Republic of the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Puerto Princesa City

SCHOOL NURSING

Presented by:
Alli, Stephannie
Badua, Dorothy Joy
Belleza, Shiella Mae
Enriquez, Meverie
Jovero, Jasmine Lyn Renee
Mardo, Honeybeth
Renardo, Ana Mae
Santos, Anne Dica
Schmidt, Brock Arthur
Tupas, Kwin Glurrie
Yanson, Honey Joy

BSN 02-BLK 01-GROUP 02

Presented on:
October 13, 2016

1
GRAND CASE STUDY 2016
 ACKNOWLEDGEMENT

As a first timer group to prepare for the grand case study and for the grand case presentation is really a
difficult task. We need hard work, knowledge, enough time, focus and cooperation as well. We went all through
the hardships and trials to complete this grand case study but though, we would like to express our appreciation
and gratitude to the following who contributed much to make this grand case study possible.

As we, the presenters, emerge victorious from being exposed to actual clinical duty, have created our
first case study, although it is a very difficult challenge, we have accomplished the requirements, quests, and
mind destroying interventions needed to come up with this presentation. We admit that we could never have
finished this case study without help and we would like to express our utmost gratitude and indescribable
appreciation.

To the Almighty God, who have had mercy towards us, and provided us with knowledge of our patient,
wisdom to decide, guidance in performing interventions, protection from catastrophic incidence while
performing home visit, and the time need

To the principal, faculty and staffs of the Ubay San Francisco Elementary School, for giving us the
opportunity to conduct our school nursing and for very much welcoming us in their beloved school.

To our clinical instructor, Mr. Johnard B. Rebato for supporting, assisting, and looking out for us while
we are in duty and giving us advices that is much appreciated by us.

To the patient and family for welcoming us in their house, giving their time and their trust to us, and
answering all of our questions respectfully.

To our parents for supporting us financially, and emotionally, and for giving their sincere advices. All of
those things are very well appreciated.

And to all the people that became a part of this journey.

Group 2s members are giving the deepest gratitude and appreciation for the contributions of the
mentioned above, for their patience and effort just to make this grand case study successful.

Thank you so much & God bless us all!

BSN 2- BLK 1 GROUP 2

2
GRAND CASE STUDY 2016
SIGNIFICANCE OF THE CASE STUDY

Given that the study has been conducted through school nursing, it can be used as a reference or an

example to all student nurses that will undergo grand case specifically involving families, children, and the

community

This study may be beneficial to the following:

Student Nurses- handling this kind of study will supply new knowledge to all student nurses. They will be able

to refer/ base their research on this clients case

Client- this study not only benefits the student nurses but the client as well, they will be more aware of the

problem that they couldnt see as a threat to their health, they will be more responsive to the common diseases

that may come and perform immediate interventions depending on the problem.

Clients School- the school also benefits from the presented study as they can widen their knowledge about

school nursing and the profit of having a school nurse on their school.

Researchers- this study would help the researcher as they are planning to conduct a research study.

3
GRAND CASE STUDY 2016
 TABLE OF CONTENTS

Title Page. 1

Acknowledgement....2

Significance of Case Study..............................................................................................................3

Table of Contents ....4

Introduction..5

Chapter 1: Demographic Data and Health History..........6

Patients Profile .......7

Present Illness ......................................................................................................................7

Past Health History ........7

Family Health History ............8

Growth and Development ...................................................................................................9

Chapter 2: Assessment of the Patient ......13

Patterns of Functioning ....14

Physical Assessment (Head to Toe) .............15

Chapter 3: Drug Study ....16

Chapter 4: Prioritization and Nursing Care Plans ...........25

Prioritization of the Problems .........................................................................................26

Family Nursing Care Plans .................33

4
GRAND CASE STUDY 2016
 INTRODUCTION

Date of interview is on September 21, 2016 at a time of 1:00 pm - 3:00 pm, located in Barangay San
Jose Campus Ville, Purok Matapat.

The target of this case study is a six-year-old Roman Catholic female child who is currently studying in
Francisco Ubay Memorial Elementary School as a first grader. She weighs 22kg and has a height of 122cm. She
is allergic to Ibuprofen. The daughter is currently in medication due to the diagnoses of the doctor as cough and
cold, medications she is taking are: Paracetamol, Carbocisteine (Ceasol), Cherifer, and has received complete
immunization. Four months ago she was diagnosed and admitted to the Wescom Military Hospital due to
amoebiasis, medicine used to treat (answer this). Two months ago she was bitten by a stray dog, and had
received three injections of anti-rabies. As stated by the mother, she is clumsy and suddenly falls down
involuntarily.

During her one to two years of age she can walk without any help, at four years of age she can tie her
own shoes, and at five years old she dresses herself without help, she also knows how to use the toilet
independently. She uses the term ihi and tae for urination and defecation. Currently she sleeps seven-eight
hours every day. Before she sleeps she brushes her teeth and watches Probinsyano. She has a habit of thumb
sucking and baby talking. Attending daycare she gained 15th honour, and best speaker and writing. Hereditary
conditions on the mothers side is hypertension, and on the fathers side is diabetes.

The family is an extended type, where it consists of six members: mother, father, grandmother, two
uncles and a daughter. The parents of the child work for the government as a navy unit, both of them are rarely
home while the grandmother takes care of the child who is in currently grade 1, the uncles are both in the fire
department. The family has a steady income of above fifteen thousand in a month. Aside from work they have
another source of income such as farming and sari-sari store.

Looking at their residence, the student nurses observed that the house is: powered by electricity proven
by working Light bulb and presence of other working electronics, composed of three rooms which was stated by
the interviewee, and is entirely made up of a heavy material, yet the sari-sari store from which they get their
secondary income, located near the house, is built out of light materials. The toilet they use was identified as a
pail system by the interviewee, and has been verified by pictures taken. Source of their drinking water is from
the water district, and from time to time they buy bottled water as stated by the mother. Their waste is collected
by the government garbage truck.

Health services where provide by a military doctor, and are always going for check-ups.

5
GRAND CASE STUDY 2016
Chapter 1: Demographic Data and Health
History

6
GRAND CASE STUDY 2016
CHAPTER 1

PATIENT PROFILE

Name: MS. A

Age: 6

Gender: FEMALE

Status: SINGLE

Occupaton: STUDENT

Religion: ROMAN CATHOLIC

Address: PUROK MATAPAT, CAMPUS VILLE, BRGY. SAN JOSE

Educational attainment: GRADE 1

Diet: IMBALANCED DIET

PRESENT ILLNESS

3 days before home visit, September 18, 2016, the client was diagnosed with cough and cold by Dr. Bescila

Bertos as stated by the mother. Mother had thought that the cause of disease was due to eating of ice cream and

slightly wet by the rain 5 days before diagnosis. During our home visit, September 24, 2016, we observed that

she had still cough and cold.

PAST HEALTH HISTORY

4 months ago, she was diagnosed and admitted to the Wescom Military Hospital due to amebiasis 2 months

ago, she was bitten by a stray dog and had received 3 injections of anti- rabies.

FAMILY HEALTH HISTORY

Grandmother stated that her husband, oldest sibling and youngest sibling died at the ages of 56, 62, and 40
respectively because of cardiac arrest due to hypertension.

7
GRAND CASE STUDY 2016
 Hypertension A Hypertension
Hypertension
56 53 62
40

Diabetes
53
A A
38 29

Legend:

- deceased

- male alive - A

- female CLIENT

8
GRAND CASE STUDY 2016
 Growth and Development

THEORY CENTRAL PRESENTING

TASK CHARACTERISTICS

The Theory Latent Period (6 The child has been observed

Psychosexual puberty) playing, communicating and
Development During this stage, the socializing with other
Was proposed by energy or libido interests children, was able to
Sigmund Freud and are suppressed. This communicate well when
described how stage is about interviewed by the SN
personality changes in development of the ego showing that she is in the
the course of childhood and superego. process of developing the
Freud believe that The onset of the stage is latent stage.
personality develop around the time the child
through a series of goes enters school and
childhood stages in becomes more
which the pleasure- concerned with peer
seeking energies of the relationships, hobbies,
id. The Id is a part of and other interests.
the personality that acts Although the sexual
as a driving force and energy is still present, it
persistently tries to is directed to other areas
fulfill our basic urges, such as intellectual
which mostly are related pursuits and social
to survival, not only interactions.
does it fulfill urges, it
also provides all of the The stage is important in
energy or libido developing social and
necessary to drive communication skills
personality. and self-confidence.

Through a series of
childhood stages
(Psychosexual stages)
where in the energies
provided by the Id is
focused on specific
erogenous areas the
personality can be
formed

9
GRAND CASE STUDY 2016
THEORY CENTRAL TASK PRESENTING
CHARCTERISTICS
The Theory of Industry (competence) vs. Industry
Psychosocial Inferiority-
Development
The child is in the process
This theory is greatly
This stage mainly focuses of developing the industry
influenced by the theory
on the learning process of aspect of her psychosocial
of psychosexual
the child on how to read, development
development, although it
write, sums, and do things
may have been a basis,
on their own Child was observed in the
both theories talks about
classroom as an organized
different aspects of
Teachers are an essential person, easy to socialize
development, the
part of this stage for they with, and can easily learn
psychosexual theory talks
are the one who teaches how to read, and write.
about the conflict
the child specific skills.
between the id and the
Peer group will gain She can make her decisions
superego and the
greater significance and on what she wants to do; an
psychosocial theory is all
will become a major example of this situation is
about ego/ social related
source of the childs self- when she decided to play
conflict.
esteem. The child now with her peers without
According to Erik, ego
feels the need to win gaining permission from
develops as it
approval by anybody.
successfully resolves
demonstrating specific
social crisis, involving
competencies that are
establishing trust in
valued by society, and
others, developing a sense
begin to develop a sense
of identity in society, and
of pride in their
helping the next
accomplishments
generation prepare for the
future.
Erikson extends on
Freudian thoughts by
focusing on the adaptive
and creative characteristic
of the ego, and expanding
the notion of the stages
of personality
development to include
the entire lifespan.

10
GRAND CASE STUDY 2016
THEORY
Theory of Cognitive
Development
According to Jean Piaget,
children passes through
four different cognitive
development as they age
(Sensorimotor stage,
Preoperational stage,
Concrete stage and Formal
operational stage) The
childrens thoughts about
the world changes every
time they pass through this
stage/ every time they
discover new things.
Jean Piaget considers
children as little scientist
as to symbolize the fact that
they are learning new
things
CENTRAL TASK PRESENTING
CHARACHTERISTIC
Preoperational The target patient, Age 6
Stage (ages 2-7)
This stage is about The target patient is an
brain development active socialize, a
on applying participative person, and is
language, children always socializing and
at this age do not playing with other children
understand concrete in her classroom
logic, cannot She is also well taught in
mentally English writing and
manipulate speaking.
information, and
are unable to take Although she is a good
the point of view of social entity she cannot take
other people, which the point of view of other
he termed people
egocentrism
Children also
becomes
increasingly adept
at using symbols, as
evidenced by the
increase in playing
and pretending
11
GRAND CASE STUDY 2016
CHAPTER 2: ASSESSMENT OF THE
PATIENT

12
GRAND CASE STUDY 2016
 PATTERNS OF FUNCTIONING

NUTRITIONAL-METABOLIC The client eats her meal thrice a day.

PATTERN She eats 2 cups of rice a day together
with soy sauce and oil. She drinks 3
cups of water a day, 1 glass of milk and
1 glass of Milo. Her favorite food is
sinigang (Filpino soup) .

ELIMINATION PATTERN The client voids 6 to 7 times a day and

ACTIVITY-EXERCISE PATTERN
moves her bowel once a day every
morning. She has mucosal discharges.
She goes to school 5 times a week and we
observed that she is friendly and loves to play
with her friends. She can walk and run
normally and she likes to dance and participate
in activities that involves physical exercise.
Last September 21, 2016, she joined their
scouting week. As stated by the mother, she is
clumsy and that sometimes she falls down
suddenly, but its her normal at her age.

SLEEP-REST PATTERN She watches probinsyano first then

brushes her teeth before she goes to
sleep. She sleeps 9 pm and awakens at
6 in the morning. When she wasnt still
at school age, she used to sleep every
early afternoon but at present, she cant
because of classes in school. But
sometimes in the late afternoon, after
her classes, she falls asleep because of
lot of activities in school.

VALUE-BELIEF PATTERN The client is a roman catholic and she

goes to church every Sunday together
with her grandmother.

13
GRAND CASE STUDY 2016
 HEAD TO TOE ASSESSMENT

RESULT
Skin - Fair complexion
- Brown
- (-) scars and lesions
Hair - Brunette
- Shiny
- Long
- Smooth
- Evenly distributed
- (-) lice
- (-) dandruff

Face - Symmetrical facial

movement
- (-) scar
Eyebrows - Hair evenly
distributed
- With skin intact
- Symmetrically align
- Equal movement
Eyelashes - Equally distributed
- Slightly curl
outward
Eyelid - Skin intact
- No discharges
- Lids close
symmetrically
Iris - brown
Nose - no flaring
- uniform in color
- air moves freely as
the client breath
through the nares
Mouth - dry lips
- dental caries of
lower molars
- white teeth
- pinkish gingivae
- (-) mouth sore
- (+) gag reflex
Ears - Color of auricles
same as facial skin
- (-) discharges and
lesions
- align with the outer
cantus of the eye
- pinna recoil after it
is being folded
- nontender

Neck - (+) mosquito bite

- (-) swelling of
lymph nodes
14
GRAND CASE STUDY 2016
 - (-) masses palpated
- Flexes easily
- (-) tenderness
- Trachea the midline
Upper extremities - (+) BCG scar
- (-) lesion
- (-) tenderness
- (-) edema
- Nails are clean and
well cut
- (+) capillary refill
- Pinkish palms and
nail beds
Lower extremities - Minimal scars
- (-) deformities
- (-) swelling
- Joints move softly
- (-) cuts/ wound
- (-) lesions
Orientation - oriented to a person,
date and time
Attention span - able to concentrate
as evidence by
answering the
questions
appropriately
Walking gait - upright posture
- opposing arms
swing unaided
- maintaining balance
Heel-toe walking - maintain a heel-toe
walking along a
straight line
Pain sensation - able to discriminate
between sharp and
dull sensation when
touch with the tip
end of the pencil and
the dull end of the
pencil

15
GRAND CASE STUDY 2016
CHAPTER 3: DRUG STUDY

16
GRAND CASE STUDY 2016
Name of Drug Classification Dose, Freq. and Mechanisms of Action Indications Contraindications Side Effects and Adverse Nursing
Route Reactions Responsibilities
Analgesic (Non- Ordered: Paracetamol may cause It is used for the Contraindicated Side Effects from Assess
Opioids) Give 1 tablespoon of analgesia by inhibiting relief of fever due in patients paracetamol are rare but can patients fever
Antipyretics syrup by oral CNS prostaglandin to influenza, hypersensitive include: or pain: type
ingestion once a day synthesis. The common colds, to drug. An allergic reaction, of pain,
after meal. mechanism of morphine tonsillitis, which can cause a location,
(PARACETAMOL is believed to involve measles, chicken Use cautiously rash and swelling intensity,
250mg/5 mL decrease in permeability pox and in patients with Flushing, low blood duration,
Suspension) of the cell membrane to pneumonia. long term pressure and a fast temperature,
sodium, which results in Useful in a variety alcohol use heartbeat this can and
Timing: diminished transmission of painful because sometimes happen diaphoresis.
7 am of pain impulses conditions therapeutic when paracetamol is Assess
therefore analgesia. including doses cause given in hospital into allergic
headache hepatotoxicity a vein in your arm reactions:
dysmenorrhea, in these Blood disorders, such rash, urticaria;
PARACETAMOL myalgias, patients. as thrombocytopenia if these occur,
neuralgias, (low number of drug may
rheumatism, Hematologic: platelet cells) and have to be
arthritis and other hemolytic leukopenia (low discontinued.
muscle and joint anemia, number of white Teach patient
pains. neutropenia, blood cells) to recognize
leucopenia, Liver and kidney signs of
pancytopenia. damage, if you take chronic
too much (overdose) overdose:
Hepatic: this can be fatal in bleeding,
Jaundice severe cases bruising,
malaise,
Metabolic: fever, sore
Hypoglycemia throat.
ADVERSE EFFECTS OF Tell patient to
THE DRUG: notify
Drowsiness prescriber for
Nausea pain/ fever
Vomiting lasting for
more than 3
days.

17
GRAND CASE STUDY 2016
Name of Drug Classification Dose, Freq. and Route Mechanisms of Action Indications Contraindicati Side Effects and Nursing Responsibilities
ons Adverse Reactions
Carbocisteine MUCOLYTIC Ordered: Carbocisteine reduces Use for the Active SIDE EFFECTS: Assess cough: type, frequency,
Give 1 goblet cell hyperplasia treatment of Peptic Allergic character
(Ceasol) tablespoon of and therefore plays a disorders of the Ulcer. reactions
syrup by oral role in the respiratory tract Hypersensiti include Advice Medical consultation for
ingestion 3x a management of associated with vity to hives, persistent cough of more than 7
day after meals. disorders characterized excessive Carbocistein difficulty in days
(CARBOCISTE by abnormal mucous. mucus, e swallowing
INE CEASOL Absorption: Rapidly indicated in and Suggest sugarless lozenges to
250mg/5 mL and well absorbed chronic and breathing, decrease throat irritation and
Suspension) from the GI tract. acute swelling the cough.
Time to peak plasma bronchitis, lips, face,
Timing: concentration: Approx pneumonia, throat or Obtain patients history
7 am 2 hr. pulmonary tongue.
of cough before
12 nn Distribution: emphysema and Blood in
bronchial therapy and
7 pm Penetrates into lung vomit
asthma. stomach reassess after giving the drug
tissue and resp
Duration: mucous. contents or
black, tarry Assess cough: type, frequency,
4-7 hours Metabolism:
Undergoes acetylation, stool. character, including sputum:
decarboxylation and provide adequate hydration to
sulfoxidation. 2L/day to decrease viscosity of
Excretion: Via urine as secretions
unchanged drugand
metabolites Monitor for
possible adverse
reactions: CNS:
drowsiness,
dizziness GI:
nausea, vomiting,
abdominal pain

Discuss on detail
all information
regarding the drug.

18
GRAND CASE STUDY 2016
Name of Drug Classification Dose, Freq. and Mechanisms of Indications Contraindication Side Effects and Nursing
Route Action Adverse Reactions Responsibilities
Brand Name: Vitami Children 7-12 Maximizes the Food supplement for Thromboemboli SIDE EFFECTS: WOF (Wall Oxygen
Cherifer Syrup ns and years: 5-10 mL (1- Child's Growth growth and sm, erythremia, Flow) hypersensitivity
with Zinc Minera 2 tsp); 2-6 years: Potential: Cherifer development of kids erythrocytosis, CNS: rarely - a
ls 2.5-5 mL, (-1 Syrup With Zinc is a with the immune- increased state of arousal.
(Pediat tsp). To be taken lemon-flavored boosting activity of sensitivity to Cardiovascular
Generic Name: ric) once a day or as vitamin preparation CM-Glucan that can cyanocobalamin system: rarely -
Vitamin B- recommended by with CGF that help in the prevention . pain in the heart,
Complex, a health maximizes the child's of recurrent colds, flu tachycardia.
Vitamin A, Cm- professional. growth potential. and respiratory tract
Allergic
Glucan, Strongly Boosts the infections, especially
reactions: rarely
Timing: Immune System: during rainy months.
Chlorella - urticaria.
7 am Cherifer Syrup With Adjuvant therapy in
Growth Factor Zinc contains 100% cold, flu, respiratory
(CGF), Taurine RENI of elemental tract infections and
and L-Lysine zinc that is essential other immune system
HCI in maintaining the threats, asthma and
integrity of the primary
immune system. Zinc complex/pediatric
supplementation tuberculosis.
reduces the incidence
of lower respiratory
tract infections.
Enhances Brain
Development:
Cherifer Syrup With
Zinc contains taurine
that enhances brain
development, visual
and motor skills of an
active, growing child.
It is fortified with zinc
that enhances
neuropsychological
function and
development.
Improves Vision:
Cherifer Syrup With
Zinc contains 105%

19
GRAND CASE STUDY 2016
 RENI of vitamin A,
which together with
taurine, plays an
essential role in the
function of the retina
to improve vision. It
is also important in
producing energy and
promoting efficient
metabolism of food
by ensuring proper
conversion of food
elements for energy
and growth. It is an
antioxidant which
helps protect cells
against diseases.
Maximizes
Metabolism and
Utilization of
Carbohydrates,
Proteins and Fats:
Cherifer Syrup With
Zinc provides sufficient
supply of B-complex
vitamins that provide
metabolic support to
maximize absorption,
metabolism and
utilization of proteins,
fats and carbohydrates.

20
GRAND CASE STUDY 2016
 References for Paracetamol
Classification: https://www.scribd.com/doc/154473457/Paracetamol

Dose, Frequency and Route: Kyle Med Paracetamol Packaging

Mechanisms of Action: https://www.scribd.com/doc/36795690/Drug-Study-Paracetamol

Indications: Kyle Med Paracetamol Packaging

Contraindications: https://www.scribd.com/doc/23131248/Paracetamol-Drug-Study

Side Effects: http://drugsfornursingstudents.blogspot.com/2009/10/paracetamol.html

http://www.nhs.uk/conditions/Painkillers-paracetamol/Pages/Introduction.aspx#side-effects

Nursing Responsibilities: http://drugsfornursingstudents.blogspot.com/2009/10/paracetamol.html

21
GRAND CASE STUDY 2016
 References for Carbocisteine
Classification: http://www.mims.com/philippines/drug/info/carbocisteine?mtype=generic

Dose, Frequency and Route: Carbocisteine (Ceasol) Packaging

Mechanisms of Action: http://www.mims.com/philippines/drug/info/carbocisteine?mtype=generic

Indications: Carbocisteine (Ceasol) Packaging

Contraindications: https://www.scribd.com/doc/6774377/Drug-Study

Side Effects: http://pharmacybook.net/carbocisteine/

Nursing Responsibilities: https://www.scribd.com/doc/6774377/Drug-Study

22
GRAND CASE STUDY 2016
 References for Cherifer
Classification: https://es.scribd.com/doc/158991532/Drug-Study-2

Dose, Frequency and Route: http://www.mims.com/philippines/drug/info/cherifer%20syrup%20with%20zinc?type=full

Mechanisms of Action: http://www.mims.com/philippines/drug/info/cherifer%20syrup%20with%20zinc?type=full

Indications: https://es.scribd.com/doc/158991532/Drug-Study-2

Contraindications: https://www.scribd.com/doc/6774377/Drug-Study

Side Effects:
http://www.medicatione.com/?c=drug&s=cherifer%20syrup%20with%20zinc&ingredient=chlorella%20growth%20factor/l-
lysine%20hydrochloride/taurine/vitamin%20a/vitamin%20b1/vitamin%20b12/vitamin%20b3%20(niacinamide)/vitamin%20
b6/zinc

Nursing Responsibilities: https://www.scribd.com/doc/158991532/Drug-Study-2

23
GRAND CASE STUDY 2016
CHAPTER 4: PRIORITIZATION AND FAMILY NURSING CARE
PLANS

24
GRAND CASE STUDY 2016
 FAMILY

RANK PROBLEM SCORE

1 Presence of breeding or resting sites of vectors of diseases (e.g. mosquitoes, flies, roaches, rodents, and etc.) 4 1/3
2 Possible cross-infection of Cough and cold 3
3 Habit of thumb sucking 3
4 Poor fluid intake 2 5/6
5 Family monthly income of 37,000 4/3

25
GRAND CASE STUDY 2016
 1. CRITERIA
SCORE
Breeding sites
Nature of the condition or
the problem presented
Scale: health threat
Modifiability of the
condition or problem
Scale: partially
Preventive potential
Scale: moderate
Salience
Scale: perceived as a
problem and need
immediate attention
WEIGHT TOTAL JUSTIFICATION
Breeding sites of disease vectors
can lead to a wide spread of
2 1 2/3 infection
The canal near their house is
owned by their neighbour thus
will be modified only if they talk
1 2 1
to the owner, emptying other
possible collection of water has
been applied
Although they have talk with their
2 1 2/3 neighbour, the owner currently
hasnt fixed the problem
The Family told the SN that the
mosquitoes were a problem, and
2 2 2
had immediately talked with the
owner to cover it up.
26
GRAND CASE STUDY 2016
 2.CRITERIA
SCORE WEIGHT TOTAL JUSTIFICATION
Poor fluid intake
Nature of the condition or Ms. A doesnt meet the standard
the problem presented 2 1 2/3 number of glass water and fluid
Scale: health threat intake in a day
Modifiability of the Fluid intake depends on the
condition or problem clients perception of drinking
Scale: partially modifiable 1 2 1 adequate amount of water

Preventive potential The mother did offer the client to

Scale: moderate drink water, yet the client refuses
2 1 2/3 to.

Salience The family did report it as a

Scale: perceived as problem problem but has not given enough
but does not need immediate interventions to achieve the
attention 1 1 1/2 expected outcome.

27
GRAND CASE STUDY 2016
3. CRITERIA
SCORE WEIGHT TOTAL JUSTIFICATION
Habit of thumb sucking
Nature of the condition or The problem has been perceived
the problem presented as a threat to the alignment of
2 1 2/3
Scale: health threat teeth which is considered as part
of health
Modifiability of the The modifiability of the problem
condition or problem depends on the client herself, as
1 2 1
Scale: partially modifiable the family has been reminding her
not to thumb suck
Preventive potential The family has applied techniques
Scale: low preventive that can prevent the reoccurrence
1 1 1/3
of the habit, but those
interventions are ineffective
Salience The family does perceive thumb
Scale: perceived as a sucking is a problem, and has
2 1 1
problem and needs given interventions to get rid of it.
immediate attention

28
GRAND CASE STUDY 2016
 4.CRITERIA
Possible cross infection
(cough & cold)
Nature of the condition or
the problem presented
Scale: health threat
Modifiability of the
condition or problem
Scale: partially modifiable
Preventive potential
Scale: low
Salience
Scale: Perceived as a
problem and needs
immediate attention
SCORE WEIGHT TOTAL JUSTIFICATION
The child has not developed the
habit of covering her mouth and
2 1 2/3 nose when coughing or sneezing,
thus spread of infection is
inevitable
Although it is easy to develop the
habit of covering her mouth, itll
1 2 1
take time and spread of infection
is already present
As stated before, developing the
habit of covering the mouth or
1 1 1/3 nose will take time thus the spread
of infection is possible during the
duration of the cough & cold
The other family members told
the child to cover her mouth when
coughing, and administered
2 1 1 paracetamol and carbocisteine
through the doctors order
29
GRAND CASE STUDY 2016
5.CRITERIA family
monthly income of SCORE
37,000
Nature of the condition or
the problem presented
Scale: wellness state
Modifiability of the
condition or problem
Scale: not modifiable
Preventive potential
Scale: low preventive
Salience
Scale: not perceived as a
problem
WEIGHT TOTAL JUSTIFICATION
The family is able to provide for
3 1 1 their needs.
The jobs of the parents and other
0 2 0 sources of income are currently
stable
The situation is not a problem,
1 1 1/3 and doesnt needs a solution
The family has not perceived this
as a problem, as their income has
sufficed their daily needs

0 1 0

30
GRAND CASE STUDY 2016
 Assessment Goal Objectives Intervention Method of Resources Evaluation
nursing Required
intervention
Problem 1st level 2nd level After After 2 hours the In the duration of 2 Home visit Money Ms. D and her family
two family will be hours the HCP will Disposable gloves are able remove the
Presence of Poor Inability to hours of able to: be discussing: Pen breeding ground of
breeding or environme recognize the nursing Recognize The sites for Notebook insects
resting sites nt presence of interven the presence of breeding of Camera
of vectors of sanitation the condition tion the the breeding site insects that Ms. D can
diseases (e.g. Specificall or problem family of disease carry viruses recognize the
mosquitoes, y: due to: will be harboring The preventive presence of the
flies, roaches, -Presence -Lack of or able to insects. measures that sites for insect
rodents, and of inadequate recogni Learn about this can be used on breeding
etc.) breeding knowledge ze the disease carrying the problem
or resting problem insects. How to apply Ms. D has
Health Threat sites of Inability to and Do preventive the preventive learned the
Subjective vectors of provide a eliminat actions on the measures importance of
Cues: Oo diseases home e the matter. The importance sealing the
mas lalong environment problem Discuss the of a protective exposing areas
dumadami conducive to . importance of net or other with protective
ang mga health eliminating the materials that nets.
lamok tuwing maintenance breeding site of can cover any
hapon lalo na and personal vectors. exposing area
pag development Know and
umuulan. due to: determine the
-Lack of consequences of
Objective inadequate most common
Cues: knowledge of disease they may
Presence of preventive acquire
water puddles measures Enumerate at
and collection least 3 treatments
of water. concerning the
breeding sites of
vectors

31
GRAND CASE STUDY 2016
 Health 1st Level 2nd Level Goal Objectives Intervention Method of Resources Evaluation
Problems Assessment Assessment contact required

Poor fluid Health threat Inability to The client will After the -Discussed the Home Visit Manpower: After nursing
intake due to make decisions understand the intervention the possible outcomes Health Effort interventions
Cues: faulty/unhealthf with respect to importance and client will be and positive effects of Teachings Time client will be
ul nutritional
taking benefits of able to: drinking the adequate Observation able to know
Subjective:
/eating habits or
appropriate water intake. amount of water. Interview Money the importance
Hindi mahilig health action a. The client -Explained to the method Laptop of water fluid
uminom ng feeding due to: To enhance the Can at least give client and to the intake
Camera
tubig yang techniques/pract Failure to capability of the any importance family the benefits of
batang yan as ices comprehend the family to carry of drinking water fluid intake. Family Family was
verbalize by the specifically: nature/ out measures to water everyday -Encourage family participation able to identify
mother of client magnitude of provide health and the client to and risk factors of
Inadequate the problem/ development. b. Family will maintain cooperation. not drinking
Objective: water intake in condition select a method drinking the adequate water.
-refuse to drink quantity. After the health how they attract amount of water to
water teaching to the Ms. A to drink 8 avoid dehydration.
-dryness of the client will be glasses of water -Provide the general
upper portion of able to drink everyday. information about on
the lip and water everyday. fluid intake.
partial portion C. To provide -Assess the family
of the lower lip Instill the client alternative ways concerning of their
to make a habit of keeping their practice in water
of drinking 8 source of water intake.
glasses of water clean and free
everyday. from any
bacteria or
disease.

32
GRAND CASE STUDY 2016
 Methods
in Resources
Health Problem Family Nursing Problems Goals Objectives Intervention Evaluation
Nursing Required
Contact
Client has a habit of thumb 1st Level 2nd Level Assessment After 20 After nursing Discuss with Notebook The family was
sucking Assessment minutes of intervention, the the family: Home able to understand
discussion, the family will; a. The Visit Ball pen the right and
Cues: Presence of a. Inability to make habit of thumb consequences appropriate
Objectives health threat decision with respect to sucking will be a. Think of improper management for
-Misalignments of teeth taking appropriate minimized and appropriate management of the habit of the
-Presence of callus on right health action due to eventually be action in looking thumb sucking thumb sucking
thumb inability to decide which removed for alternatives b. The necessary
action to take from and procedures care/treatment
Subjective among a list of to the condition. for the habit of
-Iyong bata pa siya alternatives b. thumb sucking
madalas siya mag thumb b. Inability to c. The needed to
sucking, at nawala din iyon provide adequate do for
ng 4 years old siya pero nursing care to the sick, preventing the
bigla nalang bumalik ng disabled, dependent, habit at thumb
mag 5 years sya years old vulnerable/ at risk sucking
siya at hanggang ngayon member of the family
habit niya pa din ang due to:
pagthu-thumb sucking. lack
of/inadequate
knowledge of the nature
and extent of nursing
care needed
Lack of/ inadequate
knowledge and skill in
carrying out the
necessary intervention/
procedure/ care

33
GRAND CASE STUDY 2016
Health 1st level of 2nd level of Goal Objectives Interventions Methods of Resources Evaluation
Problem assessment assessment contact required

Cough and Presence of Inability to After the n After nursing 1. Discuss with the family the Home visit Visual aids The client was
colds health threat make ursing intervention, t causes, effects and complications Man power administered with
due to: decisions interventio he family of cough and cold. paracetamol and
-possible with respect n the will: 2. Provide adequate knowledge Carbocisteine, both orally
viral cross to taking family will a.) Acquire on and 5 mL.
contaminati appropriate be able to adequate the various ways of maintaining Paracetamol - once for
on to other health action eliminate information cleanliness in their surroundings just one day
family due to the cough about the 3. Proper intake of medicines Carbocisteine - thrice for
members negative and colds a disease, or alternative one if resourcesina a week
attitude nd will pre including dequate (ex. Lagundi) and preve
towards the vent the rec signs and ntive measures such as
health urrence of symptoms of covering the mouth when
condition or the disease the disease, sneezing or coughing and proper
problem. in the immediate disposal of nasal or oral
- Threat of future. health care discharges.
cross- assistance and 4. Promote proper personal and
infection preventive environmental hygiene among
from a measures. all members of the family.
communicabl b.) Be aware
e disease on how to
case. reduce the
chances of
spreading
communicabl
e diseases to
other family
members.

34
GRAND CASE STUDY 2016
Health Problems 1st Level 2nd Level Goal Objectives Intervention Method of Resources Evaluation
Assessment Assessment contact required

Family Income Presence of Ability to After 30 minutes At the end 30 Health teaching Home visit Manpower: After nursing
Cues: wellness provide a home of health minutes on how to Health teaching Effort intervention, the
37000 pesos in condition- environment teaching the intervention the promote Time family improve
total per month Potential for conducive to family will be family will be wellness state their budgeting
enhanced health able to verbalize able to recognize to the family: Money skills as evidence
30000 pesos capability for maintenance and the process to and verbalize to Laptop by:
from the monthly health personal enhance the on how to -How to budget Camera
payment of the maintenance/ development due capability for provide a home their income for -They are able
mother health to adequate health conductive to the readiness discuss
management. financial maintenance and health about the advantages and
7000 from the resources. health maintenance and emergencies and disadvantages on
income of the management for personal sudden sickness having a
family variety - Ability to utilize the family development and and accidents prepared money
store community how to utilize -Advantages and for health
resources for community disadvantages of maintenance
health care due to resources for having prepared -Verbalize
adequate family health care budget/ money outcome of
resources, maintenance. for health having a
especially maintenance prepared budget
financial -Discuss positive for health
resources. effects of maintenance
budgeting
-Discuss
outcomes on
unprepared
financial support

35
GRAND CASE STUDY 2016
BIBLIOGRAPHY

36
GRAND CASE STUDY 2016
NAME: BROCK ARTHUR SCHMMIDT
AGE: 17
BIRTHDATE: JUNE 4, 1999
YEAR & SECTION: BSN 2 BLK 1
ADDRESS: BANCAO-BANCAO, ABUEG RD. PUERTO PRINCESA CITY

NAME: DOROTHY JOY P. BADUA

BIRTHDATE: AUGUST 13, 1998
AGE: 18 YEARS OLD
ADRESS: TINIGUIBAN, PUERTO PRINCESA CITY, PALAWAN
YEAR AND SECTION: BSN 2-BLK 1

NAME: STEPHANNIE K. ALLI

AGE:17 YEARS OLD
BIRTHDATE: DECEMBER 11, 1998
ADDRESS: KALIKASAN, BRGY. SAN PEDRO, PUERTO PRINCESA CITY
YEAR & SECTION: BSN 2- BLK 1

37
GRAND CASE STUDY 2016
NAME: MEVERIE DE CASTRO ENRIQUEZ
AGE: 17 YEARS OLD
BIRTHDATE: DECEMBER 29, 1998
ADDRESS: ABANICO ROAD, ZONE #04, SAN PEDRO, PPC.
YEAR & SECTION: BSN 2- BLOCK 1

NAME: ANA MAE CALANDAY RENARDO

AGE: 17 YEARS OLD
BIRTHDATE: DECEMBER 24, 1998
ADDRESS: TINIGUIBAN, PUERTO PRINCESA CITY, PALAWAN
YEAR & SECTION: BSN 2- BLOCK 1

NAME: HONEY JOY P. YANSON

AGE: 20
BIRTHDATE: MARCH 21,1996
ADDRESS: PANUNCIAL SUBDIVISION, BARANGAY SAN JOSE
YEAR & SECTION: BSN2-BLOCK 1

38
GRAND CASE STUDY 2016
NAME: ANNE DICA SANTOS
AGE:17 YEARS OLD
BIRTHDATE: JANUARY 29,1999
ADDRESS: MAGBABADIL, ABORLAN PALAWAN
YEAR & SECTION: BSN 2 - BLOCK 1

NAME: JASMINE LYN RENEE C. JOVERO

AGE: 17 YEARS OLD
BIRTHDATE: MAY 20, 1999
ADDRESS: 243 ABAD SANTOS EXT, BRGY. BAGONG SIKAT, PPC.
YEAR & SECTION: BSN 2 BLOCK 1

NAME: KWIN GLURRIE M. TUPAS

AGE: 18 YEARS OLD
BIRTHDATE: APRIL 11, 1998
ADDRESS: BARANGAY TINIGUIBAN, PUERTO PRINCESA CITY.
YEAR & SECTION: BSN 2 BLOCK 1

39
GRAND CASE STUDY 2016
NAME: SHIELA LYN P. BELLEZA
AGE: 17 YEARS OLD
BIRTHDATE: DECEMBER 24, 1998
ADDRESS: BARANGAY SAN MANUEL, PUERTO PRINCESA CITY.
YEAR & SECTION: BSN 2 BLOCK 1

NAME: HONEYBETH A. MARDO

AGE: 17 YEARS OLD
BIRTHDATE: DECEMBER 23, 1998
ADDRESS: PUROK WESTWOOD, BARANGAY SAN PEDRO, PPC.
YEAR & SECTION: BSN 2 BLOCK 1

40
GRAND CASE STUDY 2016
 41
GRAND CASE STUDY 2016