WISH KO LANG -Johnerz07-08 Case Presentation

8/14/2019 *WISH KO LANG* -Johnerz07-08 Case Presentation

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By:

BSN IIC – GROUP II





OBJECTIVES

General Objectives:

Generally, we aim to know the family’s Physical, Social,Emotional, Mental, and Spiritual needs as well as theirhealth problems and be able to help them.

Specific Objectives:

1. Gain trust and develop rapport on each of the familymembers.2. Establish a good and therapeutic relationship with the family.3. Gather information about their family and health background

and their present health status in order for us to know whattheir needs are.

4. Identify the different health problems present in the familysuch as disease and illness and able to categorize them ashealth threats, health deficits or foreseeable crises.

5. Formulate a diagnosis of the problem.6. Plan for an appropriate nursing care and establish our goals

and priorities.

7. Implement these plans to the family.8. Evaluate if the goals are met, partially met or not at all.



FAMILY

HEALTHASSESSMENT



Francisco

Lilibeth

Joan Jomarie Jona

HISTORY





CurrentlyAlex

Lilibeth

Alexander

AlexisAllen

Foreman

Past work of ALEX





VICINITY MAP





In making this Medical History of the Family, weconnect all the data that the family shared with us,specifically the Medical Records. These MedicalRecords was issued to them by different HealthAgencies where they had been confined and the

prescription of the doctors that was been prescribedto them. First is the General Data of Mr. AlexMiguello, a 40 years old male, married, a righthanded, Filipino, from crossing Mendez, TagaytayCity, admitted for the first time in POC on December, 2005. With a chief complaint of inability to move

BLE. History of patient illness is Nine hours PTA,patient fell from a rooftop of a building wit a heightof approximately twenty-feet. Patient fell back firstand landed on both his shoulders but denies hittinghis head. Patient immediately lost consciousness andwas carried by several of his co-workers inside theirbarracks without spinal support. An ambulance wascalled and the patient was then brought to “Ospital

”

MEDICAL HISTORY



It is at this time that the patient hadregained unconsciousness and

immediately complained of severe painon both his upper extremities. He alsonoted that his upper extremities wereweak and that was enabled to moveboth his lower extremities. On the saidHospital, several X-rays was done andpatient was assessed to have a spinal

cord injury but due to lack of facilitieshe was transferred to PhilippineOrthopedic Center for furtherevaluation and management. Hence,

the admission in general the patient



On the other hand, Nang Lilibeth was

also confined due to bleeding. Thefollowing is the findings and/ordiagnosis of the doctor: SpontaneousAbortion G8 P6 and B.W=450 gms.

Nang Lilibeth ad been examined andtreated/ confined in Roxas MemorialProvincial Hospital last February 8,

2007. According to her, the factorsthat caused her bleeding is overfatigue and the time when she foundan enemy near their neighbor

because of gossips.



Lastly, Alexander, the youngest son

of the couple that was born withinborn “Hernia”. The couples broughtthe child to different doctors toexamine the condition of their child.

All the doctors that they haveconfronted, has the same diagnosis,that the child has an “Hernia” the

doctors suggest that the child mustundergo surgery but due to lack of financial capabilities they can’t havethe child operated.



GENOGRAMJoseBelario

CatalinaCrespo

Francisco

Roberto

Grelinda

Mepthali

Dionisio

Carmelita

RodrigueBaguyo

Vilma

Eden

Lilibeth

Elizabeth

Anabel

Alma Juni

Jona Jomarie Joan

P

SST



NarcisoMiguello

FloraCorros

Alex

Cesar

Yoland

a

Danilo Aroeni

o

E

lena

Rarrio

Narci

so

Roqu

e

Glori

a

Elizabeth

Anabel

Alma Juni

Lilibeth

Alexander

Allen

Alexis

RodrigueBaguyo

Vilma

P P R R E E

S S E E N N T T



ATTACHMENT



ECOMAP



HOME & ENVIRONMENT



List of Health Problems Nature of Problem•

Family Size What Family Resources Can Adequately Provide• Faulty/Unhealthful Nutritional/Eating Habits or Feeding Techniques

Practices (food intake both in quality and quantity and faulty eating

habits)

• Financial Constraints

• Paralysis After Work Accident

• Hernia (Inguinal)

• Accident Hazards ( pointed/sharp objects and muddy area)

• Poor Home/Environmental Condition/Sanitation (inadequate living

space, presence of breeding or resting sites of vectors of diseases,

improper garbage/refuse disposal and improper drainage system)

• Unhealthful Lifestyle and Personal Habits/Practices ( poor personal

hygiene and lack of/inadequate relaxation activities)

• Stress Provoking Factors (care-giving burden)

Health Threat

Health Threat

Foreseeable Crisis

Health Deficit

Health Deficit

Health Threat

Health Threat

Health Threat

Health Threat

FAMILY HEALTHPROBLEM



Health Problem Ranking

1. Family size what family resources can adequately provide2. Faulty/Unhealthful Nutritional/Eating Habits or Feeding

Techniques Practices (food intake both in quality andquantity and faulty eating habits)

3. Financial Constraints4. Paralysis after work accident5. Hernia (Inguinal)6. Accident Hazards (pointed/sharp objects and muddy area)

7. Poor home/environmental condition/sanitation

(inadequate living space, presence of breeding or restingsites of vectors of diseases, improper garbage/refusedisposal and improper drainage system)

8. Unhealthful lifestyle and personal habits/practices (poorpersonal hygiene, lack of/inadequate exercise/physicalactivity and lack of/inadequate relaxation activities)

9. Stress provoking factors (care-giving burden)

4.64.6

4.344

3.63.6

3.6

2.9

FAMILY HEALTH PROBLEMSACCORDING TO RANK



FAMILY

HEALTH IMPLEMENTATION



Before



DuringIn side the house:



In the backyard:

f



After





HERNIA



A l e x a

n d

A l e x a

n d

e r e r



PARALYSIS



Documents

*WISH KO LANG* -Johnerz07-08 Case Presentation

WISH KO LANG -Johnerz07-08 Case Presentation