Submitted by: Sudario, Carmella Dawn B. BSN 2-1

Submitted to: Mr. Genreigh Genuino RN, MAN

August 14, 2012

FAMILY DATA SHEET

FAMILY NAME: ADDRESS:

BENILE Family B67 Excess Lot City Homes Resort Ville-2, Langkaan-II, Dasmarias, Cavite

A. FAMILY STRUCTURE AND SYSTEM

HEAD OF THE FAMILY: AGE: RELIGION:

M.B 32 years old Roman Catholic

MEMBERS Ms. B M.B

POSITION Mother Daughter

AGE 32 yo 5 y/o

SEX Female Female

CIVIL STATUS Single Single

EDUCATIONAL RELIGION ATTAINMENT Elementary Catholic Graduate Elementary Catholic Undergraduate

DESCRIBE THE TYPE OF FAMILY STRUCTURE The B family is a single-parent type of family because it is composed of unmarried single mother and her daughter.

DESCRIBE THE ROLES OF EACH MEMBER OF THE FAMILY A. Spousal Relationship Ms. B is not married to the father of M.B. First, they lived together for a month and got pregnant. After 4 months together, they separate and start their own lives without the support of each other. Now, the father has his own family. And tries to get her daughter but Ms. B didnt allow it to happen even though it will not give them financial support.

B. Parent-Children Relationship As a single mother, Ms. B is the only provider of the family. She works hard for her family to supply their needs. Even though she is a vegetable vendor she always makes it a point to bond with her daughter. As the mother described, she is getting a hard time taking care of M.B but shes giving her best to be a good mother even though M.B has no father. Yet Ms. B is caring and loving for her only daughter. She disciplines her child very well. C. Sibling Relationship M.B is the only child in their family. She has no siblings. D. Significant Others The family has a well-built relationship around their community. Almost all of her neighbors are her relatives, as I notice. ECOMAP

Father

Ms. B

M.B

LEGEND:
Female Male Close Relationship Strained Relationship Stable Relationship / Conflict Relationship [ no line ] No Relationship -

 INTERPRETATION OF ECOMAP In the illustration above, it shows that the members of the Benile Family are strongly related. They have good bonding and trust for each other. The factors outside their family like work, neighbor, school, and health care facilities have stable relationship. Some of their time is spent to these factors but in church there is no relationship established. M.B, the only child, has a conflict relationship to her father. It is because; she never met and didnt ask for her father.

DESCRIBE THE COMMUNICATION PROCESS AMONG FAMILY MEMBERS A. Expression of affection, anger, anxiety, and support The family members have almost the same style of showing their emotions for each other. Ms. B often times get mad at M.B but she didnt hurt her. The only daughter, M.B, demonstrates her emotions by caring and kissing her mother whenever she wants. B. Problem-Solving Style When family problems occur, Ms. B keeps it to herself and solves those problems by her own as part of the duties of being a parent. When she decide about a problem, for sure its final and will never be broken. She never let her problem affect their mother-daughter relationship.

ACTIVITY OF DAILY LIVING OF EACH FAMILY MEMBER At 4:00am, Ms. B and M.B wakes up. Ms. B prepares breakfast for their family. Then, M.B gets ready for her school at 5:00am. Ms. B accompanied her daughter to school, after that, she prepares and sell the vegetables along the street. When shes done selling she prepares food for their lunch and fetches M.B from school at 1:00pm. MS. B sleeps 11:00pm while M.B is 9:00pm.

B. SOCIO-ECONOMIC AND SOCIO-CULTURAL FACTORS

MAIN SOURCE OF INCOME The familys main source of income is the job of Ms. B who works as a vegetable vendor in the street.

 MONTHLY INCOME The familys estimated monthly income is P7, 500. NAMES MS. B AGE 32 y/o SEX F OCCUPATION Vegetable Vendor WORKPLACE Dasmarias, Cavite INCOME P7, 500

ESTIMATED MONTHLY FAMILY EXPENSES Food Electric & Water Bills Education Others (lending card; paluwagan) TOTAL TOTAL MONTHLY EXPENSES P4, 500 P600 P1, 250 P1, 150 P7, 500 P7, 500

TYPES OF JOBS IN THE FAMILY Ms. B is a vegetable vendor in their area. These needs manual labor and heavy duty job which is a blue-collar job.

EXPOSURE TO HAZARDOUS CONDITIONS AT THE JOB Ms. B described that her work is safe and no accidents may take place. ATTITUDES TOWARD INVOVLEMENT IN THE COMMUNITY The family is active in community programs. They also know how to utilize the health resources available in the Health Center. COMPLIANCE WITH RULES, LAWS AND SOCIETIES The family is obedient with regards to community rules and laws. They choose to be friends with everyone.

C. ENVIRONMENTAL FACTORS

I.

Housing TYPE OF DWELLING The house is a one-storey building that is made up of mixed materials. It is also a oneroom house that has a floor area of the house is 2 meters x 2 meters.

PRESENCE OF INSECTS AND RODENTS The environment is favorable for the survival of vectors. There are rodents found beneath the house, there are also mosquito flying inside the house, and there are breeding sites of cockroaches.

ADEQUACY OF FURNITURE They have one single bed for the two members of the family and television inside their house. Tables and utensils for cooking is located outside.

PRESENCE OF ACCIDENT HAZARDS The stairs of their house is not stable; it can be detached in the wall. Their medicine is not properly kept. Pointed objects like knife is placed within reached of the child.

LEVEL OF SECURITY When there is no one at home, they just close their door and window. They practice proper security even if they are friends with their neighbors.

D. FOOD STORAGE AND COOKING FACILITY The family doesnt keep their food in a storage they just prepare food that is exactly for one meal. They are make use of wood/ charcoal for their cooking purposes but sometimes they use gas stove. They use pail with water and sink for their cleaning facility.

E. WATER SUPPLY The family gets water from the district water which is NAWASA for their general use. While they buy mineral water for their drinking water supply and it stored in a large container with faucet.

F. WASTE DISPOSAL GARBAGE DISPOSAL AND TOILET FACILITY Their garbage is being collected by the garbage collector of the barangay but it needs to be brought up in the street. Their toilet is pour flush toilet and located outside their house. Its walls and floor are concrete but theres no roof. They also have open drainage system for their household waste.

II.

Neighborhood Their house has inadequate space between their neighbors and it is congested. But it safe to go out at night because the people in their place are not troublesome.

III.

Social and Recreational Activities The family goes to mall very seldom at least once year. It is only when they have budget money for it. But they join community activities when it is available.

IV.

Communication and Transportation Their means of communication is mainly through cellular phones. They dont own any vehicle thats why they ride tricycle and jeepneys when commuting to another place.

HEALTH ASSESSMENT

I.

Medical and Nursing History In the familys major past illnesses, Ms. B had anemic while M.B had UTI. Most of the illness they had is cough, fever and colds.

 IMMUNIZATIONS Names Ms. B M.B BCG

DPT 2

OPV 1 2 3 unrecalled

MEASLES

HEPA B 1 2 3

HOSPITALIZATIONS Name Ms. B 32 y/o Age Reason Childbirth Length of Confinement 3 days Operation (if any) NSD

LIFESYLE/ VICES Ms. B doesnt drink alcohol or smoke cigarettes. But she plays tong its when she had extra time and money. II. Nutritional Assessment ANTHROPOMETRIC DATA Names Ms. B M.B Height (cm) 154 109 Weight (kg) 52 18 BMI 21.8 16.0 Classification Normal Normal BP (mmHg) 90/70 n/a PR (bpm) 80 89 RR (cpm) 20 21

Names Ms. B M.B

Eating Habits/ Practices She eats 4 cups of rice, 1 cup of vegetables, 1 piece of fish and drinks 10 glasses of water and 3 cups of coffee per day. She eats 3 cups of rice, cup of vegetables and drinks 7-8 glass of water and milk or juice

III.

Family Planning Name Age 32 y/o Method of Contraception n/a

Ms. B

IV.

Dental Care Age 32 y/o 5 y/o Dental Health Status With dentures Lost teeth Remarks complete incomplete

Names Ms. B M.B

INTERPRETATION OF GENOGRAM In the illustration below, it shows that both parents of Ms. B are dead. They died because of diabetes mellitus and hypertension. The client is well. The primary disease that runs in the clients family is hypertension, diabetes mellitus and heart disease.

INDIVIDUAL ASSESSMENT

I.

Demographic Data Name: Address: Age: Sex: Date of Birth: Nationality: Occupation: Language: Educational Attainment: Religion: Information provided by: Ms. B B67 Excess Lot City Homes Resort Ville-2, Langkaan-II, Dasmarias, Cavite 32 y/o Female March 19, 1980 Filipino Vegetable Vendor Filipino Elementary Graduate Roman Catholic The client who is reliable

II.

Reason for seeking care There is no reason for seeking health care.

III.

History of Present Illness The client is well during the time of the interview.

IV.

Past Medical History The client was in a usual state until a year ago. At that time, she had anemia and advised to take vitamins. She is also recommended to eat foods that are rich in iron.

V. Personal And Psychosocial History DIETARY INTAKE Breakfast: Lunch: Snack: Dinner: USUAL DIET The client usually eats rice, fish and vegetables for her diet. EXERCISE Her form of exercise is selling vegetables in the street for almost 3-4 hours. USUAL ACTIVITIES Her usual activity in a day is selling vegetables, cooking and buying vegetables in the market to be sold the next day. HOBBIES Her hobby is playing tong its and watching television. REST AND SLEEP She sleeps every 12 am and wakes up at 4 am. ALCOHOL USE/ SMOKE Ms. B doesnt drink alcohol or smoke cigarettes. RECREATIONAL DRUG USE The client has no recreational drug use. VI. Gordons Functional Health Pattern A. Health Perception- Health Management The client describes herself as a healthy individual. She eats right and dinks plenty of water to sustain optimum health. She is quite knowledgeable of the illness running through their family like hypertension, heart disease and diabetes that is why he turn away from harmful practices that can lead to those conditions. She does not take any herbal medicine but goes to a doctor in times of illness. There is no fund in case of health emergencies. She drinks 2 cups of coffee, and eats bread every morning She eats 2 cups of rice, 1 piece of fish, and drinks 3 glasses of water Just like her meal in breakfast, she eats bread and drinks 1 cup of coffee She eats 2 cups of rice, 1 cup of vegetables, and drinks 4 glasses of water

B. Nutritional- Metabolic Client drinks 10 glasses of water and 5 cups of coffee a day. Eats full meals 3 times a day. Client eats vegetables and fish than meat. She is not a picky eater. She denied any dental visits and loss of appetite. C. Elimination Client voids about more than 6 times a day characterized as a clear and yellow. She denies having problems in urinating. She also defecates once a day usually in the evening. She described the character of her stool as usually yellowish to brownish in color and semi-solid. She denies also of using laxatives. D. Activity- Exercise The client is a moderately active. She described that she is exercising every morning for at least 3 hours. She experienced dizziness sometimes as the client verbalized. She knows that she need to have lots of energy for her every day living especially when shes selling vegetables in the street. E. Sleep- Rest During the interview, client looked relaxed and comfortable yet she has eye bags. She verbalize that she sleeps late around 11:00PM-12:00AM and usually wakes up at around 4:00AM during weekdays, she affirmed that she still feel less energized because of lack of sleep. She stated that she has difficulty in sleeping early at night and experienced headache after awakening. She verbalizes that she is not snoring, night awakening or using any sleeping aids. And she is taking a nap after she fetches MB from school. F. Cognitive- Perceptual The client answered the questions clearly. All of her senses are unharmed, as verbalize. She had a problem in forgetting things, as she express. She describes that shes making a hard time in focusing something but in making decision is too easy. The client is an elementary graduate and very short tempered person. G. Self-Perception- Self-Concept During the interview, the client projects lack of self-confidence. She express that she feels good but not satisfied about herself. She is moody especially when she has a problem. She mentioned that she has strong personality but fears of losing her daughter.

H. Role- Relationship The client stated that in her family she is the bread winner. As a single parent, she had a difficulty in taking care of MB but still shes doing her best to be a good mother. In the community, the client joins paluwagan. She stated also, that she is not fond in joining an organization but she is participating barangay assembly in their place. I. Sexuality- Reproductive

The client speak that she is contented with her sexuality. She stated that she never encounter major medical problem about her reproductive system but at times she had dysmenorrhea. She stated that she had her menarche when she was 11 years old. Her last menstrual period was 19th of June 2012 and used about 32-3 pads per day but not much soaked. The usual duration of her menstrual period is 4 days and had an irregular cycle. She experienced dysmenorrhea whenever she had menstruation. She also drinking warm water to relief those discomforts. J. Coping- Stress As the client describes, money is the common source of stress. The client verbalizes that whenever shes stress she just sleeps. She denied drinking medications when coping but she diverts her anger to things around her. K. Value- Belief The client is a believer of God and very prayerful. MB is her major priority specifically the future of her daughter. She denied using of common herbal medicine like Oregano, Banaba, Ginger, Sambong and Tuba. She does not believe either to quack doctors or superstition. She consulted doctors if the illness perceives. VII. Review of System System General Integument Skull Eyes Ears Nose and Sinuses Mouth Throat and Neck Subjective Cues Ayos lang naman, pakiramdam ko Pakiramdam ko dry ung balat ko Sa buhok ko naman, walang kuto o lisa pero may mga uban na Minsan nasakit kuko ko kaya tinatanggalan ko ng ingrone Wala naman sugat ulo ko o kaya bukol Hindi naman malabo ang mga mata ko Malinaw naman pandinig ko Wala naman akong sipon ngayon Kapaga may sipon ako, nasakit ulo ko Bihira lang ako magkasingaw Naka-pustiso nga ako e Minsan nahihirapan ako lumunok

Breast and Axila Respiratory Cardiac Gastrointestinal Urinary Musculoskeletal Hematologic Endocrine VIII. Parts Skin

Wala naman ako nararamdaman na kulani sa may leeg ko Minsan nasakit kapag tapos ko magkaroon ng mens Hindi naman ako nahihiripan huminga Wala naman akong nararamdamn ng paninikip ng dibdib Minsan nakakaramdam ako ng kabag Hindi ako nagpipigil sa pagihi Kulay dilaw nga ihi ko e Nakakaramdam ako minsan ng pananakit ng likod Alam ko anemic ako, mababa kasi lagi dugo ko Madalas akong pagpawisan lalo kapag nagtitinda ako

Physical Examination Technique Inspection Palpation Objective Cues dark in color (-) lesions (-) hyperpigmentation dry skin warm to touch good skin turgor evenly hair distribution black with some gray, fine hair no parasites evident (-) masses oily and dry round, hard, nails with pink nail beds capillary refill <3 seconds normocephalic aligned facial features (-) masses (-) nodules symmetrical blinking round and equal iris (+) opacity of the left lens non tender lacrimal apparatus symmetric (-) discharges on external ear smooth, elastic (-) tenderness symmetric (-) nasal discharges pink and moist mucosa with no lesions (-) nasal flaring (-) masses Findings

Normal

Hair

Inspection Palpation

Normal

Nails Skull and face

Inspection Palpation Inspection Palpation

Normal

Eyes and vision Inspection Palpation Ears and hearing Inspection Palpation Nose and sinuses Inspection Palpation

Normal

Normal

Normal

Mouth and oropharynx Inspection Neck Inspection Palpation Lymph Nodes Trachea Breast and Axilla Palpation Palpation Inspection Palpation Thorax and Lungs Heart Gastrointestinal Palpation Auscultation Inspection Inspection Auscultation Auscultation

Musculoskeletal

(-) tenderness pharyngeal tonsils not inflamed (-) gag reflex (-) lesions on lips, mouth and throat symmetric (+) full ROM (-) lesions (-) masses (+) smooth, firm and non tender thyroid (-) enlarged lymph nodes midline position nipples everted pale brown areola (-) dimpling, discoloration, nipple discharges (-) tenderness (-) axillary lymph nodes enlargement symmetrical thoracic expansion (-) crepitus (-) wheezing (+) apical pulse felt at 5th ICS LMC line normal heart sounds regular rate, normal rhythm normal liver span (-) masses (-) tenderness normoactive bowel sounds steady gait (+) full ROM and muscle strength of upper and lower extremeties

Normal

Normal

Normal Normal

Normal

Normal Normal

Normal

Normal

INDIVIDUAL ASSESSMENT

I.

Demographic Data Name: Address: Age: Sex: Date of Birth: Nationality: Occupation: Language: Educational Attainment: Religion: Information provided by: M.B. B67 Excess Lot City Homes Resort Ville-2, Langkaan-II, Dasmarias, Cavite 5 y/o Female November. 16, 2006 Filipino Student Filipino Elementary Undegraduate Roman Catholic The client who is reliable

II.

Reason for seeking care There is no reason for seeking health care.

III.

History of Present Illness The client is well during the time of the interview.

IV.

Past Medical History The mother described that M.B. was in a usual state until months ago. At that time, she had an UTI last May 2012 and was prescribed to take antibiotic.

V.

Obstetric- Gynecological History The client has not been having menstruation neither having problems in her reproductive system.

IX. Personal And Psychosocial History DIETARY INTAKE Breakfast: Snack: Lunch: Snack: Dinner: USUAL DIET The client usually eats rice, fish and vegetables for her diet. EXERCISE Her form of exercise is playing with her friends and classmates for 2-3 hours in the afternoon. USUAL ACTIVITIES Her usual activity in a day is going to school, playing and watching television at night. HOBBIES Her hobby is playing outside and watching television. REST AND SLEEP She sleeps every 9 pm and wakes up at 4 am. ALCOHOL USE/ SMOKE M.B. doesnt drink alcohol or smoke cigarettes. RECREATIONAL DRUG USE The client has no recreational drug use. VI. Parts Skin Inspection Physical Examination Technique Objective Cues dark in color (-) lesions (-) hyperpigmentation Findings Normal She drinks 1 glass of milk, and eats bread every morning She eats bread and drinks 1 glass of juice She eats 2 cups of rice, 1 piece of fish, and drinks 2 glasses of water like her meal in breakfast, she eats bread and drinks 1 glass of milk She eats 1 cups of rice, cup of vegetables, and drinks 3 glasses of water

Palpation Hair Inspection Palpation Nails Skull and face Inspection Palpation Inspection Palpation Eyes and vision Inspection Palpation Ears and hearing Inspection Palpation Nose and sinuses Inspection Palpation Mouth and oropharynx Neck Inspection Palpation Lymph Nodes Trachea Breast and Axilla Palpation Palpation Inspection Palpation Thorax and Lungs Inspection Inspection

dry skin warm to touch good skin turgor evenly hair distribution black with some gray, fine hair no parasites evident (-) masses oily and dry round, hard, nails with pink nail beds capillary refill <3 seconds normocephalic aligned facial features (-) masses (-) nodules symmetrical blinking round and equal iris (+) opacity of the left lens non tender lacrimal apparatus symmetric (-) discharges on external ear smooth, elastic (-) tenderness symmetric (-) nasal discharges pink and moist mucosa with no lesions (-) nasal flaring (-) masses (-) tenderness pharyngeal tonsils not inflamed (-) gag reflex (-) lesions on lips, mouth and throat symmetric (+) full ROM (-) lesions (-) masses (+) smooth, firm and non tender thyroid (-) enlarged lymph nodes midline position nipples everted pale brown areola (-) dimpling, discoloration, nipple discharges (-) tenderness (-) axillary lymph nodes enlargement symmetrical thoracic expansion

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal Normal

Normal

Normal

Auscultation Heart Auscultation Gastrointestinal Palpation Auscultation Inspection

Musculoskeletal

(-) crepitus (-) wheezing (+) apical pulse felt at 5th ICS LMC line normal heart sounds regular rate, normal rhythm normal liver span (-) masses (-) tenderness normoactive bowel sounds steady gait (+) full ROM and muscle strength of upper and lower extremeties

Normal

Normal

Normal