INITIAL DATABASE

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INITIAL DATA BASE

Our duty in the community started last September 29, 2008 and ended on September
30, 2008.
Our clinical instructor in the area, Mrs. oriented us on what will be our
assignments and routines in our
two days stay. The group was divided by pair and was instructed to choose a client
for family assessment.
This family will be their chosen subject for study.

MQP, a client during that time, who happens to have rashes all over his body,
which our
instructress identified to be measles, was our subject of study. According to the
mother, the child had a
fever for three days before those rashes appear.

Given a subject, me and my partner formulated plans and designated task to done
individually. We
ask permission to our client to be able to visit her at home. Upon the approval of
our request we set a
date of visit. The next day, equipped with the necessary tools, we proceeded in
their home for our home
visit.
A.FAMILY STRUCTURE AND DYNAMICS

No. Name of
family member
Sex Birthday
(mm/dd/yy)
Age Height
1 DDP M 12-07-78 29 y/o 5� 10��
2 NP F 05-11-80 28 y/o 5� 2��
3 MQP M 03-13-2008 6 � mos. 22 inches

Weight Civil Status Religion Educational Attainment Occupation

Relationship to family
head
69.41kg M R/C CG GRCO Head of the family
54.98kg M R/C CUG Housewife Wife
7kg C R/C N/A N/A Sibling
Family�s head DDP is 29 years old, born on December 7, 1978, 5�10�� in height and
153 lbs. in weight.
He is a GRCO graduate, presently working in CC in Boni Avenue. His wife NP is 28
years old, born on May
11, 1980, 5�2�� in height and weighs 119 lbs. She was an undergraduate of the
course Bachelor of Science in
Business Administration. Presently, she was a plain housewife to DDP and a mother
to their child. NP
was born in the Northern part of Samar while her husband was from the Western part
of it. Their three
years of marriage was blessed with a healthy baby boy named MQP. He is 61/2
mos.old, 22 inches long
and weighs 15.43 lbs. All family members are Roman Catholic. To show their
dedication they never fail to
go to church every Sunday to give thanks and praise for all the blessings God has
given them.

Their family is nuclear in structure. According to them they owned the house but
not the land, for
it is owned by the government. Common languages spoken were Waray and Tagalog. In
times of conflicts
and problems they always depend on each other in solving it. For them they can
face any kind of
hardships and problems as long as they are together.

B. SOCIO-ECONOMIC STATUS
Monthly Income: P10, 000-P15, 000
Weekly Budget: P2, 500

Amount Expenditure
P1500 Foods( Groceries)
P500 Bills: Electricity and water
P250 Transportation (Father)
P250 Savings
TOTAL: P2,500

Prioritization of Need

Rank Priorities
1 Food
2 Bills
3 Transportation

Majority of the family�s budget is allocated to their food needs. Second to this
is their budget to
their billings like electricity and water. Based from the table above you can
observe that they give
importance to their savings. This is for the preparation of their child�s future.
When it comes to their
clothing you can observe it has not been indicated above for they seldom spend
money in clothing.
Financial difficulties of the family are solved by borrowing money from friends
and relatives, to be
returned after the head of the family received his salary.

C.ENVIRONMENT

Home:
Ownership of the House Owned
Construction Materials Used Mixed
Space adequacy Adequate
Lighting Facility Electricity
Lighting Adequacy Adequate
Ventilation Adequate
Water Supply Level III (nawasa)
Drinking Water Nawasa
Food Storage Covered
Waste Disposal:
Garbage Container Covered
Method of Disposal Garbage Collection
Toilet Facility Level II (with poso negro not connected to
sewerage)
Drainage System:
Type of Drainage Open Drainage
Domestic Animals, Insects, Breeding Sites:
Pets/Animals None
Pests/Insects Rodents, Cockroaches, Mosquitoes, Flies
Way of Eradication Trapping, Using Insecticides

FLOOR PLAN MEASUREMENT

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

Name of Client: DDP

Age: 29 years old

MEASUREMENTS
RESULT NORMAL VALUES ANALYSIS
Height 5� 10��
A medium frame man
with a height of 5�10��
should have a weight
range of 151-163 lbs.
Normal
Weight 153 lbs (69.41kg)

VITAL SIGNS

Temperature 36.5 degree celcius 36-37 degree celcius Normal

Pulse Rate 63 60-100 bpm Normal
Respiratory Rate 20 16-20 bpm Normal
Blood Pressure 110/80 120/80 Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE
ASESSED
NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Skull
Scalp
Hair
Symmetry
Without flakes
Resilient hair
Symmetry
Without flakes
Resilient hair
Normal
Face
Eyebrows
Eyelashes
Eyelids
Lower palpebral
(conjunctiva)
Sclera
Cornea
Pupils
Iris
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Normal and healthy
Eye movement
Visual fields
Visual acuity
Ear canal
Hearing acuity
Internal nares
Septum
Coordinated
Can see object in peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Coordinated
Can see object in peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Normal and healthy
Normal and healthy
Lips
Gums
Teeth
Tongue
Frenulum
Cheeks, buccal mucosa
Palate
Uvula
Pinkish
Pinkish
32, smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Pinkish
Pinkish
smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Normal and healthy
Tonsils
Voice
Muscular strength
Areola
Nipples
Abdomen
Pink and smooth
Can be heard
Equal strength
Round or oval
Round and equal
Unblemished skin, uniform in
color
Pink and smooth
Can be heard
Equal strength
Round or oval
Round and equal
Unblemished skin, uniform in
color
Normal and healthy
Normal and healthy
Name of Client: NP

Age: 28 years old

MEASUREMENTS

RESULT NORMAL VALUES ANALYSIS

Height 5� 2��
A small frame man with
a height of 5�2�� should
have a weight range of
115-130 lbs.
Normal
Weight 119 lbs. (54.98 kg)
VITAL SIGNS

Temperature 37 degree celcius 36-37 degree celcius Normal

Pulse Rate 70 60-100 bpm Normal
Respiratory Rate 19 16-20 bpm Normal
Blood Pressure 100/80 120/80 Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

ASESSED
Skull
Scalp
Hair
Face
Eyebrows
Eyelashes
Eyelids
Lower palpebral
(conjunctiva)
Sclera
Cornea
Pupils
Iris
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Normal
Normal and healthy
Eye movement
Visual fields
Visual acuity
Coordinated
Can see object in peripheral
20/20 vision
Coordinated
Can see object in peripheral
20/20 vision
Normal and healthy
Ear canal
Hearing acuity
Internal nares
Septum
Lips
Gums
Teeth
Tongue
Frenulum
Cheeks, buccal mucosa
Palate
Uvula
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
32, smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Normal and healthy
Normal and healthy
Tonsils
Voice
Muscular strength
Pink and smooth
Can be heard
Equal strength
Pink and smooth
Can be heard
Equal strength
Normal and healthy
Areola Round or oval Round or oval
Nipples Round and equal Round and equal Normal and healthy
Abdomen Unblemished skin, uniform in Unblemished skin, uniform in
color color

Name of Client: MQP

Age: 6 � mos. old
MEASUREMENTS

RESULT NORMAL VALUES ANALYSIS

Height 22 inches An average weight of a 6
months old infant is
16.53 lbs.
Normal
Weight 15.43 lbs (7 kg)

VITAL SIGNS

Temperature 37.2 degree celcius 37.2 degree celcius Normal

Pulse Rate 113 bpm 120-140 bpm Normal
Respiratory Rate 48bpm 30-50 bpm Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE
ASESSED
NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Skull
Scalp
Hair
Face
Eyebrows
Eyelashes
Eyelids
Lower palpebral
(conjunctiva)
Sclera
Cornea
Pupils
Iris
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Symmetry
Without flakes
Resilient hair
Symmetry
Hair equal, intact
Intact, with curl
Aligned
Pinkish
White and clear
Transparent, shiny
Black, equal, round
Symmetry
Normal
Normal and healthy
Eye movement Coordinated Coordinated Normal and healthy
Visual fields
Visual acuity
Ear canal
Hearing acuity
Internal nares
Septum
Lips
Gums
Teeth
Tongue
Frenulum
Cheeks, buccal mucosa
Palate
Uvula
Can see object in peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
32, smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Can see object in peripheral
20/20 vision
Uniform in color
Normal voice can respond
Symmetry
Symmetry
Pinkish
Pinkish
smooth, shiny
Smooth
Smooth
Uniform in color
Soft and glistering
Light pink
Normal and healthy
Normal and healthy
Tonsils Pink and smooth Pink and smooth Normal and healthy
Voice Can be heard Can be heard
Muscular strength Equal strength Equal strength
Areola Round or oval Round or oval
Nipples Round and equal Round and equal Normal and healthy
Abdomen Unblemished skin, uniform in Unblemished skin, uniform in
color color

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

Nutritional Status
Name of Family
Member
Height Weight BMI Interpretation
DDP 5� 10�� 153lbs 22 Normal
NP 5� 2�� 119lbs 22 Normal
MQP 22 inches 15.43 lbs 23 Normal

All the family members have normal total body mass index because the ratio was
18.5-24.9.

Exercise Pattern

Name of Family Member Hours of Exercise Times per Week Normal

DDP 30 minutes 7 times a week 30 minutes/day
NP 30 minutes 7 times a week 30 minutes/day
MQP N/A N/A n/a

The father, DDP was not able to practice it everyday because of work. His wife on
the other has a daily
routine exercise in a form of dancing. Their child on the other hand was still too
young to participate in
the activity.

C.Values, Belief and Practices

Just like typical Filipinos they grow up to an environment wherein respect was
being emphasized.
The kind of environment they want their child to have and grow-up with. They do
not want him to be
stubborn or disrespectful in front of people older than him. They want him to
believe and have faith in
God just like them. For them what they plant to their child is what they will also
earn in the future.

II. ORGANIZATIONAL DATA

Cues Normal Standards Based on Reference
Subjective:
�Nilagnat siya ng tatlong araw
bagolumabas yang mga pula-pula niya sa
katawan.�
A healthy child must be free from diseases or illnesses like
fever cough and colds, rashes and the like.
Subjective:
�Ang daming ipis dito pag umaga, yung
pag binuksan mu yung ilaw, kanya
kanyang takbo na sila. Minsan din
malangaw at may magnilan-ngilang daga
na naghaharutan sa may kisame.�
A healthy home must be free from rodents and pest, it is clean,
well ventilate and free from threats.
Subjective:
�Nakakatakot lang ditto yung bukas na A healthy home must be free from rodents and
pest, it is clean,
kanal dyan sa may labas. Lalo kapag well ventilate and free from threats.
umuulan at bumabaha, baka kasi di
mapansin malusbot dun�

III. CLUSTERED DATA

Cues/Data Family Health Care Plan
6 � mos old male infant with cough and rashes
all over his body.
�Nilagnat siya ng tatlong araw bagolumabas
A. Measles and as a Health Deficit
1. Inability to provide adequate nursing care to the dependent
member with measles and cough due to:
� Lack of knowledge on the nature and management of the
yang mga pula-pula niya sa katawan.� health condition.
�Ang daming ipis dito pag umaga, yung pag
binuksan mu yung ilaw, kanya kanyang takbo
na sila. Minsan din malangaw at may
magnilan-ngilang daga na naghaharutan sa
may kisame.�
�Nakakatakot lang ditto yung bukas na kanal
dyan sa may labas. Lalo kapag umuulan at
bumabaha, baka kasi di mapansin malusbot
dun�
B. Presence of Vectors and Rodents as Health Threat
1. Inability to recognize the health threat due to lack of
knowledge about the condition.
2. Inability to make decisions with regards to the management of
the condition due to the failure on identifying what measures
are appropriate.
3.
Inability to provide home conducive to health maintenance
and personal development due to ignorance in preventive
measures.
C.Open Drainage as Health Threat
1.
Inability to make decisions with respect to taking appropriate
health actions due to lack of knowledge about alternative
solutions.
IV. PRIORITIZATION OF THE PROBLEM
1. Measles with cough
CRITERIA COMPUTATION SCORE JUSTIFICATION
Nature of the problem
Modifiability of the
problem
Preventive potential
Salience
3/3 x 1
2/2 x 1
3/3 x 2
2/2 x 1
1
1
2
1
It is a health deficit that requires immediate
intervention.
Resources needed are available.
With the compliance in the given instructions of
appropriate health providers, disease will be
manageable.
The family considers this as a problem that needs
immediate attention.

TOTAL 5

2. Presence of Vectors and Rodents

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

TOTAL 2.9

3. Open Drainage
CRITERIA COMPUTATION SCORE JUSTIFICATION
Nature of the problem 2/3 x 1 0.7 It is a health threat for it could damage the
health of
the family.
Modifiability of the
problem
� x 2 1
It is partially modifiable for the family alone can�t
solve the issue, referral to higher officials were still
needed.
Preventive potential 2/3 x 1 0.7
Solving the problem lessen the risk of the family on
acquiring infections brought about by an unpleasant
environment
Salience 1/2 x 1 0.5
The family recognizes the problem but does not think
it needs an immediate action.

TOTAL 2.9

PROBLEM PRIORITIZATION
Family Problems According to Priority
1 Measles and cough 5
2 Presence of Rodents and Vectors 2.9
3 Open Drainage 2.9

V.
FAMILY HEALTH CARE PLAN
HEALTH
PROBLEM
FAMILY
NURSIN
G
GOAL OF
CARE
OBJECTIVES OF
CARE
INTERVENTION PLAN
NURSING
INTERVENTION
METHOD OF
RESARCHERFAMILY
CONTACT
RESOURCES REQUIRED
Measles and
cough
Inability to
manage
the
condition
due to the
lack of
knowledge
regarding
its
manageme
nt.
After nursing
intervention,
the family
must be
equipped with
the necessary
knowledge
they need in
dealing with
the situation.
After nursing
intervention, the
family:
-will be able
identify the cause
and effect of the
disease.
-Know the
appropriate
intervention to
make.
1. Establish rapport.
2. Prepare the necessary
equipments needed.
3. Inform the family about
the visit.
4. Health education about
the diseases and its
management.
Home Visit Material Resources:
Visual Aids on Measles and cough.
Human Resources:
Time and effort of both the
researchers and the family.
Financial Resources:
Money for the researchers�
transportation and food (if
necessary).

FAMILY HEALTHCARE TEACHING PLAN

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

What to teach�

What is measles?
Measles is one of the most contagious viral diseases. It is caused by paramyxo
virus and is the most unpleasant and the
most dangerous of the children's diseases that result in a rash. This is due to
the complications of the disease.

How is measles transmitted?

�
Droplets transfer the infections. Although the sick person may be in isolation,
the disease may still spread from
room to room.
�
Anybody who has not already had measles can be infected.
�
Infants up to four months of age will not be infected if their mother has had
measles herself because they will be
protected by her antibodies.
�
The incubation period - the time between infection and the outbreak of the
condition - is usually one to two weeks.
�
Patients are infectious from four days before the onset of the rash until five
days after it appears.
What are the symptoms of measles?

After about 14 days the following symptoms start showing:

�
A fever at about 39�C.
�
A cold.
�
Coughing, possibly with a barking cough.
�
Sore throat - the lymph nodes in the throat may swell.
�
Reddish eyes.
�
Sensitivity to light.
�
Grayish spots, the size of grains of sand may appear in the mucous membrane of the
mouth just around the molar
teeth. These are called Koplik's spots and can be seen before the rash appears.
�
After three to four days the temperature may fall, although it can run high again
when the rash appears.
�
The rash usually begins around the ears and spreads to the body and the legs
within a day or two.
�
At first the spots are very small - a couple of millimeters - but they double in
size quickly and begin to join together.
�
The spots are a clear red color.
�
The temperature, which may run as high as 40�C, may stay that high for a couple of
days. Then it disappears
together with the rash, which may leave some brown spots.
�
After a week the child will be fit again.
How are measles treated?

The treatment is to stay in bed in a cool room without any bright lights.
Medicines for coughing and reducing the
temperature should only be given after consulting a GP.

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