FAMILY NURSING CARE PLAN WRITTEN OUTPUT

Introduction

I. Family Initial Database (Use Guide by Maglaya)

II. First and Second Level Assessment

A. Health Strengths
Health Strengths Supporting Cues
1. Potential for enchanced capability for “Madalas po gulay kinakain namin, mostly po mga
health nutrition/lifestyle sayote, ampalaya, at iba pa po, pero medyo ayaw
ko lang po ng saluyot, pero pag yung ibang mga
green leafy vegetables naman nap o madami po
akong nakakain, tsaka mahilig rin po kami sa sili
tas regular naman po yung pagkain naming at
nauubos po naming yung mga naiihanda sa
lamesa, tsaka mag babawas bawas narin po ako ng
rice at maaalat”
2. Readiness for enhanced capability for a
healthy lifestyle “Sige po iiwasan ko na kumain ng noodles na
sunod sunod/almost every kainan, tsaka medyo
mag eexercise na po kami, encourage ko po sila na
wag na kaming masyadong higa higa lang at
lutaytay kundi galaw galaw din kami at mag
increase po kami ng pag inom ng tubig”
3. Potential for enhanced capability for health
maintenance / health management “opo mag papacheck up na po ako sa dentist, tsaka
sabihin ko rin po sa mga kapatid ko na bumisita sa
health center, tsaka opo iinom na po kami ng
madaming tubig at mag eexercise nap o.”
B. Health Problems
Health Problem (First Level Supporting Cues Second Level Assessment (Family
Assessment) Nursing Diagnosis)
A. Health Deficits

1. Pain “Febie Lictao is complaining of Inability to make decisions with

tooth pain and upon assessment respect to taking appropriate
the certain tooth causing pain is healthy actions due to the far
already accumulating plaques’ distances of health care facilities
and already showing signs of
necrosis, also there is minimal Inability to recognize the
bleeding noted. presence of threats of the
2. Cough and Colds “Febie and her cousin Dexter are condition and how important
(Coryza) sniffing in their mucus, and they early treatment is, due to lack of
were also coughing, they also attention given to the condition
admitted that they are feeling
some presence of phlegm in their Inability to make decisions in
chest and neck” respect to taking appropriate
health actions due to
3. Hypertension “Their grandmother nanay misconceptions or erroneous
paulene ramos had a BP of information about proposed
150/90 and she was feeling dizzy courses of action
and weak
Inability to provide adequate
4. Hyperthermia “Nanay paulene Ramos was nursing care to the sick, disabled
warm to touch and upon taking and at risk members of the family
her V/S she had an RR of 26 and due to lack of the necessary
HR: 80, SPo2: 93%, and facilities, equipments and
Temperature of 38.5 degrees supplies for care.
celcius”

B. Health Threats

1.Unhealthy lifestyle and “Febie: Mahilig po kasi ako sa Inability to provide a home
personal habits instant noodles at minsan environment conducive to health
napapadami ko yung kain ko lalo maintenance and personal
nap o ng rice dahil sa sili mahilig development due to lack of
din po kasi ako sa maaanghang, knowledge of importance of
 Kulang din po kami sa tubig at hygiene, sanitation and lack of
hindi po masyado nag eexercise” knowledge of preventive
measures
“Paulene Ramos: nakaka 8 cups
of coffee ako per day” Inability to recognize presence of
the condition (aggravating factor)
2. Lack of Immunization “paulene ramos and Wilda Lictao: due to philosophy in life and
medyo hindi naming na kumpleto habitual actions and dietary
yung mga bakuna naming noon practices which hinders the
at hindi pa naman uso kasi noon recognition of its effect to
yung mga ganyan ganyan.” herself.

3.Poor environmental sanitation, Open drums, pots, cans tires, Failure to utilize community
presence of nesting places for and wooden feeding long bowl resources for health care due to
mosquitoes and improper that are full of water around the failure to recognize its benefits
drainage disposal environment, it is a little bit for each member of the family
messy and there are some and if left untreated its severity
hanged clothes in the inside of and impact to the family
the house but mostly are outside, members.
Febie Stated: “ Opo may
nadengue na ditto dati” Inability to recognize the health
threats of the condition due to
lack of knowledge of how it
develops
C. Foreseeable Crisis
Situation

1.Possible spread of Cough and “Febie and dexter have Cough Inability to recognize the health
colds to younger siblings and Colds, They live at the same threat of the condition due to
house, and they tend to cling and lack of knowledge on how it is
they are close to their younger transmitted
siblings”
2.Aggravate hypertension “High intake of Caffeine can lead Inability to recognize the health
to vasoconstriction and increased threat to one’s self due to lack of
intake of sodium and processed knowledge and information about
foods hence increase the blood the lifestyle, products and things
pressure” that they use or consume in their
3.Potential for Obesity “Febie is a little bit heavy for her daily lives.
height and she admits it, also she
stated that she is a heavy eater
and eat lots of ric, who sits
around all day and has minimal
exercise, and also is not a fan of
water (drinking water)”

III. Prioritization of Health Problems

i. Computations
Problem: pain as a Health Deficit
Criteria Computation Score Justification
1. Nature of the (3/3)X1 1 This factor can alter the
Problem patients comfort and
2. Modifiability of the (½)X2 1 even her immune
Problem system, it could lead to
3. Preventive Potential (3/3)x1 1 fever and can alter the
4. Salience of the (2/2)X1 1 mobility of the patient, it
Problem could also make her
TOTAL SCORE 4 irritable and have other
complications if left
untreated
Problem: Cough and colds as a Health Deficit
Criteria Computation Score Justification
1. Nature of the (3/3)X1 1 This is one factor that
Problem could alter the state of
2. Modifiability of the (½)X2 1 the patient because it is
Problem concerned with her
3. Preventive Potential (3/3)X1 1 airway giving her
4. Salience of the (2/2)X1 1 discomforts and also can
Problem hinder her mobility, and
TOTAL SCORE 4 also lead to infection if
left untreated
Problem: Hypertension as a Health Deficit
Criteria Computation Score Justification
1. Nature of the (3/3)X1 1 She already has
Problem hypertension and she is
2. Modifiability of the (½)X2 1 maintaining it the only
Problem threat here is when it
3. Preventive Potential (2/3)X1 0.67 has fluctuations and
4. Salience of the (2/2)X1 1 when her BP goes up it
Problem could alter her general
TOTAL SCORE 3.67 health status and lead
to several discomforts
such as pain
Problem: Hyperthermia as a Health Deficit
Criteria Computation Score Justification
1. Nature of the (3/3)X1 1 She is already feeling
Problem the fever but it may be
2. Modifiability of the (½)X2 1 caused by other factors
Problem this could also alter the
3. Preventive Potential (2/3)X1 0.67 comfort of the patient
4. Salience of the (2/2)X1 1 but pain would still be
Problem prevalent and this
TOTAL SCORE 3.67 problem has lots of
interventions that could
ease the patient.
Problem: Unhealthy lifestyle and personal habits as a Health Threat
Criteria Computation Score Justification
1. Nature of the (3/3)x1 1 This is one major threat
Problem because today lifestyle
2. Modifiability of the (1/2)x2 1 shapes our life, and if
Problem not corrected lots of
3. Preventive Potential (2/3)x1 0.67 complications would
4. Salience of the (1/2)x1 0.50 arise
Problem
TOTAL SCORE 3.17
Problem: Lack of Immunization as a Health Threat
Criteria Computation Score Justification
1. Nature of the (3/3)x1 1 This is also a factor that
Problem could expose the patient
2. Modifiability of the (1/2)x2 1 to different threats for
Problem not having a fortified
3. Preventive Potential (2/3)x1 0.67 defense but atleast we
4. Salience of the (1/2)x1 0.50 have our natural
Problem antibodies
TOTAL SCORE 3.17
Problem: Poor environmental sanitation, presence of nesting places for mosquitoes and improper drainage disposal
as a Health Threat
Criteria Computation Score Justification
1. Nature of the (3/3)x1 1 This could lead to health
Problem problems specially on
2. Modifiability of the (1/2)x2 1 dengue and on diarrhea
Problem and the place could
3. Preventive Potential (2/3)x1 0.67 culture bacteria wherein
4. Salience of the (1/2)x1 0.50 they would acquire
Problem different types of
TOTAL SCORE 3.17 disease because of the
said cultured bacteria
Problem: Possible spread of Cough and colds to younger siblings as a Foreseeable Crisis
Criteria Computation Score Justification
1. Nature of the (3/3)x1 1 This could hinder the
Problem family because if the
2. Modifiability of the (1/2)x2 1 other members would
Problem get infected it would be
3. Preventive Potential (2/3)x1 0.67 hard to eradicate and it
4. Salience of the (1/2)x1 0.50 would also immobilize
Problem
TOTAL SCORE 3.17 the family so this should
be one of our concerns
Problem: Potential for Obesity as a Foreseeable Crisis
Criteria Computation Score Justification
1. Nature of the (3/3)x1 1 This is still a potentiality
Problem but Febie might get to
2. Modifiability of the (1/2)x2 1 this point if she doesn’t
Problem modify her diet
3. Preventive Potential (2/3)x1 0.67
4. Salience of the (1/2)x1 0.50
Problem
TOTAL SCORE 3.17
Problem: Aggravate hypertension as a Foreseeable Crisis
Criteria Computation Score Justification
1. Nature of the (3/3)x1 1 This could aggravate the
Problem condition of lola ramos
2. Modifiability of the (1/2)x2 1 but this is still a risk so
Problem lola should also modify
3. Preventive Potential (2/3)x1 0.67 her consumptions to
4. Salience of the (1/2)x1 0.50 prevent further
Problem complications
TOTAL SCORE 3.17
1. Problem: Potential for enchanced capability for health nutrition/lifestyle
as a Health Strength
Criteria Computation Score Justification
1. Nature of the (2/3)x1 0.67 This is one of our
Problem greatest on concerns
2. Modifiability of the (1/2)x2 1 but at last priority
Problem because they already
3. Preventive Potential (2/3)x1 0.67 know some part of what
4. Salience of the (1/2)x1 0.50 a health nutrition is
Problem
TOTAL SCORE 2.84
1. Problem: Readiness for enhanced capability for a healthy lifestyle
as a Health Strength
Criteria Computation Score Justification
1. Nature of the (2/3)x1 0.67 This is also one of our
Problem greatest concerns but
2. Modifiability of the (1/2)x2 1 not our most priority
Problem because at least they
3. Preventive Potential (2/3)x1 0.67 already know how to
4. Salience of the (1/2)x1 0.50 manage their lifestyle in
Problem some way but they are
TOTAL SCORE 2.84 still lacking some
Problem: Potential for enhanced capability for health maintenance / health management as a Health
Strength
Criteria Computation Score Justification
1. Nature of the (2/3)x1 0.67 They are able to do
Problem interventions of their
2. Modifiability of the (1/2)x2 1 own In terms of disease
Problem processes but they still
3. Preventive Potential (2/3)x1 0.67 need to learn a lot of
4. Salience of the (1/2)x1 0.50 things and interventions
Problem so we just need to
TOTAL SCORE 2.84 fortify them so I placed
this as last priority
because at least they
already know a lot it just
needs polishing.

ii. List of Prioritized Health Problems

Health Problem Rank Total Score
1. Pain as a Health Deficit 1 st
4pts
2. Cough and Colds as a Health
Deficit 2nd 4pts
3. Hypertension as a Health 3rd
Deficit
3.67pts
4.Hyperthermia as a Health 4th
Deficit 5th 3.67pts
5.Unhealthy lifestyle and 6th
personal habits as a Health
Threat
7th 3.17pts
8th
6. Lack of Immunization as a
Health as a Health Threat
9th 3.17pts

7. Poor environmental sanitation, 10th 3.17pts

presence of nesting places for
mosquitoes and improper
drainage disposal as a Health 11th
Threat

8. Possible spread of Cough and 3.67pts

colds to younger siblings as a
foreseeable crisis 12th

9. Potential for Obesity as a 3.17pts

foreseeable crisis
13th
10. Aggravate hypertension as a 3.17pts
foreseeable crisis

11.Potential for enchanced 2.84pts

capability for health
nutrition/lifestyle as a Health
strength

12. Readiness for enhanced

capability for a healthy lifestyle 2.84pts
as a Health Strength

13. Potential for enhanced

capability for health maintenance 2.84pts
/ health management as a Health
Strength

IV. Family Nursing Care Plan (Top 2 Problems)

A. Health Problem (First Level Assessment): Cough as a Health Deficit

1. Family Nursing Diagnosis/es (Second Level Assessment):

a. Acute pain related to physical agent and inflammatory process

b. Ineffective airway clearance related to presence of secretions in the tracheobronchial tree

2. Supporting Cues

a. Subjective Data:

Pain: “masakit po yung ngipin ko sa lower left na part ng bunganga ko”

Cough and Colds: “opo meron po akong nararamdaman na plema sa leeg at dibdib ko tsaka meron din kaming
ubot sipon ng pinsan kong si dexter”

b. Objective Data:

Pain: Defensive mechanism when pressure is applied to the site of pain, Grimaces when tooth is
touched with tongue depressor, There is presence of plaque, bleeding and a minimal necrosis of the tooth, tooth
appears to be color dark green, gums are inflamed and left cheek is warm to touch. Pricking Pain is felt on the
lower left tooth aggravated by chewing and alleviated by stabilizing the site, intermittent and rated as 7/10.
 Cough and Colds: Coughing and blowing her nose, Productive cough and running nose, secretions
characterized as minimal, viscous and green in color, with clear breath sounds, DOB noted, mouth breather and
with a VS of: RR 25, PR 93, Temp: 36.9, SPo2: 91%.
2. Goal/s:

Pain: after 8 hours of nursing interventions, the patient will be able to experience gradual reduction/relief of pain,
the patient will display improved well being such as baseline levels for pulse Bp respirations and relaxed muscle
tone or body posture, patient will describe satisfactory pain control at a level less than 3 to 4 on a rating scale of 0
to 10

Cough and Colds: After 2-4 hours of nursing intervention the client will demonstrate enhanced breathing pattern,
after 2-4 hours of nursing interventions respiratory status of the patient will become patent as evidenced by not
compromised respiratory rate, moves sputum out of airway and no adventitious breath sounds

4. Objectives
a. Long-term Objectives:

Pain: After 3 days of nursing interventions the client will describe satisfactory pain control at a level less than 1-2
on a pain scale of 0 to 10

Cough and Colds: After 3 days of nursing intervention the client will be able to expectorate retained secretions
and maintain normal breathing pattern and be relieved from any difficulties and irritability and have normal
respirations and other vital signs, even without the supervision of a health care provider,

B. Short-term Objectives:

Pain: After 3 hours of nursing interventions the patient will be able to report that pain is relieved with a pain scale
of 5/10 from 7/10, after 10 minutes of nursing interventions the patient will be able to verbalize understanding of
why is she experiencing pain, after 5 minutes of health teaching s the patient will show signs of interest to have a
check up to her dentist, after 10minutes of health teachings the patient will demonstrate use of relaxation skills
and divisional activities and verbalize methods that provide relief, after 2minutes of health teaching the patient will
perform Deep breathing exercises.

Cough and Colds: after 1 hour of nursing interventions the client will be able to maintain airway patency and
clear breath sounds, after 5minutes of health teaching the client will be able to understand and perform DBE and
coughing exercises to facilitate expectoration of phlegm, after 30 minutes of nursing interventions the client will be
able to verbalize signs of relief from DOB.

5. Nursing Interventions
Interventions Rationale Method of Resources Remarks
Nurse-Family Needed
Interaction
Pain: Pain Activities: Assessment Patient is able
tools and to
Provide To Discussion and confidence acknowledge
comfortmeasures providenonpharmacologic pa health teaching health
such asuse of in management. Health teachings and
incentivespiromet Return teachings able to perform
Demonstration the desired
ry or blow bottles. The human bodyis believed
Correct tasks
Encouragerelative to haveenergy fields Motivate and information
s to perform thatexpress support ideas Family
touchtherapy aberrant patterns when and eradicate members are
bodysystems erroneous cooperative
areinsulted.Therapeutic beliefs and a
Touchis thought torealign teamplayer.
aberrantfields. One on one
Encourage discussion
andassist client to Deep breathing for relaxatio
dodeep n is easyto learn Home visits
breathingexercise andcontributes to painrelief
and/or reduction by reducing Oberservation
s.
muscle tension and anxiety

Encourage To prevent fatigue

adequate rest and
sleep To promote circulation.
Encourage
mobilization of
the left upper Some people deny the
extremity to assist existence of pain
with ROM
exercises Such variables play a bif role
Assess for signs in modifying the patients
and symptoms expression of pain
relating to pain

7.Assess to Cough and Colds:

what degree
cultural To gain clients and relatives
environmental trust
intrapersonal and
intrapsychic
To obtain baseline data
factors may
contribute to pain
To take advantage of gravity
or pain relief
Breath sounds are normally
clear or scattered fine
crackles at bases, which
Cough and Colds clear with deep breathing.
The presence of coarse
Establish Rapport crackles during late
inspiration indicates fluid in
Monitor V/S the airway; wheezing
indicates an airway
obstruction.
Elevate head of
bead A normal respiratory rate for
an adult without dyspnea is
Auscultate breath 12 to 16. With secretions in
sounds the airway, the respiratory
rate will increase.

Have client inhale deeply,

hold breath for several
seconds, and cough two to
three times with mouth open
while tightening the upper
abdominal muscles.
This technique can help
increase sputum clearance
Monitor
and decrease cough spasms
respiratory
(Celli, 1998). Controlled
patterns,
coughing uses the
including rate,
diaphragmatic muscles,
depth, and effort
making the cough more
forceful and effective.

To clear the airway

Help client to
deep breathe and
perform controlled
Maintaining patent airway is
coughing.
always the first priority,
especially in cases like
trauma, acute neurological
decompensation, or cardiac
arrest.
Assist with
clearing
secretions from
pharynx by
offering tissues

Assess airway for

patency.
5. Evaluation
-Patient acknowledged health teachings and she responded to the nursing interventions making her
relieved from DOB, able to facilitate movement of secretions and expectorate them, stabilizing her vital
signs with the latest V/S of BP:100/80 RR:19, HR: 82, Temperature: 36.5, SPo2: 96% her pain rate was
decreased from 7/10 to 4/10 in the pain scale and she acknowledged that she would have a check-up in
the nearest clinic, barangay health center and dentist, she also acknowledged that she would do our health
teachings, cover the open waters, and to do the preventive measures that we have taught.

V. Learning Insights
- There are lots of people who are in need of health teachings and nursing interventions, a lot of
people, especially in the community are in need of our tender loving care, many needs to be
motivated to consult or seek for check-up, and many needs to learn how to counter diseases
prevent them and promote health, they also need to learn what are the simple interventions that
they could do and use to uphold their well-being and health.

- truly It is a beauty to help others we are able to see smiles of relief and we are able to help in
every way we can

- Kapangan truly is one of the wondrous places of the Philippines.