General Objectives:

After the family case study, we as student

nurses will be able to enhance our knowledge
in understanding family dynamics and
functions, improve in planning and
implementing nursing interventions and
display desirable attitude towards the family.
Specific Objectives:

Knowledge

 Determine the type of family & functions

of each member.
 Determine family’s health status.
 Identify health related problems of the
family and prioritize them.
Skills
 Formulate appropriate health care plan
 Implement right nursing intervention
 Assist the family in dealing with health
problems by providing proper information
Attitude

Show respect to the customs and

beliefs of the family and;
Establish good rapport to each of
the family members
 INTRODUCTION
Family is a single word, with many different
meanings. People have many ways of
defining a family and what being a part of a
family means to them. Families differ in terms
of economic, cultural, social, and many other
facets, but what every family has in common
is that the people who call it a family are
making clear that those people are important
in some way to the person calling them his
family.
 Family is the basic unit of society, a primary
unit in health care or institution responsible for
the physical, emotional and social support of its
member. Its foundation is marriage, the group
which ensures continuity through its
reproductive function and socialization. A family
refers to two or more individuals joined by ties
of blood, marriages, or adoption and who
constitute a single household, interact with each
in their respective familial roles, and who create
and maintain a common culture. -Tinkman and
Voorhies (1972, in Baylon and Maglaya, 1978)
 Family is love, even if love can be a weird
thing. Family is acceptance. Sure there are
disagreements and arguments, and those
holidays that have mashed potatoes thrown, but
it doesn’t go away. Family doesn’t go away, no
matter how annoying at times. Families can be
difficult, they can be comforting, they can be
frustrating, and they can be wonderful. Love
them or hate them, families are one of the
biggest influences on our lives. So much of our
personalities, our emotions, our dreams, our
fears, all come from our families. They are there
even if we don’t want them to be. They always
have advice even if it is something we don’t want
to hear or admit that is right.
 A family living in a poor environmental
condition without enough resources and
lacks knowledge and experiences about
health and its management. Though tiring as
it is, reaching out to this family and mingling
with them makes us student nurses feel the
sense of fulfilment as we share our
knowledge, skill and time to aid in uplifting
the condition of the family .
CHAPTER I: FAMILY
ASSESSMENT

A. FAMILY STRUCTURE,
CHARACTERESTICS AND
DYNAMICS
 POSITION IN EDUCATIONAL
NAME AGE BIRTHDATE CIVIL STATUS OCCUPATION
THE FAMILY ATTAINMENT

R.D. - Aug. 15, 1933 - Father - N/A

Elementary
F.A.D. 55 May 16, 1963 Widow  Mother Vendor
undergraduate

F.A. D. 37 April 27, 1981 Married Daughter College Undergrad Company Checker

R. A. D. 35 June 3, 1983 Married Brother Associate Graduate Tricycle Driver

R. A. D. 32 Dec. 23, 1985 Married Daughter High School Grad. Teacher

Soap Dealer
S. A. D. 29 Sept. 17, 1988 Single Daughter College Grad.
 

R. A. D. 26 Sept. 2, 1991 Single Son College Student N/A

X.J.D. 6 March 10, 2012 Single Grandson Grade 1 N/A

X.A.E. 4 Nov. 6, 2013 Single Grandson Kinder N/A

Family Structure
 
It is extended family it is composed of
mother, daughter and three
grandchildren.
 General Family Relationship and
Dynamics
 

Criteria Status Additional Information

The children are

Observable
(+) disobedient and
conflicts between
Observable conflict hard headed except
family members
the youngest.
 The mother
and her
daughter has
no time to
speak with
each other
Characteristic especially the
(+)
s of mother who is
Partially
communicatio working all
effective
n day until 9 in
the evening
and children
doesn’t
usually open
about their
 Although the
mother and
her daughter
doesn’t have
time to speak
each other
Interaction they were
(+)
patterns able to
Effective
among others maintain
harmonious
relationship
with each
other
including the
Decision Making

In decision making Family D practice

Egalitarian power where the parent has the
power to make decision for the good of all
family members. When it comes to health
and financial matters M.RS. F.A.D. is the one
makes the decision but when it comes to
other decision making she asks the opinion
of her daughter and decide what is good for
their family.
Eating Patterns

Family eats three times a day but they

usually eats together during lunch and
dinner because Mrs. F.D. wake up early in
the morning “4am”, drinks only coffee and
prepare to leave for her work
Family Dietary Habits
 
The family eats always three times a day.

Breakfast
Usually cooked rice and egg if they don’t have a rice
they just drink coffee and bread.
Lunch
They cooked rice but they bought their dish outside
usually fish and vegetables.
Dinner
They cooked rice and they eat leftovers from their lunch
especially the fruits and vegetables and sometimes if
they have extra money they cooked noodles.
Leisure

Despite of their hectic schedule they

always find ways to bond each other
especially during weekends like strolling to
plaza with her children eating ice cream and
street foods such as “baga, chicken skin and
fishballs” and if they have extra money they
sometimes eats at Jollibee.
SOCIO- ECONOMIC AND CULTURAL
FACTORS

Income and Expenses

Family D gets their income for their daily
expenses mainly from the Gradmother
Mrs.F.A.D who works as a Vendor and earns
Php. 6,000.00 monthly. And from Ms. S.A.D
who works as a Soap dealer who Earn Php.
2,500 monthly

Total Monthly Income: Php. 8,500.00

 Allocations:
Php. 4500/month; Php
Food
1125/week

Water (MKWD) Php. 200/month

Electricity (AKELCO) Php. 200/month

Education ( Daily allowance and

Php. 1200/month
transportation / 300 per week)

Others ( shampoo,soap,toothpaste) Php. 2400/month

Total Expenses in one Month: Php.

Implication:
This implies that the monthly income of the
family is exact to their everyday expenses
 Educational Attainment

F.A.D. is elementary undergraduate, their eldest

child F.A.D. is a 1st year college undergraduate
taking BSBA, the second child R.A.D. finish an
associate degree in automotive, the third child
R.A.D. is a 1st year college undergraduate
taking BS Criminology, the fourth child S.A.D. is
a college graduate of BSCS, and their youngest
child is a graduating student in civil
engineering course .
Ethnic Background and Religious
Affairs

Family D is all Roman Catholic but they

don’t go to church every Sunday because
F.A.D was busy with her work and S.A.D is
preoccupied in taking care of her children.
“Nakasimba man ako saibana religion
pareho it Baptist, Seventh Day Adventist
agabu pang iba”, as verbalized by F.A.D.
She also claimed that she lived what she
learn in the church and always pray to God.
 Awareness of Community
Organization

The family is not aware of any

existing organization in their barangay.
The family considered Neil Candelario
and William S. Lachica as their formal
leader in their barangay.
 HOME AND
ENVIRONMENT
Description of the House
 
The family owned the house which is located in
Barangay Oyotorong St., Poblacion, Kalibo, Aklan.
Their house is a combination of cement, wood and
bamboo. Their house measures approximately 4.26
meters in length and 5.2 meters in width. It is
approximately 300 meters away from the main
road. Upon entering the house you will see the
living room with cabinet made of stainless, which
contains television, speaker, picture and souvenirs
items, stuff toys and with bamboo chair and table.
This receiving area extends to their kitchen sink
where they place their eating utensils. There is also
a small altar and unused bed in their kitchen.
 In the 2nd floor, you will see a cabinet
where their clothes are kept. There are also
bags for their extra clothing. Clothes are
also hanging everywhere. There is a display
television and small altar. There’s an open
small room where they sleep together and
its wall is cover with a curtain.
 Adequacy of living space

Upon the entrance to their house, you will see

a small living room with cabinet made of
stainless, which contains television, speaker,
picture and souvenirs items, stuff toys and with
bamboo chair and table. This receiving area
extends to their kitchen sink where they place
their eating utensils. There is also a small altar
and unused bed in their kitchen.
In the 2nd floor, you will see their small room
where they are sleeping and a partition which
separates the room from their clothes cabinet
and bags for their extra clothing.
Sleeping Arrangement
Mrs. F. A. D. sleep together with
her daughter and grandchildren in
their bedroom.
Crowding Index -
Describes the ease by which
communicable disease will be
transmitted to another susceptible
host.
FORMULA:
= No. of̶family
No. of rooms
= 5/1
=5

Result = 5 members are sleeping in the room

Ideal Crowding Index: 2 persons in one room (2:1)

Implication: Base on the result, the family has a

higher risk in acquiring a communicable disease if
one of the family member has a disease.
Appliances, Furniture and Equipment

The family owns two television, 2

electric fan, speakers, 1 cellular phone, 2
lights bulb. They also have long chair
made of wood, a small wooden table and
other eating and cooking utensils such as
plates, spoon, fork, mugs, glasses,
casserole and etc.
Presence of accident hazard

Protruding nails, faulty electricity and

broken stairs can cause accident
especially to their children and whole
family.
Garbage Disposal
The family practice proper garbage disposal.
Their garbage is segregated before they
dispose it, and collected everyday by garbage
collector.

Water Supply and Storage

 
The water of the family is supplied mainly by
MKWD, which they used for cooking, bathing
and for their laundry. Their drinking water is a
purified drinking water
Food Storage and Cooking
Facility

The family stored their food in a

Tupperware and a with cover. They put
their food storage on the 2nd floor to avoid
food contamination because sometimes
pets and insects goes in and out in their
kitchen. For cooking facility they used
clay stove and sometimes if they have
extra money they bought charcoal
Toilet Facility
 
According to F.A. D their toilet was
inherited from her mother, it is a pour flush
type of toilet facility and it is located
approximately 25 meters away from their
house. It is made up of concrete and, walls
are covered with a plastic waterproof sheet,
the roof is made up of galvanized iron and
the floor is concrete. It measures
approximately 1.5 m by length and 1 m by
width.
Drainage System

The family’s drainage is open the water flows

everywhere.

Household pet
 
The family owns 4 chicken.
 
Presence of electricity
 
The family’s source of electricity is from AKELCO
but they only share it from their neighbour.
Communication and Transportation

Family has one cellular phone and one tablet

which they use for emergency purposes; the family
don’t own any vehicle they only commute
whenever they go anywhere.

Kind of Neighbourhood

They have an open relationship with their

neighbour and they treat each other as family. If
they lack a certain needs, they just borrow and ask
help from their neighbour.
Social and Health Facilities

Family is active and participate in every

program in Health Center. When the family
member gets sick they went to their
municipal health Center first for
consultation and if the doctor is not
available they went to DRSTMH.
CHAPTER II: REVIEW OF
SYSTEM

FAMILY HEALTH HISTORY

Mother

Name: F.A.D Age: 67 years old

VITAL SIGNS:

Temperature: 35.4 C/axillae Weight: 53 kg

Pulse Rate: 66 bpm. Height: 156 cm

Respiratory Rate: 17 cpm BMI: 21.9

Blood Pressure: 100/80 mmHg

PAST MEDICAL HISTORY

The client is fully immunized and has no known

allergy. According to her she has been hospitalized
at DRSTMH last 1993 and verbalized“ naospital ako
pagkatapos mamatay ang asawa dahil naover
fatigue ako”
.
PRESENT MEDICAL HISTORY

T The client has no complaint on her present

health condition.
Gynecologic /Obstetric History

According to the client she has her

menarche at the age of 13 that usually last for
5 days and had her menopause at 48 years
old. All her children are breastfeed by her, and
have not undergone BSE. She has the
following obstetric history: G5T5P5A0L5
undergone BSE. She has the following obstetric
history: G5T5P5A0L5
 G1 – 1981 , full term baby via NSD at home; no
complications.
 G2– 1983 , full term baby via NSD at home; no
complications.
 G3– 1985 , full term baby via NSD at home; no
complications.
 G4– 1988 , full term baby via NSD at home; no
complications.
 G5– 1991 , full term baby via NSD at home; no
complications
Daughter

Name: S.A.D Age: 29 years old

VITAL SIGNS:

Temperature: 35.4 C/axillae

Weight: 44 kg. Height: 154cm

Pulse Rate: 70 bpm Respiratory Rate: 16 cpm

BMI: 18.9 Blood Pressure: 100/80 mmHg

PAST MEDICAL HISTORY

The client is fully immunized and has no known

allergy. She was been hospitalized at DRSTMH last
March 2012 for 3days and November 2013 for 5
days due to giving birth via normal spontaneous
delivery of her 1st and 2nd child.

PRESENT MEDICAL HISTORY

The client has no complaint on her present

health condition.
Gynecologic /Obstetric History
According to the client she has her
menarche at the age of 13 that usually last
for 3-4 days and had 2-3 soaked napkin, she
has a regular menstrual cycle of 28 days. All
her children are breastfeed by her, and has
not undergone BSE. She has the following
obstetric history: G3T3P0A0L3
 G1 – 2012, full term baby via NSVD at
DRSTMH; no complications.
 G2 – 2013, full term baby via NSVD at
DRSTMH; no complications.
 G3 – 2016, full term baby via NSVD at
Home; no complications.
1st Grandchild

Name: X.J.DAge: 6 years old

VITAL SIGNS:

Temperature: 35. 6ᵒC/axillae Weight: 13 kg

Pulse Rate: 98bpm Height:112 c

Respiratory Rate: 15cpm BMI:10.2 (underweight)

PAST MEDICAL HISTORY

X.J.D. is a fully immunized child, no

hospitalization and no known allergy for food and
medication. He has no history of childhood illness
and chronic illness

PRESENT MEDICAL HISTORY

 
No presence illness complaint.
 2nd Grandchild

Name: X.A.E. Age: 4 years old

VITAL SIGNS:

Temperature:35.3 ᵒC/axillae Weight: 14 kg

Pulse Rate: 86bpm Height:104 cm

Respiratory Rate: 25cpm BMI: 12.1 (underweight)

 
PAST MEDICAL HISTORY

X.A.E. is a fully immunized child, no

hospitalization. He has no history of childhood and
chronic illnesses. He has no-known allergy.
 
PRESENT MEDICAL HISTORY

No presence illness complaint.

3rd Grandchild
 
Name: X.A.D. Age: 2 years old
 

VITAL SIGNS:

Temperature:36 ᵒC/axillae Weight: 11kg

Pulse Rate: 130bpm Height:71cm

Respiratory Rate: 22cpm BMI: 22.3 (normal)

PAST MEDICAL HISTORY

“Si Xiah hay kumpleto man imaw sa bakuna”

asverbalized by the mother. No history of
childhood illess. She has no known allergy.

PRESENT MEDICAL HISTORY

No presence of illness complaint

 
Mother : F. A. D
 
General Survey

On June 9, 2018, F.A.D. is wearing a white

t-shirt and pants clients appears not well groom.
No mannerism noted. Client smiles and
expresses his thought easily in moderate tone
voice.
Skin

 Skin is brown in color and has fair complexion.

 It is warm to touch bilaterally with a good skin
torgur.
 Uses lotion frequently for his skin care.

Hair

 Hair is black and evenly distributed.

 Has variable amount of body hair.
 Scalp is rough and no lesions noted.
 Uses shampoo daily for her hair care habits.
Nails
 Fingernails are trimmed and unclean.
 Nail beds are pinkish in color.
 Has good capillary refill at least 2 seconds.

Head
 Head is round, symmetric, smooth skull
contour, still and upright.
 Can perform Temporomandibular movement
(TMJ) with full range of motion without
tenderness and crepitation. 
 Able to turn head smoothly from left to right
with resistance without tenderness. Trachea is
in midline.
Eyes

 Eyes are symmetric, outer canthus of the

eye are aligned to the auricles.
 Eyebrows are black and fairly distributed.
 Eyelashes appeared to be equally
distributed and curled slightly outward.
 The sclera is clear, iris is black in color flat
and round. Able to perform 6 cardinal eye
movement.
Ears

 Ears are symmetric; auricles are aligned at the

outer canthus of the eyes.
 Pinna recoils when folded.
 Cerumen noted upon assessment.

Nose and sinuses

 
 Nose appeared symmetric without deviation.
 Skin color is the same with the surrounding
skin.
 No nasal flaring observed.
 No tenderness upon palpation on sinuses.
Mouth and Pharynx

 Lips are dry and slightly pink in color without

lesion. Tongue is moist, pink, with papillae
present.
 Uvula is intact and hangs in the midline.
 All teeth are presence of all cavities and have
15 teeth.
 Brushes his teeth two times a day.
Neck

 Neck is in midline, skin is the same with the

surrounding skin.
 Jugular vein and carotid artery are not
distended, no bruits heard upon auscultation.
 No palpable nodes or lumps noted.
 Patient is able to perform full range of
motion.
Breast and Axillae
 Breast skin is light brown in color, no palpable
mass noted.
 Axilla has no lesion, masses and presence of few
hairs.
 Uses deodorant and plucks axillary hairs every
day after taking a bath.

Lungs

 Respirations 16 breaths per min (bpm) without

the use of accessory muscle.
 Normal lung sound heard upon auscultation No
wheezes or crackles upon auscultation.
 
Heart
 
 No visible jugular venous pulsation or distension
present.
 Carotid pulse is 2+ (normal) bilaterally.
 Heart rate is normal (2+) at 66 bpm with no
murmurs noted.

Gastrointestinal 
 Umbilicus is in midline.
 Normal bowel sounds elicited in the 4 quadrants
upon auscultation.
 No tenderness upon palpation.
 Client eliminates once a day to a brown and well
- formed stool.
Peripheral vascular
 
 Arm circumference is 30 cm bilaterally; legs
circumference is 46 cm bilaterally.
 Skin is warm to touch and no distended
(varicose) veins noted in both legs.
 Has good capillary refill less than 2 seconds.
 No clubbing of nails is noted.

Genito urinary
 
 Client refuses to inspect her genitals.

 
Musculoskeletal
 
 The client can stand with bare foot evidenced by
even weight baring can performed ROM against
full resistant.

Neurologic
 
 She is coherent and oriented to time and place.
Express herself fluently in clear and
understandable manner.
 With symmetrical facial expressions.
 Answer questions correctly and speaks in loud and
clear voice.
CRANIAL NERVES RESULT

Cranial Nerve – I (Olfactory) Identifies the smell of coffee and venigar.

Crania Nerve – II (Optic ) Patient was able to read printed writing

held at a distance of 14 inches.

Intact. Pupil equally round reactive to light

Cranial Nerve – III,IV & VI (Oculomotor, and accommodation, can able to perform 6

Trochlear and Abducens) cardinal eye movements.

  

Intact. Patient has no tenderness felt

with mastication and was able to

Cranial Nerve – V (Trigeminal Nerve)
identify sensation such as pain and

pressure on cheeks.

Able to smile, fwrinkle forehead, show

Cranial Nerve – VII (Facial) teeth, puff out cheeks, raise eyebrows, and

open eyes against resistance.

Client heard the sound during tick watch

Cranial Nerve – VIII (Acoustic nerve)
test within 2ft.
  

Intact. Client is able to swallow

Cranial Nerve IX and X
and was able to identify sweet
(Glossopharyngeal &Vagus)
from salty.

Client was able to shrug shoulders

Cranial Nerve XI (Accessory
and moves head to right and left
Nerve)
against resistance.

Cranial Nerve XII (Hypoglossal) Tongue is in midline. Patient was able

to say letter d, l, n, and t.

 Daughter
S.A.D.
 
General Survey

The client is female, 152cm in height, clients

appears not well groom during the 1st day of
assessment. Has normal gait and she wears
appropriate clothing, yellow shirt and blue short.
Expresses her thoughts easily as long as she can
understand the question
SKIN

 Skin has a fair complexion uniform over the

body.
 It is warm to touch bilaterally, she has a
good skin turgor less than 3 seconds.
 Moles are noted scattered in her body.
 Scar is noted on her right leg approximately
1 inch in length “ napaso abi dun it tambutso
it motor” as verbalized by the client.Uses
soap and lotion for her skin care.
HAIR

 Hair is within the shoulder level, it is black

in color and evenly distributed.
 Lice and nits are noted during inspection.
 She takes a bath everyday uses shampoo
for her hair care habits.
NAILS

 Nails are trimmed and has presence of dirt

during inspection.
 It is thick and brittle forming 160 angles at the
base. Nail beds are pink in color and has a
good capillary refill at least 2 seconds.
 Trims her nails once a week.
HEAD
 
 Head held still and upright and oval in shape
with smooth contour.
 Having a symmetrical facial features with
rough uniform skin without lesions and
masses.
 Tempo mandibular joint are in Range of
Motion without crepitation.
EYES
 
 Eyebrows hair is evenly distributed.
 Eyebrows are symmetrically aligned and showed
equal movement when asked to raise and lower
eyebrows.
 Eyelashes appeared to be equally distributed and
curled slightly outward.
 Eyelids have no presence of discharges, no
discoloration and lids close symmetrically.
 The sclera appeared white.
 Iris is black in colour, flat and round.
 The client able to read the newsprint held at a
distance of 12 inches.
NECK
 
 Neck is symmetric with head in center.
 The client showed coordinated, smooth head
movement with no discomfort.
 The lymph nodes of the client are not
palpable. Trachea is placed in the midline.
 The thyroid gland is not visible upon
inspection.
 No masses or tenderness noted.
BREAST AND AXILLAE
 
 Bilateral breast are sagged and slightly
asymmetric. Breast skin is light brown with
brown areolas with nipples that are everted.
 It is rough and warm to touch.
 No venous pattern noted.
 Free of Dimpling or retraction.
EARS
 
 The Auricles are symmetrical and has the
same colour with his facial skin.
 The auricles are aligned with the outer
canthus of eye.
 The pinna recoils when folded.
 During whisper test client was able to hear
the whispered word “ Maganda ako” within 1
feet.
 She clean her ears twice a week.
NOSE AND SINUSES
 
 The nose is midline, straight and uniform .
 Nasal septum is in midline without
deviation.
 There was no presence of discharge or
flaring.
 When lightly palpated, there were no
tenderness and lesions.
 No rhinitis, sneezing noted.
MOUTH AND PHARYNX
 
 Lips are pinkish in color.
 Presence of 22 teeth that are white in color .
 Gums are pink without lesion.
 Buccal mucosa is pinkish and moist.
 The tongue of the client is centrally positioned.
 It is pink in color and moist .
 Hard palate and soft palate is pinkish in color.
 The uvula of the client is positioned in the
midline.
 The clients brush her teeth 3x a day.
LUNGS
 
 Client reported no difficulty on breathing or chest
pain. RR is 16cpm.
 Breathing is effortless.
 No presence of masses, and lesions upon
inspection no pain reported during palpation.
 Normal breath sounds elicited over all lung fields
and no adventitious sound noted upon
auscultation.
HEART
 No visible jugular venous pulsation or
distension.
 No carotid bruits during auscultation.
 Carotid pulse is (2+) bilaterally.
 No visible apical impulse heaves or lifts over
pericardium.
 Heart rate is increased (2+) at 70 bpm.
 No family history of hypertension or CVA.
PERIPHERAL VASCULAR

 Skin is warm, dry and intact.

 Colour and temperature are same bilaterally
in upper and lower extremities.
 Capillary refill in 2 seconds bilaterally.
 No edema in ankles or feet.
 No discoloration, no distended veins and
swollen glands detected.
GASTROINTESTINAL

The abdominal area is round and white in

color. The umbilicus is in the midline, not
protruding and round. Normal bowel sounds
heard in all quadrants. Absence of pain, non-
tender and soft on each quadrant of the
abdomen upon palpation. She defecates once a
day every morning to a brown well-formed
stool. And presence of stretch mark noted.
GENITO-URINARY
 
 Client refuses to assess her genitalia but
given subjective data.
 According to the client her pubic hair is
distributed. Genitalia are moist, intact, no
discharge and odorless.
 No masses, swelling or any abnormal
discharges noted.
 Client urinate 4-5 time a day to a yellowish
urine.
MUSCULOSKELETAL
 
 Good body posture.
 Client can stand on heels or toes.
 No edema and lesions noted.
 Can perform different ROM such as flexion,
extension of hands and feet.
 Client reported no difficulties in performing
daily activities.
 CRANIAL NERVES RESULTS

Client can able to identify smell

CN I (OLFACTORY)
like kalansi and coffee.

Client can read a newspaper print

CN II (OPTIC)
held 12 inches away from her.
  

The client was able to

CN II
perform 6 cardinal eye
(OCCULOMOTOR),
movement. Pupil equally
IV (TROCHLEAR),
round and reactive to light
VI (ABDUCEN)
and accommodation.

 
  
Client has no tenderness felt with
mastication and was able to to
CN V (TRIGEMINAL) identify sensation such as pain
and pressure on cheeks.

The client able to smile and

wrinkled forehead as instructed

CN VII (FACIAL)
without any difficulties. Client can

identify different flavor.

CN VIII (ACOUSTIC/ Client can hear whisper word 1

CN IX  
The client can identify different taste. No
(GLOSSOPHARYNGEA difficult of swallowing. Can speak clearly
without difficulties. Uvula is in midline.
L),
.
X (VAGUS)

 
The client can shrug shoulder against resistance and
CN XI (SPINAL
move head from right to left and left to right.
ACCESSORY)
 

CN XII Tongue is midline. Tongue can move side to side

and down and upward
(HYPOGLOSSAL)
2nd Child
X.A.D

General Survey
 
X.D is a 5 years old boy, upon
assessment client is wearing a stripes
gray T- shirt and white short, slipper,
appears clean and groom. Skin is light
brown in color and facial features are
symmetrical.
SKIN
 Skin color is light brown, even, smooth and intact.
Has good skin torgur, no edema, bruises or
masses observed.
 Has presence of mosquito on right legs.
 Uses body soap for every day skin care habits.

HAIR
 Hairsare black in color and evenly distributed on
the scalp, straight and short (army cut).
 Scalp is intact, no lesions and masses noted.
Present of lice and nits observed.
 According of his mother his hair is Trims once a
month.
 Uses shampoo for every day hair care habits.
NAILS
 Nails is long, untrimmed.
 Nail bed are pinkish in color angle is 160 degrees,
Round cuticle, thin and smooth.
 Capillary refill is less than 2 second.
 Client trims his nails by his mother oncea week for nail
care habits.

HEAD
 Head is oval shape, face is smooth, no present of scar,
lesions and masses noted upon inspection and
palpation.
 Facial expression appropriate and symmetrical, neck
symmetrical with head in central position, head is able
to turn side to side and up and down without any
difficulties.
EYES
 Eyes are symmetrically align to the ears.
 Eyebrows are black and distributed.
 Eyebrows are symmetric.
 Eyelids are uniform in color.
 No lesion, edema noted.Bony orbits are in equal size
and movement, firm, non-tender.
 No edema and discharges noted.
 Eyelashes are short, straight and distributed, both
bulbar and palpebral conjunctiva are pinkish in color,
both Sclera appears white and clear. I
 ris areuniform in color, round, smooth, and is
symmetric. Cornea areclear and moist.
 Pupils are brown in color equal in size, round, reactive
to light and accommodation. He can identify shape
presented 12 inches away from him.
NECK
Neck is proportion in head, trachea in midline, no
present of lesion, masses lymph nodes and no
enlargement of thyroid gland noted upon
inspection and palpation.

BREAST AND AXILLAE

Breast are flat.
Breast and axillae skin are uniform in color.
No palpable masses and lymph nodes.
No edema and lesions noted.
Areola and nipple is inverted andbrownish in color.
Has no hair on the axillae.
No palpable nodes on the axillae.
EARS

 Client’sears are symmetric, uniform in color.

 Auricle are smooth, mobile,firm and non-
tende. Pinna smooth to touch, no nodules,
lesions and swelling noted.
 Mastoid process and tragus on both ears has
no lesions, masses and pain present.
 No present of cerumen, able to hear the
whisperedword "Dog" within 1 feet away
from him. No history of ear infection.
NOSE AND SINUSES

 Nose is midline, no discharges, swelling,

lesions and masses noted during inspection
and palpable.
 Mucous membrane pinkish in color, able to
identify different scent like calamansi
andcoffee.
MOUTH AND PHARYNX

 Lips are pinkish in color, smooth, intact, free of lesion

and symmetric.
 All teeth are presents of cavities; teeth are yellowish
in color.
 Teeth are 12 in number.
 No bleeding of gums sore throats and mouth
lesionsnoted .
 Tongue is moist and pinkish in color Hard and soft
palate, tonsils and uvula are pinkish, moist and
intact.
 Uvula in the midline and move freely.
 No difficulty in mastication.
 Brushes teeth two times a day for mouth care habits
LUNGS
 RR: 25 bpm.
 Breathing is effortless.
 No use of accessory muscles.
 Has good body posture.
 No nasal flaring observed.
 Has equal lung expansion. Nail is pinkish and
without clubbing.
 Trachea is at midline.
 No chest tenderness upon palpation. .
HEART

 Does not experience any chest pain,

palpitations and dyspnea.
 No family History of heart diseases.
 ugular and carotid vein is non-protruding.
 No thrills noted on the arteries.
 No bruits heard upon auscultation on the
carotid artery.
 No murmurs heard upon auscultation on the
carotid vein.
 Apical and radial pulse is 86 bpm.
PERIPHERAL VASCULAR

 Skin is intact, warm to touch, no pain, no

edema in the arms and legs.
 Arms are 51cm in length bilaterally symmetric
in size and shape.
 No prominent venous patterning.
 Capillary refill is less than 2 seconds.
 Pulse rate is 86bpm, all pulses are palpable
regular rhythm.
 No bruits upon auscultation on the carotid
vein. No palpable nodes noted.
GASTROINTESTINAL

 Abdomen is round.
 Skin is intact on four quadrant of abdomen,
uniform in color,smooth, no lesions, masses,
rashes and bruises noted upon inspection
and palpation.
 No veins and striae present.
 No mark pulsation of the aorta, no visible
peristalsis. Umbilicus is at midline, and
inverted. Normal bowel sound on the four
quadrants of the abdomen.
 No tenderness felt upon palpation.
 No muscular resistance.
 Has good skin turgor.
 Borborygmi can hear upon auscultation.
 No change in the appetite.
 Stool is well form and brownish in color
described by his mother. Client bowel
movement pattern is once a day, every
morning.
GENITO-URINARY
 He refused to be examined.
 His mother stated he has no problem in urination,
Urination pattern is 4 times a day.
 No history of UTI.

MUSCULOSKELETAL
 He has good posture.
 Head is at midline.
 Can perform different ROM such as flexion and
extension of hands and feet without pain or difficulties.
 Skincondition is warm, moist; color is light brown
without discoloration.
 Arms and legs are symmetric in size and shape.
 Even weight bearing is evident.
CRANIAL NERVES RESULTS

 
Client able to identify any kind
CN I (OLFACTORY) of odor like vinegar and coffee
without any difficulties.
 

 
Client can identify the object
CN II (OPTIC) presented 14 inches away from
him
 
  
Pupil are equal size and reactant
CNII (constricted)to light. Able to move her
(OCCULOMOTOR),
IV (TROCHLEAR), eyes 6 cardinal eye movements, eyes
VI (ABDUCEN)
are able to follow the pen without

moving his head.

 
Intact. Client has no tenderness felt with
mastication and was able to identify
CN V
sensation such as pain and pressure on
(TRIGEMINAL)
cheeks.
  
Intact. Client has no tenderness felt
with mastication and was able to
CN V
identify sensation such as pain and
(TRIGEMINAL)
pressure on cheeks.
 
 
 
Client able smiles, frown, wrinkles
forehead, and shows teeth, puff out
CN VII cheeks, purse lips, raise eyebrows, and
(FACIAL) closes eyes against resistance. As
instructed. Movements are symmetric.
Client can identify correct flavor.
 
 Client able to repeat word
CN VIII (ACOUSTIC/
whispered”mango” 1 feet
VESTIBULOCOCHLEAR)
away(whispered test).

Gag reflex is intact. Has no

CN IX
difficulty on swallowing. Uvula and
(GLOSSOPHARYNGEAL)
soft palate rise bilaterally and
X (VAGUS)
symmetrically on phonation.
 The client can move his shoulders
CN XI (SPINAL
without any pain or discomfort,
ACCESSORY)
Client can turn head against
 
resistance from left to right.

CN XII Client is able to move his tongue

(HYPOGLOSSAL) side to side and it can protrude
3rd Child
X.A.D

General Survey

X.A.D is a 2 years old girl, upon

assessment client is wearing floral blouse
and checkered short, slipper. Skin is light
brown in color and facial features
symmetric.
SKIN

 Skin color is light brown, even, smooth an

intact.
 Has good skin torgur, no edema, bruises or
masses observed.
 Has presence of mosquito bite on right foot.
Uses body soap for every day skin care habitss.


HAIR
 Hair is black in color, thin and curly, evenly
distributed on the scalp.
 Scalp is intact, no lesions noted.
 Uses shampoo for hair care habits.
NAILS

Nail bed are pinkish in color, well-trimmed,

round cuticle, thin and smooth with good
capillary refill.
Trim once a week for nail care habits.

HEAD
Head is oval shape, face is smooth, no present
of scar, lesions and masses noted upon
inspection and palpation, facial expression
appropriate and symmetrical, neck
symmetrical with head in central position,
head is able to turn side to side and up and
down without any difficulties or facial
EYES
Eyes are symmetrically align to the ears,
eyebrows are black and distributed, eyelashes
are short, straight and distributed, no discharge
on eyelids, both bulbar and palpebral
conjunctiva are pinkish in color, both sclera are
whitish, no discharges, pupils are black in color
and equally round, reactive to light and
accommodation(PERRLA),

BREAST AND AXILLAE

Breast skin color is even with the
surrounding skin
EARS
Both ears are symmetrical and eye level,
uniform in color , pinna smooth to touch, no
masses or lesions noted, present of earring on
both ears, mastoid process auricle and tragus
on both ears has no lesions, masses, pain
present noted upon inspection and palpation,
present of cerumen.

NOSE AND SINUSES

Nose is midline, no discharges, swelling,
lesions and masses noted duringinspection
and
MOUTH AND PHARYNX
 Lips are pinkish in color, moist and intact. He
refused to examined his mouth.

LUNGS
 RR is 19 cpm.
 Breathing is effortless and in regular rhythm.
 No use of accessory muscles.
 Has good body posture.
 No nasal flaring observed.
 Has equal lung expansion.Trachea is at midline.
 No chest tenderness upon palpation.
HEART
No murmurs present.

PERIPHERAL VASCULAR

 Skin uniform in color and warm to touch, presence of

mosquito bites on her right foot.
 Good capillary refill less than 3 second.
 Arms are 42 cm in length bilaterally symmetric in size and
shape, all pulses are palpable.
GASTROINTESTINAL
 Abdomen is round.
 Skin is intact on four quadrant of abdomen,
uniform in color, smooth, no lesions, masses,
rashes and bruises noted upon .
 Umbilicus is atmidline, and inverted.
 Has good skin turgor.
 Borborygmi can hear upon auscultation.
 No change in the appetite.
 Stool is well form and brownish in color described
by his mother.
 Client bowel movement pattern is once a day,
every morning.
CRANIAL NERVES RESULTS

 
Client able to identify any kind of odor like
CN I (OLFACTORY)
coffee and calamansi. without any difficulties.
 

 
Client can identify the shape presented 14
CN II (OPTIC)
inches away from him
 
CN II Intact, pupils equally round
(OCCULOMOTOR), IV
(TROCHLEAR), VI reactive to light and
(ABDUCEN)
accommodation.

 
Client can identify which part had
been touch on his face, able to
CN V (TRIGEMINAL)
open her mouth against
resistance
.
 Client able smiles, Movements are
CN VII (FACIAL) symmetric. Client can identify
correct flavor.

CN VIII (ACOUSTIC/ Client able to repeat word

VESTIBULOCOCHL whispered”ganda” 1 feet away
EAR) (whispered test).

CN IX
(GLOSSOPHARYNG Has no difficulty on swallowing
EAL),
X (VAGUS)
  
The client can move her
CN XI (SPINAL
shoulders without any pain or
ACCESSORY)
discomfort.
 

 
CN XII
(HYPOGLOSSA Client is able to move her tongue
L)
side to side and it can protrude.
 
GORDON’S HEALTH
PATTERN
 HEALTH PERCEPTION-HEALTH
MANAGEMENT
The family considered a person as healthy
individual if feeling well they don’t any sign of
illnessThe family considered a person as
healthy individual if they feeling well and don’t
have any signs of fatigue or illness. They
bought OTC drugs for fever. Whenever they are
seeking medical assistant they go immediately
to MHO for consultation and comply for health
regimen.out-patient and comply for their health
regimen.
NUTRITIONAL-METABOLIC PATTERN

Their usual meal during Lunch cook

viand and rice and for dinner are fish, rice
and vegetables. They do not have any
complain in mastication, ingestion, or
digestion.
ELIMINATION PATTERN
 
The family don’t have any problem when it comes
to elimination. The mother usually eliminate
every day and the daughter Ms. S. A. D. eliminates
once a day every morning with yellow formed stool
and her 3 grandchildren X.J.D, X.A.E and X.A.D
eliminates once a day.

ACTIVITY-EXERCISE PATTERN
 
“ uwa man gid kami ga exercise pero sa amon nga
ginaobra adlaw adlaw sa baeay hay parang ga
exercise man kami.” as verbalized by the mother
SLEEP-REST PATTERN
 
The Mother sleep at 9 pm and wake up at 5am
to cook bananaque. Her daughter sleep at 8:30 pm
together with her grandchildren and wake 5:00 am
to prepare food for her children.
 
COGNITIVE-PERCEPTUAL PATTERN
 
They are alert and response immediately when
they are about to answer questions. They speak
clearly in Aklanon and can understand Tagalog and
a few English. They are updated to news via
television and radio. When it comes to decision
making she’s the one to decide to their family.
 SELF PERCEPTION and SELF
CONCEPT PATTERN
 
When they asked regarding their
beliefs they replied” gapati kami
kapag may nabdos hay mahumot sa
mga aswang”
 ROLE-RELATIONSHIP PATTERN

The mother has good relationship

with her daughter.
they help each other in times of
needs especially if it is for their
family. The daughter also
established a healthy relationship
with her children. She is able to take
care and guide them well.
SEXUAL-REPRODUCTIVE PATTERN
 
“ simula nga namatay akon nga asawa wa eot a
ag nadueaan ako it gana. Verbalized by the client

COPING-STRESS TOLERANCE PATTERN

 
The family experience stress when it comes to
their life status but they help its each other and
they do some way to provide their daily needs.
VALUES-BELIEFS PATTERN
 
“Gapati kami sa ginoo kapin pa sa kalisod
ko among pangabuhi uwa na gid kami
ginapabay-an”. as verbalizes by the mother.
VALUES AND PRACTICES ON
HEALTH PROMOTION
Immunization Status of the Family

They are all fully immunize.

B.2. Consult Person for Health related

Problems
 
Whenever a family member is sick or ill they
immediately seek for medical assistance directly
in the health Center.
Medical and Financial
 
According to the mother they were not a member of
PhilHealth but they register in Paymaya for their
medical assistance, and also ask assistance to the
government agency and for their financial
assistance they ask help from their relatives.

Infant Feeding Practices

 
According to the mother she practice breastfeeding
to her 5 children
 
P
renatal Care
 
The mother comply all the prenatal check-up in
their Health Center.

Postnatal Care
 
Ms. S.A.A’s postnatal care was rendered in their
Health Center.

Dental Health
 
The family don’t undergo any dental check-up.
 CHAPTER III

COMPUTING AND JUSTIFYING

SCORE OF HEALTH PRONBLEMS
 Accident hazard specifically protruding nails
and faulty wiring as health threat

COMPUTAT ACTUAL
CRITERIA JUSTIFICATION
ION SCORE

Nature of the This problem is a health threat to the

problem 2/3x1 0.6 family because it can cause injury to the

Health Threat family.

The problem is easily modifiable through

Modifiability of
health education and if the family
the problem 2/2x2 2
implement the plan of care to correct the
Easily Modifiable
identified problem.
 Preventive This problem is highly preventable through

potential 3/3x1 1 proper education and immediate action to fix

High the identified health problem.

Salience The family perceived that this is a problem

Problem needing needing immediate attention, but due to lack of

2/2x1 1
immediate time and negative attitude towards the problem,
attention
the problem still remain.

Total Score: 4.6

 Inadequate Living Space as
Health Threat
COMPUTATIO ACTUAL
CRITERIA JUSTIFICATION
N SCORE

Nature of the It is a health threat because there is a high

problem 2/3X1 0.6 risk for easy transmission of disease due

Health Threat to inadequate space.

Modifiability of
The problem is partially modifiable
the problem
1/2X2 1 because of inadequate space and actual
Partially
condition of their house.
modifiable
 This problem has a moderate

Preventive preventive potential, if family

potential 2/3X1 0.6 will be able to improvised and

Moderate extend their bedroom to the

vacant space on the 2nd floor.

The family doesn’t see it as a

Salience problem because they are

0/2x1 0
Not a felt problem comfortable sleeping beside each

other.

Total Score:2.2
 Presence of breeding site
(Open Drainage)
CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

Nature of the This problem is a health threat because

problem 2/3x1 0.6 this could be a possible shelter of disease

Health Threat causing insects like mosquito.

Modifiability of The problem is easily modifiable through

the problem health education to the family that this

2/2x2 2
Easily could lead to breeding sits for mosquito

Modifiable and other pest.

 The problem has high

Preventive preventive potential because

potential 3/3x1 1 materials and other resources

High to be used in intervention is

available.

The family don’t perceive this as

Salience a problem, since the family don’t

0/2x1 0
Not a felt problem have any idea that it could be a

possible breeding site.

Total Score: 3.6

 Poor Lighting and Ventilation as
Health Threat

COMPUTATI ACTUAL
CRITERIA JUSTIFICATION
ON SCORE

This is a health threat because it can

Nature of the
cause unnecessary injury and heat can
problem 2/3x1 0.6
be uncomfortable to the family
Health Threat
members and may cause common

illnesses.
 The problem is partially
Modifiabili
modifiable since the family
ty of the
electricity only connect to their
problem 1/2x2 1
neighbor and due to financial
Partially
constraint they are not able
Modifiable
address the health problem

Preventive The problem has low preventive

potential 1/3x1 0.3 potential primarily because of

Low financial constraint.

 Salience The family perceive this a

Problem but problem but doesn’t need

doesn’t need 1/2x1 0.5 immediate attention

immediate because they are used to

attention this kind of living.

Total Score: 2.4

 Uncovered Eating Utensils as health
threat

COMPUTA ACTUAL
CRITERIA JUSTIFICATION
TION SCORE

Nature of the This is a health threat because

problem it can nurture the presence of

2/3x1 0.6
Health disease causing

Threat microorganisms.
 The problem is easily modifiable
Modifiability of
through health teaching and
the problem 2/2x2 2
providing them a dish cabinet they
Easily Modifiable
can use to address the problem.

The problem has a highly preventive

Preventive potential
3/3x1 1 potential by making sure that this
High
utensils is in their dish cabinet.
 The family sees the

problem that needs

Salience
immediate attention, but
Not a felt 0/2x1 0
they can’t afford to buy a
problem
dish cabinet because of

financial constraint.
Total Score: 3.6
 Malnutrition as Health Deficit

COMPUTATI ACTUAL
CRITERIA JUSTIFICATION
ON SCORE

This problem is a health deficit

Nature of the
because of inability of the family to
problem 3/3x1 1
recognize the malnutrition due to
Health Deficit
lack of knowledge.
 The problem is easily
Modifiability of
modifiable through health
the problem 2/2x2 2
teaching about good
Easily Modifiable
nutrition.

The problem has high

Preventive
preventive potential by eating
potential 3/3x1 1
nutritious food like fruits and
High
vegetables.
 Salience
The family sees the
Needing
2/2x1 1 problem that needs
Immediate
immediate attention.
attention

Total Score: 5
 Presence of Nits and Lice as Health
Deficit

COMPUTATIO ACTUAL
CRITERIA JUSTIFICATION
N SCORE

This is health deficit, because

the mother and her daughter

Nature of the
have it, and may cause
problem 3/3X1 1
additional health problem
Health deficit
especially it can be easily

transmitted to the children.

 This problem is partially

modifiable, despite their

knowledge of available
Modifiability of the
treatment of the said
problem
1/2X2 1 problem like shampoos and
Partially
cream that contain
Modifiable
pediculicides they don’t have

the financial capabilities to

buy such at a constant basis.

 The problem has a moderate preventive

potential because of the financial capability

Preventive
of the family they may not be able to buy
potential 2/3x1 0.6
the above treatment, but can improvise to
Moderate
prevent the spread of lice especially to the

children through health education.

The family does not perceived this as a

Salience
0/2x1 0 problem, primarily because of their lack of
Not felt a problem
knowledge.

Total Score: 3.6

 
Unorganized Clothing as Health Threat
 

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

This problem is a health

threat because this could

Nature of the
be a possible shelter for
problem 2/3x1 0.6
mosquitoes which can
Health Threat
cause diseases such as

dengue.
Modifiability of the Problem is easily modifiable through

problem 2/2x2 2 health teaching and proper

Easily Modifiable organization of clothes.

This problem has high preventive

Preventive potential
2/3x1 0.6 potential because interventions are
High
available.

Salience The family don’t perceive this as a

0/2x1 0
Not a felt problem problem.

Total Score: 3.2

 Ranking in the Problems of the Family

Rank Problem Actual Score

1 Malnutrtion 5

Accident Hazard specify to : Protruding

2 4.6
nails and faulty wires

 
Presence of breeding site (Open Drainage)
3 3.6
 
 Presence of breeding site
(Open Drainage)
3 3.6
 

4 Uncovered Eating Utensils 3.6

5 Presence of Nits and lice 3.6

6 Unorganized Clothing 3.2

  

7 Poor Ventilation 3.2

Inadequate Living
8 1.9
Space
CHAPTER IV

FAMILY NURSING CARE

PLAN
Health Problem No. 1: MALNUTRITION
Nursing Diagnosis:
Inability of the family to recognize the problem
related to lack of financial resources to support
the nutritional needs of the family members.

Goal of Care:
After the intervention the family will recognize the
problem about malnutrition and will gain
knowledge about the benefits or importance of
proper nutrition for the health of every member of
the family.
Objective of Care:

After the nursing intervention the family will

be able to;

 Verbalize understanding having a good

nutrition.
 Recognize and accept malnutrition as a
problem
 Identify at least 3 healthy foods that is
nutritious and rich in vitamins and minerals.
Nursing Intervention:

 Discuss to the family the importance of good

nutrition and eating healthy food.
 Enumerated foods that is nutritious and rich in
vitamins and minerals such as green leafy
vegetables, fruits and having exercise at least
30 minutes a day.
 Emphasized to the family the benefit of having
good nutrition such as preventing from having
complication and occurrence of some disease.
 Encouraged them to avail the health services
and free vitamins that is available in their health
center.
Methods of family used contact:
Home visit

Resources required:
 Visual aids and low cost materials needed for
actual demonstration.
 Time and effort on the part of nurse and family.

Evaluation:
Goals met. The family was able to recognize
the problem and was able to verbalize
understanding in the importance of good
nutrition, was able to identify foods that is
nutritious.
Health Problem No. 2: ACCIDENT
HAZARD

 Faculty wiring
 Protruding nails on the wall

Family nursing problem:

Inability to recognize the presence of hazard
condition in the house due to inadequate
knowledge on the effects of the hazard
conditions.
Objective of care:

 After nursing intervention, the family will able

to:
 Distinguish the hazard condition and its
effect to the members of the family.
 Execute actions to repair or modify the
identified hazard.
 Recognize the importance of a home free
danger.
Goal of care:
After nursing intervention the family will be able
to recognize the presence of hazard in faulty wiring
and protruding neils in the wall.

Nursing intervention:
 Assessed the following perception with regards to
the problem identified.
 Discussed with the family, the identified hazard
found inside the house and its effects to each
members.
 Provided suggestions about preventive measures
of injuries such as organize the wiring into the
proper place that children would not reach it to
enchance the safety of the family members.
Method of nursing family contact:
Home visit

Resource requires:
 Knowledge in giving health teachings.
 Time and effort of the students as well as the
family.

Evaluation:
Goals met, the family specifically the
parents had recognized the problem &
cooperates in organizing, repairing, the perceived
accident hazard.
Health problem no. 3:
PRESENCE OF BREEDING SITE (Open
drainage)

Family nursing problem:

Inability to provide a home

environment which is conducive to health
maintenance and personal development due
to:
 Ignorance of the importance of hygiene and
sanitation.
 Lack of knowledge of preventive measures.
Goal of care:

After nursing intervention the family will be

able to maintain cleanliness in their drainage.

Objective of care:

 Determine the importance of good

sanitation
 Identify the causes of breeding sites to
prevent the occurrence of disease such as
dengue and malaria.
 Eliminate the presence of this site.
Nursing intervention:

 Conduct health teachings that the open

drainage is possible for breeding sites of
mosquito which can cause diseases such as
dengue.
 Cited the causes and effects of the prevalence
of these breeding sites.
 Suggested alternative/methods that would
eliminate the breeding sites such as cleaning.
 Emphasize to the family the proper sanitation
that may affect their health.
 Demonstrated proper cleaning of the drainage
and make a canal so that the water can flow to
prevent stagnation.
Method of family used contact:
Home visit
Resources required:
 Time and effort in the part of the student and
the family member.
 Knowledge and skills in the part of the student
nurse
 Glove and shovel

Evaluation:
Goals met, the family was able to show
behavior and compliance on measure on how to
maintain a clean environment.
 
Health Problem No. 4:
UNCOVERED EATING UTENSILS

Family nursing problem:

Inability to recognize the presence of health
problem due to lack of knowledge and
negative attitude.

Goal of care:
After nursing intervention the family will able
to find out the importance of keeping the
utensils covered.
Objective of care:

After the nursing intervention the family will

able to:
 Find out the importance of keeping the
eating utensils covered;
 Washing their utensils after used.
 Maintain the cleanliness of the eating
utensils.
 Utilize a dish cabinet wherein they can place
their eating utensils.
Nursing intervention:
 Educated the family importance of keeping
the utensils clean.
 Educated the family to maintain the
cleanliness of their eating utensils.
 Demonstrated the proper cleaning of the
kitchen utensils.
 Provided clean dish cabinet, dishwashing soap
and sponge.

Method of family used contact:

Home visit
Resources required:

 Knowledge, skills, time and effort of the

student.
 Dish cabinet provided by the students.

Evaluation:

Goals met, the family has knowledge to

determine the purpose of keeping utensils
covered and able to maintain the cleanliness
of utensils
Health Problem no. 5:
PRESENCE OF LICE AND NITS
(Pediculosis humanus capitis disease)

Family nursing problem:

 Inability of the mother to in pause proper
hygiene to her children
 Unavailability of extra budget to buy agents
used to kill lice.
 Knowledge deficit.
Goal of care:

 After nursing intervention, the family

members will be able to get rid of lice
through different effective measures used to
prevent increasing number of lice;
 The family is capable of doing measures in
impending the increase number of lice such
as.
a) Applying anti-head lice shampoo
especially to those who are effected;
b) Regular cleaning of the utensils shared by
the family like pillow case, mats, combs,
and bed linens.
Nursing intervention:

 Broaden the knowledge of the family about the

occurrence and cause of parasites and its
possible effects by health teaching.
 Demonstrate to the mother or other family
members the application of anti-head lice
shampoos.
 Advice the mother to improve proper hygiene to
her and her children.

Evaluation:
Goals met; presence of lice is eliminated and the
mother verbalize understanding about the
importance of proper hygiene.
Health problem no. 6:
UNORGANIZED CLOTHING

Family nursing problem:

Inability to provide a home environment
which is conducive to health maintenance and
personal development due to lack of time and
financial resources.

Goal of care:
After nursing intervention, the family will
able to maintain proper arrangement of their
clothing.
Objective of care:

After the nursing intervention the family will

able to:
 Demonstrate proper arrangement of their
clothes.
 Determine the importance of putting the
clothes in proper place; and
 Formulate plans where they can put their
clothes neatly and properly
Nursing intervention:

 Conducted health teachings about the

possible illness they can aquire because of
improper placing of their clothes to an open
environment where cockroach and the
insects are present.
 Provided clean boxes where they can place
their clothes properly.

Methods of nurse contacts:

Home visits
Resources required:

 Time and effort in the part of the student and

the family member.
 Knowledge and skills in the part of the
student nurse.
 Clean boxes

Evaluation:
Goals met, they able to understand the
instructions given as evidence by proper
arrangement and organization of their clothing.
Health Problem No. 7:Poor
ventilation

Family nursing problem:

Inability to provide a home environment
which is conducive to health maintenance and
personal development due to financial
constraint, limited physical resources, failure to
see benefits of investment in home
improvement.

Goal of care:
After nursing intervention, the family will be
able to understand the importance of having
good ventilation at their home.
Objectives of care:

After the nursing intervention the family will

able to:
 Identify possible effect of poor ventilation in
their health.
 Recognize and accept poor ventilation as a
problem .
 Formulate plans of action to resolve the
problem.
Nursing intervention:

 Discussed to the family the importance of

proper ventilation.
 Encouraged the family to improve their
home condition.
 Explained the benefit of good ventilation.

Method of family used contact:

Home visit
Resources required:

 Time and effort in the part of the student and

the family member.
 Knowledge and skills in the part of the
student nurse.
 Finances in the part of the family to improve
their home.

Evaluation:
Goals met, they were able to recognize the
importance of having a good and proper
ventilation
Health Problem no. 8: INADEQUATE LIVING
SPACE

Family nursing problem:

Inability to provide home environment which
conducive for health maintenance and presonal
development due to inadequate family
resources specifically financial resource

Goals of care:
After the nursing intervention the family will
develop ways on how to minimize the problem
as evidenced by rearrangement of furniture to
maximize their living space.
Objectives of care:

After the nursing intervention the family

should be able to:
 Identify risk factors that contribute to the
congestion in the area such unused things.
 Demonstrate techniques to promote good
environment condition such as proper
arrangement of appliances.
 Verbalized understanding about the
importance of having adequate living space.
Nursing intervention:

 Suggest ways on how to maximize the

available living space by re-arrangement.
 Advice the family to seperate things that
they don’t use anymore.
 Inform the family regarding the easy
transmission of deficit due to inadequate
space.

Methods of family used contact:

Home visit
Resources required:

 Visual aids and low cost materials needed for

actual demonstration.
 Time and effort on the part of nurse and
family.

Evaluation:
The family which consists of 5 members or
more slept in one room with the kitchen and
dining table.
 CHAPTER V

GENERAL HEALTH
TEACHINGS
 Educate the family with the possible risk
factors and the importance of solving the
problem and on maintaining an
environment which is safety at home.
Rationale: To reduce risk factors and protect
self from injury.
 
 Educate to the family about the benefit of
having a good ventilation
Rationale: Promotes awareness that having
poor ventilation can affect their health.
 Practice the family in proper organizing of
clothing
Rationale: For them to be organized and
have a clean environment

 Educatethe family to have good hygiene

Rationale : To reduce the spread of
communicable diseases including nits and lice
 Emphasize the importance of having clean
environment
Rationale: for them to identify its
importance

 Educate the family about the importance of

good sanitation specifically in their eating
utensils
Rationale: To promote awareness about the
transfer of microorganism that can cause
certain disease.
 Encourage them to organize their things in
proper place.
Rationale: To maximize their living area.

 Encourage the mother to prepare foods rich in

vitamins and nutrients.
Rationale: To promote good nutrition. 
 Emphasized to them the importance of
having good nutrition and the possible
complications that may occur having poor
nutrition.
Rationale: To increase awareness and
prevent further complication.

 Provideadequate rest and sleep.

Rationale: To help body to fight stress and to
boost immune system.
 
 RECOMMENDATIONS

Family D should
 
 Maintain good personal hygiene in each
family member.
 Maintain cleanliness in their environment
 Maintain their clothes organized or properly
arranged.
 Wash their dishes after they eat.
 Separate their used clothes from the clean
one.
 Fix their bed before getting out.
 Make sure to fix theirprotruding nails to
prevent accident hazard.
 Perform hand washing before and after
eating.
 Keep their eating utensils covered at all
times.
 Encourage to eat healthy foods.
 Avoid eating unhealthy food such as; fatty,
salty and junk foods.
 SUMMARY AND CONCLUSION
A family is a group of people bound by that
complex set of relationships. The set of concepts,
values, knowledge and skills of each members
depend on each other. Throughout the journey,
family may experience both happiness and
suffering. Problems and conflicts also arises with
each member because of individual differences.
But in spite of these obstacles it helps family to
have stronger bond and make them more mature
to face this kind of consequences. Thus, there are
many factors that can affect the health of family
members in his or her whole being.
 As in the case of family D which is
assigned to us, financial constraints and
lack of knowledge are the main reasons that
contributed to the health status of each
member of the family and these are the
reasons that increases their risk to other
potential problems that may occur if left
neglected.
 As we established working
relationship and developed rapport
during our home visit services, we were
able to make assessments, identify
problems, determine outcome plan,
implemented care and provided health
teachings.
The following are identified problems
presented by the family through assessment
of the researchers:

Accident hazard specify to; protruding nails

and faulty wires, Malnutrition, Uncovered
eating utensils, Presence of nits and lice ,
Presence of breeding sites, Unorganized
clothing, Poor ventilation and inadequate
living space.
 Therefore, we conclude that there are lots of
factors that affect the health status of the
family members, not only physically, financially
but as a whole. It is really important that
through health teaching, we will be able to
enhance their knowledge, formulate preventive
measures and other alternative ways to
promote the health of the family which can
help them to improve their health status.
God Bless!