INITIAL DATA BASE

INITIAL DATABASE

A. FAMILY STRACTURE CHARACTERISTICS & DYNAMICS HEAD OF THE FAMILY : Ernesto Faustino ADDRESS : Iba, Hagonoy Bulacan CONTACT NO. : 09157002913 TYPE OF FAMILY : Extended INTERVIEWEE : Florencia De Guzman and Ernesto Faustino DATE OF INTERVIEW : July 08, 2009 at Brgy Iba, Hagonoy bulacan

FAMILY

MEMBERS

RELATION TO HEAD OF THE

FAMILY

GENDER

BIRTHDATE

STATUS

RELIGION

Ernesto Head of the family Male March 04, 1930 Married Roman CatholicFlorencia Daughter Female June 17, 1964 Married Roman CatholicFroilan Son In Law Male April 11, 1962 Married Roman CatholicJeffrey Grandson Male September 12, 1983 Single Roman CatholicJeric Grandson Male October 25, 1992 Single Roman CatholicJanile Granddaughter Female March 09, 1994 Single Roman Catholic

As Tatay Ernesto said “ simula nung bata ako dito na ako nakatira, taga dito kasi ang ama ko” which made their family as

patrilocal in location. When we ask about who will make most of the decision in the family, especially in health care tatay Ernesto verbalized “ ako at ang asawa ng anak ko na si froilan, siya kasi ang nagtatrabaho samin”. They do not belong in an ethnic group. Tatay Ernesto, Florencia and his 3 grandchildren originally resides from Iba and Froilan from Calumpit. Froilan transfer in Iba for almost 5 years. The primary dialect they used is Tagalog. As we ask if there is any problem in their family regardless of what cause, he answered mostly simple misunderstanding and they handle it by means of having open forum. Their family is considered patriarchal because Tatay Ernesto is considered the Head of the Family. There is no problem in communication with each member of the family, in exception to Froilan which is in Saudi Arabia, But they call him thru the used of cell phone about 3-4 times a week. And their family is considered a simple and happy family. B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

Tatay Ernesto is a high school graduate, he was a former farmer at his time, then Florencia is a BS Commerce graduate, she spends her time mostly at home. Froilan highest educational attainment is a high school graduate and working as a family driver in Riyadh, Kingdom of Saudi Arabia earning of approximately P 15 000 per month. The eldest son, Jeffrey is a college graduate and working as a sales clerk in a mall at Pullilan and earning of approximately P 10 000per month. Then Jeric is a 2 nd year BS Industrial Technology student at Bulacan State University while Janile, the youngest is a 4rth year high school student at Iba National High School. All of the members of their family are Roman Catholic, and they go to church every Sunday and they consider it as form of recollection and a bonding moment. Florencia is a member of “ Samahan ng mga Kababaihan” which is a small local cooperative in their community. There is no problem in their participation in the community work or task like the program “ Tapat mo Linis mo” and they considered it as a form of helping their own community.

When we asked if their monthly income is enough to sustain their family needs, they verbalized “ Oo naman, pero paminsan minsan pag may hindi inaasahang gastos na dumarating tulad ng sakit, nakakautang pa kami” If they encounter this specific condition they borrow money to Ate Maricar, as they call her, which is the oldest cousin of Froilan and originally resides in Sapang Bayan, Calumpit Bulacan.

MONTHLY BREAKDOWN OF EXPENSES

EXPENSES AMMOUNT

ELECTRIC BILL P 180 – P 250WATER BILL P 350FOOD P 10 000 (ESTIMATED)EDUCATION

P 500 – P 1 000 (JANILE) P 1 000 – P 2 000 (JERIC)

TOTAL P 12 030 – P 13 600

NAME INCOME PER MONTHFroilan P 10 000 was sent here in the

Philippines in his total income of P 15 000 per month.

Jeric P 4 000 was given to his family in his total income of P 10 000.

TOTAL P 14 000

C. HOME AND ENVIRONMENT

The family of Tatay Ernesto is living in their ancestral house composed of 3 bedrooms, 1 kitchen, 1 bathroom, a living room and a storage area. On 1 room Florencia and Froilan sleep, the 2nd room is for Tatay Ernesto and Jeffrey and the last room is for Jeric and Janile. The house has 10 windows, the 2 windows are in the front of their house, the 4 windows are in the second floor of their house the other 1 is in the kitchen, 1 in the CR, 1 window in the storage area and 1 in the roon which is in the main fool of their house. According to them there is no problem in ventilation. They used manual or “ dibuhos” system in their bathroom. They have 2 florescent lamps and 2 incandescent bulbs. They often walk barefoot inside their house. As they verbalized “ pag mainit electric fan ang gamit namin, gumagamit din kami ng katol o di kaya baygon spray para bugawin ang mga lamok”. Because some stagnant water outside their house can be a good reservoir of Dengue Carrying Mosquito.

They used LPG in cooking, their source of clean water is through their faucets and the water is come from a public water station ( NAWASA ). The clean their house about once a week every Sunday. Their family garbage was often collected by a truck and sometimes they just burn it. Those garbage are came from everyday life ( eg. Cooking, Biodegradable waste like dried leaves etc, ) They have open free drainage at the back of their house. The stair is considered hazardous to Tatay Ernesto because of his old age and sometimes this carelessness. As we ask if they are having check up in the Barangay Center , they verbalized “ pag may free immunization lang, kasi pag nagkakasakit kami, kung di naman malala kadalasan self medication lang ang ginagawa naming”. They used tricycle, jeeps and bicycle as their means of transportation and cell phone for communication.

FLOOR PLAN

FIRST FLOOR:

Washing Area

CR

Storage Area stairs

Door

Sofa

Sofa Sofa

window window

door

SECOND FLOOR:

Downstairs

BedBed

windowwindow

windowwindow

D. HEALTH STATUS OF EACH FAMILY MEMBER

As Tatay Ernesto verbalized “ di ako naniniala sa mga doctor lalo lang akong magkakasakit pag dinala ako sa ospital” “dati nung nasugat ang mata ko binigyan ko lang ng dinurog na asin, tapos hinugasan ko ng tubig, sa awa ng diyos gumaling naman” In order to maintain good health they just eat nutritious foods like plenty of fruits ( banana, mango), vegetables and take vitamin supplement every day. The only form of exercise of Jeric & Jeffrey is by playing basketball, tatay Ernesto, Florencia and Janile are no fun of having exercise. If they have health problems they often go to “ manghihilot” or “ mananawas” as their primary source of care. Or just having self medication if there is no serious medical problem. They often encounter fever, flu, cough and some benign skin allergies like not so serious dermatophytes infection. There is no mention case of Tineas and Pediculus Humanus Capitis infection in any of their family member.

None of the family experience serious accidents in exception in some minor bicycle accidents. At present none of their family member is sick. They also believed in effects and benefits of some herbal medication like the use of lagundi to treat cough and guava leaves as an antibiotic agent. And if one of their family members is sick and not responding in herbal meds and folk remedies, they just go directly to hospital and seek for some scientific explanation. Tatay Ernesto is a hard smoker as well as Froilan each of them can consume about 2 cases of cigarette every day. They also drink alcohol beverages occasionally.

E. HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

According to Tatay Ernesto he do not received any immunization required for then at his time. Then as Florencia verbalized “ kumpleto sa vaccine ang mga anak ko” These vaccines are BCG, DPT, OPV, HEPATITIS B and AMV. But she does not have any records of immunization. Their healthy lifestyle practices are eating nutritious foods, maintain proper hygiene and clean the surroundings. They sleep about 7-8 hours at night and take household chores as a form of exercise. There are no deviations in sleeping. As a form of relaxation they just watch television. They take vitamins as a promotive or preventive health care.

PHYSICAL ASSESSMENT

DONE ON July 09, 2009 AT BRGY IBA, HAGONOY BULACAN

NAME : ERNESTO FAUSTINO VITAL SIGN:AGE : 79 YEARS OLD T = 36.4oCWEIGHT : 72 Kg P = 69bpmHEIGHT : 1.7 m R = 17cpmBMI : 25.5 ( NORMAL ) BP = 70/100 mmHg

GENERAL SURVEY As we observed the pt. body built, height & weight there is no deviation from normal it is all appropriate in his age and lifestyle. He has a relaxed, erect posture with coordinated body movements. The pt. overall hygiene is clean and neat, there no presence of unpleasant body odor and no distress noted upon the entire physical examination. The pt. attitude is cooperative, have understandable and moderate tone of voice, there is relevance and organization of thoughts and pt. mood is appropriate to situation.

ASSESSMENT

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

SKIN

1. Inspected skin colorInspection

Varies from light to deep brown or Yellow overtone to Olive

Yellow overtone to Olive normal

2. Inspected uniformity of skin color.

Inspection

Generally uniform except in

areas exposed to the sun; area of

Generally uniform except in areas

exposed to the sun.

normal

lighter pigmentation.3. Assessed edema, if present (location, color, temperature, shape)

Inspection, palpation No edema No edema present normal

4. Inspected, palpated, and described skin lesions. Inspection, palpation

Freckles, some birthmarks, some flat and raised nevi, no abrasions

or lesions.Presence of moles normal

5. Palpated skin moisture.Palpation

Moisture in skin folds and the axillae

Presence of moisture in skin folds normal

6. Palpated skin temperature.Palpation Uniform, within normal range Warm and even temperature normal

7. Noted skin turgorInspection

Skin springs back to previous state

Springs back to previous state normal

HAIR

1. Inspected evenness of growth over the scalp. Inspection Evenly distributed hair Evenly distributed hair normal

2. Inspected hair thickness or thinness. Inspection Thick hair Thin hair normal

3. Inspected hair texture and oiliness.

Inspection Silky, resilient hair Dry hair

Deviation from normal due to inadequate vitamins

REFERENCE: FUNDAMENTALS OF

NURSING 8TH EDITION, KOSIER, ERB & SNYDER

4. Noted presence of infections or infestations by parting the hair in several areas, checking behind the ears and along the hairline at the

Inspection No infection No infection noted. normal

neck.5. Inspected amount of body hair.

Inspection Variable Variable normal

ASSESSMENT

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

NAILS

1. Inspected fingernail plate to determine its curvature and angle. Inspection

Angle of nail plate about 160 degrees

Nail plate angle of 160 degrees normal

2. Palpated fingernail and toenail texture. Inspection Smooth texture Smooth texture normal

3. Inspected fingernail and toenail bed color. Inspection Highly vascularized Vascularized normal

4. Inspected tissues surrounding nails. Inspection Intact epidermis Intact epidermis normal

5. Checked capillary refillInspection

Prompt return of usual color (generally less than 4 sec)

Return of usual color (generally less than 4 sec)

normal

SKULL AND FACE

1. Inspected skull for size, shape, and symmetry. Inspection

Rounded, symmetrical, smooth skull contour

Normocephalic and symmetrical normal

2. Palpated the skull for nodules or masses and depressions. Palpation Absence of nodules and masses. No nodules or masses normal

3. Inspected the facial featuresInspection Symmetric facial features Symmetrical normal

ASSESSMENT

TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS

ANALYSIS

4. Noted symmetry of facial movements Inspection Symmetric facial movements Symmetric facial movements normal

EYES

1. Inspected eyebrows for hair distribution and alignment and skin quality and movement. Inspection Hair evenly distributed Evenly distributed hair normal

2. Inspected eyelashes for evenness of distribution. Inspection

Equally distributed; curled slightly outward

Equally distributed; curled slightly outward

normal

3. Inspected eyelids, ability to blink. Inspection

Lids close symmetrically 15-20 involuntary blinks/min

Lids close symmetrically 15-20 involuntary blinks/min

normal

4. Inspected conjunctiva and sclera

InspectionConjunctiva in pink color,

sclera appears whiteYellowish conjunctiva

Deviation from normal due to aging or present of

unknown diseases



5. Inspected cornea and iris Inspection Transparent, shiny and smooth; iris is flat and

symmetrical

Cloudy, iris is flat and symmetrical

Deviation from normal due to aging



6. Inspected pupils for color, shape and symmetry of size. Inspection

Brown to black in color, round, equal in size

Brown, equal in size, round normal

7. Tested visual acuity

Inspection Can read newsprintCan read newsprint w/o use of

eye glassesnormal

EARS

1. Inspected auricles for color Inspection Color same as facial skin Color same as facial skin normal2. Tested hearing acuity

InspectionNormal voice tones audible, able to hear ticking in both

ears

Normal voice tones audible, able to hear ticking in both

earsnormal

NOSE

1. Inspected external nose for any deviations in size, shape or color

InspectionSymmetric and straight, no

dischargeSymmetric and straight, no

dischargenormal

2. Inspected the nasal cavities for the presence of redness, swelling, growths and discharge, using the flashlight

InspectionMucosa pink in color, clear watery discharge, no lesions

Mucosa pink in color, clear watery discharge, no lesions

normal

3. Inspected the nasal septum between chambers

InspectionNasal septum intact and in

midlineIntact and in midline normal

4. Tested patency of both nasal cavities

InspectionAir moves freely as the client

breathes through the noseAir moves freely as the client

breathes through the nosenormal

5. Lightly palpated for areas of tenderness, masses

Palpation No tenderness, no lesions No lesions and tenderness normal

MOUTH

1. Inspected outer lips from symmetry, color and texture

InspectionPink in color, moist,

symmetricLight pink in color

Deviation from normal due to inadequate vitamin used



2. Inspected buccal mucosa for color, moisture, texture and presence of lesions

InspectionMoist, smooth, soft and elastic

textureMoist and smooth normal

TEETH

Inspected for color, number, condition and presence of dentures

Inspection32 adult teeth, white and shiny

tooth enamel1 adult teeth, light yellow and

shiny tooth enamel

Deviation from normal due to missing teeth



GUMS

Inspected for the color and conditions

InspectionPink gums; moist and no

retraction of gumsPink gums normal

ASSESSMENT

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

TONGUE/FLOOR OF THE MOUTH

1. Inspected for color and texture of the mouth floor and frenulum

InspectionSmooth tongue base with

prominent veinsSmooth tongue normal

2. Inspected and palpated the position, color and texture, movement and base of the tongue

Inspection, palpation Moves freely, no tenderness Moves freely normal

3. Palpated for any nodules, lumps or excoriated areas

PalpationSmooth with no palpable

nodulesSmooth no nodules normal

NECK

1. Located/palpated lymph nodes and note for tenderness

Palpation No tenderness No tenderness normal

2. Inspected and palpated trachea for placement

Inspection, palpationCentral placement in midline, spaces are equal for both sides

Central placement in midline of the neck.

Normal

3. Inspected symmetry and visible masses

InspectionGlands ascends during swallowing; not visible

Glands not visible Normal

ASSESSMENT

TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS

ANALYSIS

4. Palpated for smoothness and areas of enlargement, masses or nodules

Palpation Not palpable Not palpable Normal

POSTERIOR THORAX

1. Inspected the shape, symmetry, and compared the diameter of anteroposterior thorax to transverse diameter

InspectionAnteroposterior to transverse

diameter is 1:2 ratio, chest symmetric

Anteroposterior to transverse diameter is 1:2 ratio

Normal

2. Inspected the spinal alignment Inspection Spine vertically aligned Spine vertically aligned Normal3. Palpated for temperature, tenderness, masses.

Palpation Uniform temperature, chest wall intact, no lumps masses

and areas of tenderness

Uniform temperature, no masses or tenderness

Normal

4. Assessed respiratory excursion.

InspectionThumb separation at

inspirationThumb separates at inspiration Normal

5. Palpated vocal fremitus.Inspection

Bilateral symmetry of vocal fremitus

Bilateral symmetrric normal

6. Percussed the posterior thorax.

Percussion Resonant sound Resonant sound Normal

7. Auscultated the posterior thorax.

Auscultation No adventitious sound No adventitious sound Normal

ANTERIOR THORAX

1. Inspected breathing patterns.Inspection

Quiet rhythmic and effortless respiration

Quiet and effortless respiration Normal

2. Palpated for temperature, Palpation Uniform temperature, no Uniform temperature, no Normal

tenderness, masses.tenderness and masses

tenderness and masses upon palpation

3. Assessed respiratory excursion.

InspectionThumb separation at

inspirationThumb separates at inspiration Normal

4. Palpated vocal fremitus.

Bilateral symmetry of vocal fremitus

Bilateral and symmetric Normal

5. Percussed the anterior thporax. Percussion Resonant sound Resonant sound Normal

6. Auscultated the trachea.Auscultation

Bronchial/tubular breath sounds

Bronchial/tubular breath sounds

Normal

7. Auscultated the anterior thorax.

Auscultation No adventitious sound No adventitious sound Normal

ASSESSMENT

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

CARDIOVASCULAR

1. Aortic and pulmonic areas. Auscultation No pulsations No pulsations Normal2. Tricuspid area. Auscultation No pulsations No pulsations Normal3. Aspical area.

AuscultationPulsations visible, no lifts or

heavesPulsations visible, no lifts or

heavesNormal

4. Epigastric area. Auscultation Aortic pulsations Aortic pulsations Normal

CAROTID ARTERIES

1. Palpated carotid artery with extreme caution.

Palpation Symmetric pulse volume Symmetric pulse volume Normal

2. Auscultated the carotid arteries.

AuscultationNo sounds heard on

auscultationsNo sounds heard Normal

JUGULAR VEINS

1. Inspected jugular veins. Inspection Veins not visible Veins not distended Normal

UPPER EXTREMITIES

1. Motor strength InspectionEqual strength on each body

sideNot equal strength on each

body side

Normal(decreased muscle strength is normal due

aging)


NURSING 8TH EDITION, KOSIER, ERB &

SNYDER.

2. Muscle tone Palpation Firm, uniform tonicity slug, not uniform tonicity

Normal(decreased muscle tonicity and firmity is

normal due aging)


NURSING 8TH EDITION, KOSIER, ERB &

SNYDER.3. Presence of lesions, deformities, and varicosities

InspectionNo lesions; no deformities; no

tendernessNo lesions; no deformities;

tendernessNormal

LOWER EXTREMITIES

1. Motor strength InspectionEqual strength on each body

sideEqual strength Normal

2. Muscle tone Palpation Firm, uniform tonicity slug, not uniform tonicity

Normal(decreased muscle strength is normal due

aging)



3. Presence of lesions, deformities, and varicosities

InspectionNo lesions; no deformities; no

tendernessNo lesions; no deformities;

tendernessNormal

JOINTS

1. Range of motion Inspection

Varies to some degree in accordance with person’s

genetic makeup and physical activity

Some smooth joint movements, moderate range of

motionNormal

NOTE: ONLY TATAY ERNESTO WAS AVAILABLE WHEN WE CONDUCTED THE PHYSICAL EXAMINATION, 2 OF HIS GRANDCHILDREN

WERE IN SCHOOL, JERIC WHICH IS THE ELDESTS WERE IN THE HIS WORK, FROILAN IS IN SAUDI ARABIA AND FLORENCIA IS NOT AVAILABLE IN THAT TIME BECAUSE OF SO MANY HOUSE HOLD CHORES NEEDED TO BE FINISHED.

FAMILY NURSING CARE PLAN

HEALTH PROBLEM

FAMILIY NURSING PROBLEM

GOAL OF CARE

OBJECTIVE

OF CARE

NURSING

INTERVENTION

METHOD OF

NURSE-FAMILY

CONTACT

RESOURCE S REQUIRED

@ Knowledge deficit related to unfamiliarity with information or resources

@ Lack of specific information necessary for patient and S.O to make informed choices regarding of what condition, therapies or treatment.

@ After nursing intervention the family will be able to understand the importance of medical intervention rather than the used of wrong folk remedies.

@After 1 hour of nursing intervention the family:

a. Will participate in learning process.

b. Will verbalized understanding of condition, disease process or treatment.

a. Discuss the importance of receiving right medical intervention in a particular health problem.

b. Discuss the consequences or practicing wrong folk remedies.

c. Discuss some nursing intervention which is applicable in

a. Home visit

b. Health teaching

Material resources:

a. Visual aid

b. Maglaya and Cuevas books

Human resources:

a. Participation of every family member.

b. Time & effort of health care provider.

c. And will initiate necessary lifestyle changes.

their everyday life.

Financial resources:

a. Teaching aid

b. Transportation fees

FIRST LEVEL ASSESSMENT

Cues/Data Family Nursing Problem

FIRST LEVEL ASSESSMENT

The hazardous place for the client is the stairs because they are at risk for fall.

“Malakas kaming magkape lalo na si Tatay halos nakaka-anim na beses sya isang araw” as verbalized by the client.

The house of the client is near the highway wherein a lot of vehicles are passing day by day and it cause air and noise pollution that may cause psychological stress.

I. Presence of Health Treats

A. Accident Hazard

Stairs

B. Faulty and Unhealthy Nutrition

Excessive intake of coffee

C. Poor environmental condition

Air and noise pollution

“Si tatay malakas manigarilyo siguro nakaka dalawang pakete sya sa isang araw.” as verbalized by the client.

“Wala lagi lang si tatay nakaupo dyan sa me labas, minsan nakikipagkuwentohan” as verbalized by the client.

“Marunong akong mag-alis ng katarata, lalagyan ko lang ng tubig na may asin tapos, lilinaw na yung paningin ko, kaya lang mahapdi nga lang” as verbalized by the client.

D. Unhealthful lifestyle and Personal Habits

Excessive consumption of cigarettes

Lack of exercise

“Eh, nung araw hindi pa naman uso ung mga bakuna na yan eh. Pero kumpleto naman ng bakuna ung mga anak ko.” as verbalized by the client.

“Eh, parang napansin ko lang habang tumatagal parang lumalabo ung mata ko, pero nakakabasa pa din naman ako.” as verbalized by the client.

Self medication

E. Inadequate immunization

II. Presence of Health Deficits

Sometimes feeling of loneliness.

“ Kasi si Tatay madalas nagse-self medicate lang.” as verbalized by the client.

The family have different point of views regarding medical care for

Lolo he uses the traditional way of medication.

Aging

III. Presence of stress points/ foreseeable crisis situation

Death of the member

SECOND LEVEL ASSESSMENT

I. Inability to make decisions with respect to taking appropriate health actions due to:

A. Conflicting opinions among family members or significant

“Hindi naman kami kumukunsulta sa center pagdating sa mga check-up check-up eh, umiinom na lang kami ng gamot.” as verbalized by the client.

“Bihira kaming kumunsulta sa doctor, kasi nga magastos pa. ” as verbalized by the client.

others regarding action to take.

II. Failure to utilize community resources

A. Failure to perceived the benefits of health care

B. Unavailability of required care/ service

HOW COULD IT BE, THAT YOU WERE ABLE TO FORMULATE THE FNCP, WITHOUT DOING THE PROBLEM IDENTIFICATION, THEN THE TYPOLOGY AND PRIORITIZAION?

Documents

INITIAL DATA BASE