Initial Data Base For Family Nursing Practice

A. Family Structure, characteristics, and dynamics Family Name Members Relationship to Age the Head of the Family Sex Status

Address: 168 Brgy Ilaya, Alfonso, Cavite Type of Family structure: Extended / Patriarchal General family Relationships: During weekdays, the grandfather is always left alone at home. He is deaf and mostly blind due to his cataract. B. Socio- economic and cultural characteristics Family Members Name Occupati on Pla ce of wo rk Monthly Income Educational Attainment Ethnicit Relig y ion

Adequacy to meet basic needs: Who makesdecisions about money and how is it spent: Role they play in familys life: Relationship of the family to larger community: C. Home and Environment 1. Housing a. Adequacy of living space b. Sleeping arrangement c. Presence of breeding sites d. Presence of accident hazards e. Food starage and cooking facilities f. Water supply-source,awnership,potability g. Toilet-facility-type,ownership,sanitary condition h. Garbage-refusal disposal-type,sanitary condition i. Drainiage system-type sanitary condition 2. Kind of neighborhood (congested slum?) 3. Social and health facilities available 4. Communication and transportation facilities available D. Health History and Practices of each member of the Family 1. Medical and nursing history indicating current or past significant illnesses or beliefs or practices conducive to health and illness History of past and present illness: Family Health Members History Name Danny Dabatian Hypertension 2. Nutritional assessment Risk Factor Assessment Drinking alcohol

a. Anthropometric data: wt: ht: midarmcircumference: b. Dietary history:quality and quantity intake per day c. Eating habits:food preference 3. Lifestyle: alcohol,smoking, hypertension.. 4. Physical assessment of present illness 5. Lab tests E. Values, habits, practices on health promotion, maintenance and disease prevention 1. Immunization status of family members 2. Healthy lifestyle practices 3. Adequacy of a. rest and sleep b. exercise/activities c. use of protective measures(footwear,bednets,..) 4. use of promotive-preventive health services

First Level of Assessment

Cues/Data

Family Nursing Problems care-giving burden to grandfather 1. Inability to recognize the presence of condition or problem due to: a. Attitude in life which hinders recognition of a problem 2. Inability to make dicisions with respect to taking appropriate health action due to: a. Negative attitude towards the health condition b. Inaccessibility of appropriate resources for care specifically cost constraints 3. Inability to provide adequate nursing care to the disabled family member due to: a. Inadequate family resources for care specifically, 1. Absence of responsible member 2. Financial constraints b. Philosophy in life which negates caring for the disabled

Hypertension, TB, deafness, blindess due to cataract as a health deficit

Scale for Ranking Health Conditions and Problems According to Priorities

1. Stress-provoking factors: care giving burden Criteria Nature of the Problem Modifiability of Problem Preventive Potential Computation 2/3 x 1 the 1/2 x 2 3/3 x 1 Actual Score 2/3 1 1 Justification It is a Health threat that doesnt need immediate action. The familys resources will not reach the goal to increase living space. Increasing living space: - reduces possible transfer of communicable diseases - provides a bigger space to allow enough movement when performing household activities. At present, the family doesnt perceive it as a problem that needs to be changed due to financial problems.

Salience Total

0x1

0 2 2/3

2. Fall hazards due to inappropriate structure of stairs Criteria Nature of the Problem Modifiability Problem of Computation 2/3 x 1 the 1/2 x 2 3/3 x 1 0x1 Actual Score 2/3 1 1 0 2 2/3 Justification It is a Health threat that needs to be fixed due to risk for falls of the pregnant mother. It is partially modifiable. It might not be accomplished since the familys resources are not available. Though the fixing the stairs will ensure the safety of the family, accidents are still possible. The family doesnt recognize this as a problem since they are used to it.

Preventive Potential Salience Total

3. Lack of immunization/ inadequate immunization status especially of children Criteria Nature of the Problem Modifiability Problem of Computation 2/3 x 1 the 2/2 x 2 3/3 x 1 1/2 x 1 Actual Score 2/3 2 1 Justification It is a Health threat that needs to have immediate action. It is easily modifiable since vaccines are available in the health center of the community. The child will have a good body resistance to various diseases if this health problem is met. The mother doesnt recognize that it is a serious problem. Due to lack of interest and time, she doesnt think it needs immediate action.

Preventive Potential Salience

Total

4 1/6

4. Hypertension as health deficit to the father Criteria Computation Actual Score Nature of the Problem 3/3 x 1 1 Modifiability of Problem Preventive Potential Salience the 1/2 x 2 2/3 x 1 2x1 2/3 2

Justification It is a Health deficit that requires medical attention The presence of illness cannot be eradicated but can be controlled. The present illness can be partially prevented by regular blood pressure monitoring and check-ups. This condition can further develop another illness

Total

3 1/3

5. Unsanitary food handling and preparation Criteria Computation Actual Score Nature of the Problem 2/3 x 1 2/3 Modifiability Problem of the 0/2 x 2 1/3 x 1 0x1 0 1/3 0 1

Preventive Potential Salience Total

Justification It is a Health threat that needs to be fixed due to unsanitary food handling and preparation. It is not modifiable because of no available electric outlets and lack of financial resources for proper storage of food There is no appliance such as refrigerator and no available electric outlets The family doesnt recognize this as a problem since they are used to it.

RANKING 1. Lack of Immunization 2. Hypertension 3. Fall hazards 4. Inadequate living space 5. Unsanitary food handling and preparation Second Level of Assessment Family Nursing Care Plan Health Problem / Family Diagnosis Inadequate living space 1. Inability to recognize the presence of problem due to: a. getting used to the present home environ ment related to: - few family resources 2. Inability to provide a home environment conducive to health maintenance and personal development due to: Goal Care of Objectives

Score 4 1/6 3 1/3 2 2/3 2 2/3 1

After the 8 hours of nursing Intervention, the family will be able to: 1.Recognize the existing problem 2.Increase living space by rearranging the things in the room

After 8 hours of nursing intervention , the family will be able to: General: - Increase health maintenanc e of home environmen t.

Intervention Plan Nursing Method Intervent of Family ions contact -Home visit

Resource s required Time and effort of the nurse and the family

Evaluat ion After the nursing interven tions, the client was able to: -agree and realized the importa nce of a clean and adequat e space of living

administer health teaching Specific: regarding -Be advantage educated s of about the having consequenc sufficient es of having living inadequate space living space Encourage -Provide client to tips on how dispose all to have the things

a. Inadequate family resources, specifically: - financial constraints/ limited financial resources

more space inside the house -Provide clean home environmen t

that are needed anymore Encourage client to clean the house at least everyday to minimize accumulat ion of dust; help the mother clean the house

Health Problem / Family Diagnosis Fall Hazards 1. Inability to recognize the presence of problem due to: a. developing of physical tolerance in the activity 2. Inability to provide a home environment conducive to health maintenance and personal development due to: a. failure to see benefits of investments in home environment improvement

Goal of Care After the Nursing Intervention s, the client will be: 1.educated about the prevention potentials of the problem

Objectives

General: To fix/ improve structure of stairs Specific: -give tips on how to fix the stairs within the familys resources

Interventoin Plan Nursing Method Intervent of Family ions contact -Home visit

Resource s required Time and effort of the nurse and the family

Evaluat ion After the nursing interven tions, the client was able to: respond ed not very attentiv ely because they dont see it as a problem

-provide knowledge on importance of improving structures

- find materials that might help on enhancing / constructi ng a better and safe staircase such as using of wood or metal - discuss the possible risks to increase interest on the objective

Health Problem / Family Diagnosis Hypertension 1. Inability to recognize the presence of possible complication due to: a. lack of knowledge

Goal Care

of Objectives

After 8 hours of Nursing Intervention s, the family will be able to:

After 8 hours of nursing intervention , the family will be able to:

Interventoin Plan Nursing Method Intervent of Family ions contact -Home visit

Resource s required Time and effort of the nurse and the family

Evaluat ion After the nursing interven tions, the family was able to: perceive the fathers conditio n and follow appropri ate health actions in addressi ng his conditio n

properly General: manage Be aware 2. Inability to hypertensio of the utilize resources n condition for health care and due to: practice a. Failure to effective perceive health the benefits manageme of health nt care b. Lack of inadequate knowledge of community resources for health care

Specific: Ensure that the father will have regular blood pressure check ups to the local health center -

Administer health teaching , specificall y: a. The signs and symptoms presented by Mr. Dabatian b. The consequen ces of failure to take appropriat e action on the health problem -Discuss with the family about ways on how to maintain and properly manage the health of the father through regular visits to the health center for blood pressure monitoring

Health Problem / Family Diagnosis Lack of immunization 1. Inability to make decisions with respect to taking appropriate health action due to: a. inadequate knowledge of community resources for care 2. Failure to utilize community resources for health care due to: a. fear of consequences of action specifically: - financial consequences

Goal Care

of Objectives

Short term goal: After 8 hours of nursing intervention s, the mother will: show interest and concern on the health of her child and will start having vaccinations Long term goal: Approxim ately after one year, the child will complete all the vaccines

After 8 hours of nursing intervention s, the family will - discuss be: the Expanded General: immunizat Oriented ion with the program resources (EPI) on of the the health community center is free. Also Specific: inform Educated about the with time regards to schedules the of the resources health of their center and health refer her center child on the said program

Intervention Plan Nursing Method Intervent of Family ions contact -Home visit

Resource s required Time and effort of the nurse and the family -referral to the officials of communit y

Evaluat ion After the nursing interven tions, the client was able to: underst and the importa nce of immuniz ation showed gestures of approva l by asking more question s about the said problem