INITIAL DATABASE

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INITIAL DATA BASE

Our duty in the community started last September 29, 2008 and ended on September 30,

2008. Our clinical instructor in the area, Mrs. oriented us on what will be our assignments and

routines in our two days stay. The group was divided by pair and was instructed to choose a

client for family assessment. This family will be their chosen subject for study.

MQP, a client during that time, who happens to have rashes all over his body, which our

instructress identified to be measles, was our subject of study. According to the mother, the

child had a fever for three days before those rashes appear.

Given a subject, me and my partner formulated plans and designated task to done

individually. We ask permission to our client to be able to visit her at home. Upon the approval

of our request we set a date of visit. The next day, equipped with the necessary tools, we

proceeded in their home for our home visit.

A. FAMILY STRUCTURE AND DYNAMICS

No. Name of

family member

Sex Birthday

(mm/dd/yy)

Age Height

1 DDP M 12-07-78 29 y/o 5’ 10’’

2 NP F 05-11-80 28 y/o 5’ 2’’

3 MQP M 03-13-2008 6 ½ mos. 22 inches

Weight Civil Status Religion Educational

Attainment

Occupation

Relationship to family

head

69.41kg M R/C CG GRCO Head of the family

54.98kg M R/C CUG Wife

Housewife

7kg C R/C N/A N/A Sibling

Family’s head DDP is 29 years old, born on December 7, 1978, 5’10’’ in height and 153

lbs. in weight. He is a GRCO graduate, presently working in CC in Boni Avenue. His wife NP is

28 years old, born on May 11, 1980, 5’2’’ in height and weighs 119 lbs. She was an

undergraduate of the course Bachelor of Science in Business Administration. Presently, she

was a plain housewife to DDP and a mother to their child. NP was born in the Northern part of

Samar while her husband was from the Western part of it. Their three years of marriage was

blessed with a healthy baby boy named MQP. He is 61/2 mos.old, 22 inches long and weighs

15.43 lbs. All family members are Roman Catholic. To show their dedication they never fail to

go to church every Sunday to give thanks and praise for all the blessings God has given them.

Their family is nuclear in structure. According to them they owned the house but not the

land, for it is owned by the government. Common languages spoken were Waray and Tagalog.

In times of conflicts and problems they always depend on each other in solving it. For them

they can face any kind of hardships and problems as long as they are together.

B. SOCIO-ECONOMIC STATUS

Monthly Income: P10, 000-P15, 000

Weekly Budget: P2, 500

Amount Expenditure

P1500 Foods( Groceries)

P500 Bills: Electricity and water

P250 Transportation (Father)

P250 Savings

TOTAL: P2,500

Prioritization of Need

Rank Priorities

1 Food

2 Bills

3 Transportation

Majority of the family’s budget is allocated to their food needs. Second to this is their

budget to their billings like electricity and water. Based from the table above you can observe

that they give importance to their savings. This is for the preparation of their child’s future.

When it comes to their clothing you can observe it has not been indicated above for they

seldom spend money in clothing.

Financial difficulties of the family are solved by borrowing money from friends and

relatives, to be returned after the head of the family received his salary.

C.ENVIRONMENT

Home:

Ownership of the House Owned

Construction Materials Used Mixed

Space adequacy Adequate

Lighting Facility Electricity

Lighting Adequacy Adequate

Ventilation Adequate

Water Supply Level III (nawasa)

Drinking Water Nawasa

Food Storage Covered

Waste Disposal:

Garbage Container Covered

Method of Disposal Garbage Collection

Toilet Facility Level II (with poso negro not connected to

sewerage)

Drainage System:

Type of Drainage Open Drainage

Domestic Animals, Insects, Breeding Sites:

Pets/Animals None

Pests/Insects Rodents, Cockroaches, Mosquitoes, Flies

Way of Eradication Trapping, Using Insecticides

FLOOR PLAN MEASUREMENT

7

ROOM

SALA KITCHEN CR

77

10

B. HEALTH STATUS

GEONOGRAM OF PALIMA FAMILY

NPDD P

LP ES YSRP

NoneHypertension, Diabetes

PHYSICAL ASSESSMENT

Name of Client: DDP

Age: 29 years old

MEASUREMENTS

MQP

RESULT NORMAL VALUES ANALYSIS

Height 5’ 10’’A medium frame man with a height of 5’10’’ should have a weight range of 151-163 lbs.

Normal

Weight 153 lbs (69.41kg)

VITAL SIGNS

Temperature 36.5 degree celcius 36-37 degree celcius NormalPulse Rate 63 60-100 bpm NormalRespiratory Rate 20 16-20 bpm NormalBlood Pressure 110/80 120/80 Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE

ASESSED

NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Skull

Scalp

Symmetry

Without flakes

Symmetry

Without flakes

Normal

Hair

Face

Eyebrows

Eyelashes

Eyelids

Lower palpebral

(conjunctiva)

Sclera

Cornea

Pupils

Iris

Eye movement

Visual fields

Visual acuity

Ear canal

Hearing acuity

Resilient hair

Symmetry

Hair equal, intact

Intact, with curl

Aligned

Pinkish

White and clear

Transparent, shiny

Black, equal, round

Symmetry

Coordinated

Can see object in

peripheral

20/20 vision

Uniform in color

Resilient hair

Symmetry

Hair equal, intact

Intact, with curl

Aligned

Pinkish

White and clear

Transparent, shiny

Black, equal, round

Symmetry

Coordinated

Can see object in

peripheral

20/20 vision

Uniform in color

Normal and

healthy

Normal and

healthy

Internal nares

Septum

Lips

Gums

Teeth

Tongue

Frenulum

Cheeks, buccal mucosa

Palate

Uvula

Tonsils

Voice

Muscular strength

Areola

Normal voice can respond

Symmetry

Symmetry

Pinkish

Pinkish

32, smooth, shiny

Smooth

Smooth

Uniform in color

Soft and glistering

Light pink

Pink and smooth

Can be heard

Equal strength

Round or oval

Normal voice can respond

Symmetry

Symmetry

Pinkish

Pinkish

smooth, shiny

Smooth

Smooth

Uniform in color

Soft and glistering

Light pink

Pink and smooth

Can be heard

Equal strength

Round or oval

Normal and

healthy

Normal and

healthy

Normal and

Nipples

Abdomen Round and equal

Unblemished skin, uniform

in color

Round and equal

Unblemished skin,

uniform in color

healthy

Normal and

healthy

Name of Client: NP

Age: 28 years old

MEASUREMENTS

RESULT NORMAL VALUES ANALYSIS

Height 5’ 2’’A small frame man with a height of 5’2’’ should have a weight range of 115-130 lbs.

Normal

Weight 119 lbs. (54.98 kg)

VITAL SIGNS

Temperature 37 degree celcius 36-37 degree celcius NormalPulse Rate 70 60-100 bpm NormalRespiratory Rate 19 16-20 bpm NormalBlood Pressure 100/80 120/80 Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE

ASESSED

NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Skull

Scalp

Hair

Face

Eyebrows

Eyelashes

Eyelids

Lower palpebral

(conjunctiva)

Sclera

Cornea

Pupils

Iris

Symmetry

Without flakes

Resilient hair

Symmetry

Hair equal, intact

Intact, with curl

Aligned

Pinkish

White and clear

Transparent, shiny

Black, equal, round

Symmetry

Symmetry

Without flakes

Resilient hair

Symmetry

Hair equal, intact

Intact, with curl

Aligned

Pinkish

White and clear

Transparent, shiny

Black, equal, round

Symmetry

Normal

Normal and

healthy

Eye movement

Visual fields

Visual acuity

Ear canal

Hearing acuity

Internal nares

Septum

Lips

Gums

Teeth

Tongue

Frenulum

Cheeks, buccal mucosa

Palate

Uvula

Coordinated

Can see object in

peripheral

20/20 vision

Uniform in color

Normal voice can respond

Symmetry

Symmetry

Pinkish

Pinkish

32, smooth, shiny

Smooth

Smooth

Uniform in color

Soft and glistering

Light pink

Coordinated

Can see object in

peripheral

20/20 vision

Uniform in color

Normal voice can respond

Symmetry

Symmetry

Pinkish

Pinkish

smooth, shiny

Smooth

Smooth

Uniform in color

Soft and glistering

Light pink

Normal and

healthy

Normal and

healthy

Normal and

healthy

Tonsils

Voice

Muscular strength

Areola

Nipples

Abdomen

Pink and smooth

Can be heard

Equal strength

Round or oval

Round and equal

Unblemished skin, uniform

in color

Pink and smooth

Can be heard

Equal strength

Round or oval

Round and equal

Unblemished skin,

uniform in color

Normal and

healthy

Normal and

healthy

Name of Client: MQP

Age: 6 ½ mos. old

MEASUREMENTS

RESULT NORMAL VALUES ANALYSIS

Height 22 inches An average weight of a

6 months old infant is

16.53 lbs.

Normal

Weight 15.43 lbs (7 kg)

VITAL SIGNS

Temperature 37.2 degree celcius 37.2 degree celcius Normal

Pulse Rate 113 bpm 120-140 bpm Normal

Respiratory Rate 48bpm 30-50 bpm Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE

ASESSED

NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Skull

Scalp

Hair

Face

Eyebrows

Eyelashes

Eyelids

Lower palpebral

(conjunctiva)

Symmetry

Without flakes

Resilient hair

Symmetry

Hair equal, intact

Intact, with curl

Aligned

Pinkish

Symmetry

Without flakes

Resilient hair

Symmetry

Hair equal, intact

Intact, with curl

Aligned

Pinkish

Normal

Normal and

healthy

Sclera

Cornea

Pupils

Iris

Eye movement

Visual fields

Visual acuity

Ear canal

Hearing acuity

Internal nares

Septum

Lips

Gums

Teeth

Tongue

White and clear

Transparent, shiny

Black, equal, round

Symmetry

Coordinated

Can see object in

peripheral

20/20 vision

Uniform in color

Normal voice can respond

Symmetry

Symmetry

Pinkish

Pinkish

32, smooth, shiny

White and clear

Transparent, shiny

Black, equal, round

Symmetry

Coordinated

Can see object in

peripheral

20/20 vision

Uniform in color

Normal voice can respond

Symmetry

Symmetry

Pinkish

Pinkish

smooth, shiny

Normal and

healthy

Normal and

healthy

Frenulum

Cheeks, buccal mucosa

Palate

Uvula

Tonsils

Voice

Muscular strength

Areola

Nipples

Abdomen

Smooth

Smooth

Uniform in color

Soft and glistering

Light pink

Pink and smooth

Can be heard

Equal strength

Round or oval

Round and equal

Unblemished skin, uniform

in color

Smooth

Smooth

Uniform in color

Soft and glistering

Light pink

Pink and smooth

Can be heard

Equal strength

Round or oval

Round and equal

Unblemished skin,

uniform in color

Normal and

healthy

Normal and

healthy

Normal and

healthy

ABNORMAL FINDING:

Skin Smooth and

unblemished

Rashes all over the

body

Measles is an

infection

characterized by

fever rashes and

symptoms

referable to upper

respiratory tract,

the eruption is

preceded about 2

days coryza, during

which stage

grayish peck

(Koplik Spots) may

be found on the

inner surface of the

cheeks. A

morbilliform rash

appears on the 3rd

or 4rth day

affecting the face,

body and

extremities.

( Public Health

Nursing pp. 267)

Nutritional Status

Name of Family Height Weight BMI Interpretation

Member

DDP 5’ 10’’ 153lbs 22 Normal

NP 5’ 2’’ 119lbs 22 Normal

MQP 22 inches 15.43 lbs 23 Normal

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

Exercise Pattern

Name of Family

Member

Hours of Exercise Times per Week Normal

DDP 30 minutes 7 times a week 30 minutes/day

NP 30 minutes 7 times a week 30 minutes/day

MQP N/A N/A n/a

The father, DDP was not able to practice it everyday because of work. His wife on the other

has a daily routine exercise in a form of dancing. Their child on the other hand was still too

young to participate in the activity.

C. Values, Belief and Practices

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

II. ORGANIZATIONAL DATA

Cues Normal Standards Based on Reference

Subjective:

“Nilagnat siya ng tatlong araw

bagolumabas yang mga pula-pula

niya sa katawan.”

A healthy child must be free from diseases or illnesses

like fever cough and colds, rashes and the like.

Subjective:

“Ang daming ipis dito pag umaga,

yung pag binuksan mu yung ilaw,

kanya kanyang takbo na sila. Minsan

din malangaw at may magnilan-

ngilang daga na naghaharutan sa

may kisame.”

A healthy home must be free from rodents and pest, it is

clean, well ventilate and free from threats.

Subjective:

“Nakakatakot lang ditto yung bukas

na kanal dyan sa may labas. Lalo

kapag umuulan at bumabaha, baka

kasi di mapansin malusbot dun”

A healthy home must be free from rodents and pest, it is

clean, well ventilate and free from threats.

III. CLUSTERED DATA

Cues/Data Family Health Care Plan

6 ½ mos old male infant with cough and

rashes all over his body.

“Nilagnat siya ng tatlong araw

bagolumabas yang mga pula-pula niya sa

katawan.”

“Ang daming ipis dito pag umaga, yung

pag binuksan mu yung ilaw, kanya

kanyang takbo na sila. Minsan din

malangaw at may magnilan-ngilang daga

na naghaharutan sa may kisame.”

“Nakakatakot lang ditto yung bukas na

kanal dyan sa may labas. Lalo kapag

umuulan at bumabaha, baka kasi di

A. Measles and as a Health Deficit

1. Inability to provide adequate nursing care to the

dependent member with measles and cough due to:

Lack of knowledge on the nature and management of

the health condition.

B. Presence of Vectors and Rodents as Health Threat

1. Inability to recognize the health threat due to lack of

knowledge about the condition.

2. Inability to make decisions with regards to the

management of the condition due to the failure on

identifying what measures are appropriate.

3. Inability to provide home conducive to health

maintenance and personal development due to

ignorance in preventive measures.

mapansin malusbot dun”

C.Open Drainage as Health Threat

1. Inability to make decisions with respect to taking

appropriate health actions due to lack of knowledge

about alternative solutions.

IV. PRIORITIZATION OF THE PROBLEM

1. Measles with cough

CRITERIA COMPUTATIO

N

SCORE JUSTIFICATION

Nature of the problem

Modifiability of the

problem

Preventive potential

Salience

3/3 x 1

2/2 x 1

3/3 x 2

2/2 x 1

1

1

2

1

It is a health deficit that requires immediate

intervention.

Resources needed are available.

With the compliance in the given instructions of

appropriate health providers, disease will be

manageable.

The family considers this as a problem that

needs immediate attention.

TOTAL 5

2. Presence of Vectors and Rodents

CRITERIA COMPUTATIO

N

SCORE JUSTIFICATION

Nature of the problem

Modifiability of the

problem

Preventive potential

Salience

2/3 x 1

½ x 2

2/3 x 1

1/2 x 1

0.7

1

0.7

0.5

It is a health threat that needs an immediate

attention.

The family has the necessary resources but does

not utilize them properly.

The susceptibility in acquiring other infections

can be prevented if the problem will be solved.

The problem was recognized by the family but

they do not think it needs an immediate

attention.

TOTAL 2.9

3. Open Drainage

CRITERIA COMPUTATIO

N

SCORE JUSTIFICATION

Nature of the problem

Modifiability of the

problem

Preventive potential

Salience

2/3 x 1

½ x 2

2/3 x 1

1/2 x 1

0.7

1

0.7

0.5

It is a health threat for it could damage the

health of the family.

It is partially modifiable for the family alone

can’t solve the issue, referral to higher officials

were still needed.

Solving the problem lessen the risk of the family

on acquiring infections brought about by an

unpleasant environment

The family recognizes the problem but does not

think it needs an immediate action.

TOTAL 2.9

PROBLEM PRIORITIZATION

Family Problems According to Priority

1 Measles and cough 5

2 Presence of Rodents and Vectors 2.9

3 Open Drainage 2.9

V. FAMILY HEALTH CARE PLAN

HEALTH

PROBLE

M

FAMILY

NURSIN

G

GOAL OF

CARE

OBJECTIVES

OF CARE

INTERVENTION PLAN

NURSING

INTERVENTION

METHOD OF

RESARCHER-

FAMILY

CONTACT

RESOURCES REQUIRED

Measles

and cough

Inability

to

manage

the

After

nursing

intervention,

the family

After nursing

intervention, the

family:

1. Establish rapport.

2. Prepare the

necessary equipments

needed.

Home Visit Material Resources:

Visual Aids on Measles and

cough.

condition

due to

the lack

of

knowledg

e

regardin

g its

managem

ent.

must be

equipped

with the

necessary

knowledge

they need in

dealing with

the

situation.

-will be able

identify the

cause and effect

of the disease.

-Know the

appropriate

intervention to

make.

3. Inform the family

about the visit.

4. Health education

about the diseases and

its management.

Human Resources:

Time and effort of both the

researchers and the family.

Financial Resources:

Money for the researchers’

transportation and food (if

necessary).

FAMILY HEALTHCARE TEACHING PLAN

NURSING

INTERVENTION

METHOD OF

RESARCHER-FAMILY

CONTACT

RESOURCES REQUIRED

1. Analyze with the family

the problems measles and

cough.

Home Visit Material Resources:

Visual Aids on Measles a cough.

2. Discuss with the family

the appropriate courses of

action.

3. Enumerate to the family

the danger signs they need

to watch out for namely:

inability of the infant

to drink or

breastfeed

vomits everything

convulsions

abnormally sleepy or

difficulty to awaken

Human Resources:

Time and effort of both the researchers and the family.

Financial Resources:

Money for the researchers’ transportation and food (if

necessary).

What to teach…

What is measles?

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

How is measles transmitted?

Droplets transfer the infections. Although the sick person may be in isolation, the disease may still spread from room to room.

Anybody who has not already had measles can be infected. Infants up to four months of age will not be infected if their mother has had measles herself

because they will be protected by her antibodies. The incubation period - the time between infection and the outbreak of the condition - is usually one

to two weeks. Patients are infectious from four days before the onset of the rash until five days after it appears.

What are the symptoms of measles?

After about 14 days the following symptoms start showing:

A fever at about 39ºC.

A cold. Coughing, possibly with a barking cough. Sore throat - the lymph nodes in the throat may swell. Reddish eyes. Sensitivity to light. Grayish spots, the size of grains of sand may appear in the mucous membrane of the mouth just

around the molar teeth. These are called Koplik's spots and can be seen before the rash appears. After three to four days the temperature may fall, although it can run high again when the rash

appears. The rash usually begins around the ears and spreads to the body and the legs within a day or two. At first the spots are very small - a couple of millimeters - but they double in size quickly and begin

to join together. The spots are a clear red color. The temperature, which may run as high as 40ºC, may stay that high for a couple of days. Then it

disappears together with the rash, which may leave some brown spots. After a week the child will be fit again.

How are measles treated?

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

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