INITIAL DATA BASE FOR FAMILY NURSING PRACTICE A.

Family Structure, Characteristics, and Dynamics Member of the household Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon Member of the household Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon Relationship to the head of the family Father/ husband wife Son daughter age 45 44 19 18 sex Male Female Male Female Civil status Married Married Single Single Position in the family Father/husband Mother/wife Eldest child/son/brother Youngest child/daughter/sister General family relationship or dynamics Short temper/ easily irritated Good listener Joker Easily irritated

Place of residence of each member of the family Living independently Living independently Living with parents Living with parents

Type of family structure Patriarchal/n uclear Patriarchal/n uclear Patriarchal/n uclear Patriarchal/n uclear

Dominant family members in terms of decision making

B. Socio-economic and Cultural Characteristics Member of Income and expenses the occupation Place of Income of each Adequacy to Who makes household work working meet basic decisions member necessities about money Leland N. Production Bulacan P15,000.00/mo Adequate de Leon manager Marciana S. Landlady Manila P4,000.00/mo Adequate de Leon Mark BTM PUP Leland S. de student Leon Elaine S. de BSN student UERMMMC Leon

C. Home and Environment The de Leon Familys House is made of concrete and has three bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. Every member of the family has their own bedrooms. Mr. and Mrs. de Leon share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and roaches present in de Leon familys house. Their foods are stored in closed door cabinets and the refrigerator. The de Leons water supply comes from deep well and not from NAWASA. They use water septic tank for their water supply. The water coming from the septic tank is used for washing, cleaning, and bathing and not for drinking purposes. The de Leon family buys distilled water from water refilling stations. The de Leon family has their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by Mrs. de Leon and sometimes the siblings. Their garbage is taken out everyday and collected by garbage trucks everyday. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Mr. de Leon built a poso negro near the laundry area and is been cleaned every once in a while to check for clogs. Their neighborhood is not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility. D. Health Status of Each Member Member of the household Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon Medical and nursing history Nutritional assessment Dietary history 4x a day Rheumatic heart 2x a day disease 4x a day dengue 3x a day Risk factor assessment

Eating habits and practices Meat, fruits Cigarette and and vegetables tobacco smoking Sea foods Meat, fish, obesity fruits and vegetables meat, fruits, stress less vegetables and fish

E. Value, Habits, Practices on Health Promotion, Maintenance and Disease Prevention Member of the Immunization status Healthy lifestyle Practices household of family members Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon Adequacy of : Member of Rest/ the household sleep Exercises/ activities Use of protective measures Relaxation and other stress management activities Rest or watch TV or listen to jazz music Rest and watch TV Rest or eat Rest and watch TV or surf the internet complete complete complete complete Biking everyday Stretching and eating fruits Basketball (occasionally) Badminton, Walking and eating fruits

Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon

9 hours 8 hours 6-8 hours 6 hours

10-20 minutes 5-10 minutes 1 hour 1 hour

Uses jacket Uses slippers in and out the house and umbrella Use pads Use umbrella when raining, and handkerchiefs

FIRST LEVEL ASSESSMENT SMOKING Structured Questions: 1. Why do you smoke? I smoke because it relieves my stress and its already been a habit and a part of my everyday practice.

2. Do you know the consequences of smoking? I know that smoking is dreadful for the health especially for the lungs but smoking has already been a habit for me.

3.

Did you try to stop smoking? I did not try to stop smoking.

STRESS Structured Questions: 1. Why are you always stressed out? There are a lot of things I have to do so I sleep late and have to wake up early to go to school.

2. Do you have enough rest or sleep? No, because now that Im in college. I usually sleep only for about 5 or 6 hours.

3. How do you relieve stress? Whenever I came home from school, I tried to rest for an hour or just lay back and watch TV

RHEUMATIC HEART DISEASE Structured Questions: 1. What do you do to improve your health? I drink my medicine on time and eat right amount of food.

2. Do you have regular check-ups with your doctor? I usually go to heart center on the date that the doctor asked me to come back

3. Do you take in alternative medicines or other herbal medicines you think that will improve you current health? I intake herbal drink and herbal supplements from recommendations from friends and relatives. I also drink multivitamins and vitamin C tablets.

PRIORITIZATION SMOKING Criteria 1. Nature of the Problem 2. Modifiability of the Problem 3. Preventive Potential 4. Salience of the Problem Computation 2/3 x 1 2/2 x 2 Actual Score 0.66 2 Justification It is a health threat that does not demand immediate action Resources are available and interventions are feasible Smoking can be reduced or minimized The family recognizes it as a problem. It does not seem the problem as needing immediate action.

3/3 x 1

1/2 x 1

0.5

TOTAL SCORE

4.16

2. STRESS Criteria 1. Nature of the Problem 2. Modifiability of the Problem 3. Preventive Potential Computation 2/3 x 1 2/2 x 2 Actual Score 0.66 2 Justification It is a health threat that does not demand immediate action Resources are available and interventions are feasible. Stress can be reduced or minimized

3/3 x 1

4. Salience of the Problem

1/2 x 1

0.5

The family recognizes it as a problem but does not required immediate action

TOTAL SCORE 3. RHEUMATIC HEART DISEASE Criteria 1. Nature of the Problem Computation 3/3 x 1

4.16

Actual Score 1

1/2 x 2 2. Modifiability of the Problem 3. Preventive Potential 4. Salience of the Problem TOTAL SCORE THE PRIORITIZED HEALTH PROBLEMS: 3/3 x 1

Justification It is a health deficit that requires immediate attention and adequate management. Current knowledge, interventions and resources are available to solve the problem Disease can be prevented. The family perceives it as a serious problem needing attention.

2/2 x 1

RANK 1 RANK 2 RANK 3

RHEUMATIC HEART DISEASE SMOKING STRESS

5 4.16 4.16

FAMILY NURSING DIAGNOSIS forget HEALTH GOAL OF PROBLEM CARE FAMILY DIAGNOSIS Smoking To improve the 1. inability condition of to the client recognize the presence of the condition or problem due to: attitude/p hilosoph y in life which hinders recogniti on/accept ance of a problem 2. inability to make decisions with respect to taking appropria te health action due to: failure to compreh end the nature, magnitud e and scope of the problem

OBJECTIVES

NURSING INTERVENTI ON

EVALUATI ON

General: To eliminate or minimized smoking habits. Specific: 1. to educate about the cause and effects of smoking. 2. to provide activities that will disregard from smoking. 3. to give appropriate medication and counseling for the client

1. the client will be able to recognize the bad effects of 1. Health smoking. Teaching 2. the patient will be able to eliminate 2. Guide the or family as minimize motivation d al strategy. smoking. 3. discus with the family the cause and effects of smoking and how does it affects ones health

3. Inability to provide adequate nursing care to the sick, disabled, dependen t or vulnerabl e/at-risk member of the family due to: lack of knowled ge about the health condition 4. inability to provide a home environm ent conduciv e to health maintena nce and personal develop ment due to; negative attitude / philosop hy in life which is not conduciv e to health

maintena nce and personal develop ment 5. Failure to utilize communi ty resources for health care due to: lack of inadequat e knowled ge of communi ty resources for health care HEALTH PROBLEM FAMILY DIAGNOSIS Stress 1. inability to recognize the presence of the condition or problem due to: lack of or inadequate knowledge 2. inability to make decisions with respect to taking appropriate health action due to: failure to comprehend the GOAL OF CARE OBJECTIVES EVALUATION

nature/magnitu de of the problem/condit ion 3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/atrisk member of the family due to: 4. inability to provide a home environment conducive to health maintenance and personal development due to; 5. Failure to utilize community resources for health care due to: HEALTH PROBLEM FAMILY DIAGNOSIS Rheumatic Heart Disease 1. inability to recognize the presence of the condition or problem due to: 2. inability to make decisions with respect to taking appropriate health action due GOAL OF OBJECTIV CARE ES NURSING INTERVENTI ON EVALUATION

to: 3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk member of the family due to: 4. inability to provide a home environment conducive to health maintenance and personal development due to; 5. Failure to utilize community resources for health care due to: