INITIAL DATABASE

www.nursingdepartment.blogspot.com

INITIAL DATA BASE

Our duty in the community started last September 29, 2008 and ended on September 30, 2008. Our clinical instructor in the area, Mrs. oriented us on what will be our assignments and routines in our two days stay. The group was divided by pair and was instructed to choose a client for family assessment. This family will be their chosen subject for study. MQP, a client during that time, who happens to have rashes all over his body, which our instructress identified to be measles, was our subject of study. According to the mother, the child had a fever for three days before those rashes appear. Given a subject, me and my partner formulated plans and designated task to done individually. We ask permission to our client to be able to visit her at home. Upon the approval of our request we set a date of visit. The next day, equipped with the necessary tools, we proceeded in their home for our home visit.

A.
No.

FAMILY STRUCTURE AND DYNAMICS

Name of Sex Birthday (mm/dd/yy) Age Height

family member

1 2

DDP NP

M F

12-07-78 05-11-80

29 y/o 28 y/o

5 10 5 2

MQP

03-13-2008

6 mos.

22 inches

Relationship to family Weight Civil Status Religion Educational Attainment Occupation head

69.41kg 54.98kg

M M

R/C R/C

CG CUG

GRCO Housewife

Head of the family Wife

7kg

R/C

N/A

N/A

Sibling

Familys head DDP is 29 years old, born on December 7, 1978, 510 in height and 153 lbs. in weight. He is a GRCO graduate, presently working in CC in Boni Avenue. His wife NP is 28 years old, born on May 11, 1980, 52 in height and weighs 119 lbs. She was an undergraduate of the course Bachelor of Science in Business Administration. Presently, she was a plain housewife to DDP and a mother to their child. NP was born in the Northern part of Samar while her husband was from the Western part of it. Their three years of marriage was blessed with a healthy baby boy named MQP. He is 61/2 mos.old, 22 inches long and weighs 15.43 lbs. All family members are Roman Catholic. To show their dedication they never fail to go to church every Sunday to give thanks and praise for all the blessings God has given them.

Their family is nuclear in structure. According to them they owned the house but not the land, for it is owned by the government. Common languages spoken were Waray and Tagalog. In times of conflicts and problems they always depend on each other in solving it. For them they can face any kind of hardships and problems as long as they are together.

B. SOCIO-ECONOMIC STATUS

Monthly Income: P10, 000-P15, 000 Weekly Budget: P2, 500

Amount P1500 P500 P250 P250 TOTAL: P2,500

Expenditure Foods( Groceries) Bills: Electricity and water Transportation (Father) Savings

Prioritization of Need

Rank 1 2 3

Priorities Food Bills Transportation

Majority of the familys budget is allocated to their food needs. Second to this is their budget to their billings like electricity and water. Based from the table above you can observe that they give

importance to their savings. This is for the preparation of their childs future. When it comes to their clothing you can observe it has not been indicated above for they seldom spend money in clothing. Financial difficulties of the family are solved by borrowing money from friends and relatives, to be returned after the head of the family received his salary.

C.ENVIRONMENT
Home: Ownership of the House Construction Materials Used Space adequacy Lighting Facility Lighting Adequacy Ventilation Water Supply Drinking Water Food Storage Owned Mixed Adequate Electricity Adequate Adequate Level III (nawasa) Nawasa Covered

Waste Disposal: Garbage Container Method of Disposal Covered Garbage Collection

Toilet Facility Drainage System: Type of Drainage Domestic Animals, Insects, Breeding Sites: Pets/Animals Pests/Insects Way of Eradication

Level II (with poso negro not connected to sewerage) Open Drainage None Rodents, Cockroaches, Mosquitoes, Flies Trapping, Using Insecticides

FLOOR PLAN MEASUREMENT

ROOM SALA

KITCHEN

CR

7 7

10

B.

HEALTH STATUS
GEONOGRAM OF PALIMA FAMILY

RP

LP

ES

YS

Hypertension , Diabetes DD P

None
NP

MQP

PHYSICAL ASSESSMENT
Name of Client: DDP Age: 29 years old MEASUREMENTS

RESULT Height Weight 5 10 153 lbs (69.41kg)

NORMAL VALUES A medium frame man with a height of 510 should have a weight range of 151-163 lbs.

ANALYSIS Normal

VITAL SIGNS Temperature Pulse Rate Respiratory Rate Blood Pressure 36.5 degree celcius 63 20 110/80 36-37 degree celcius 60-100 bpm 16-20 bpm 120/80 Normal Normal Normal Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE ASESSED Skull Scalp Hair

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Symmetry Without flakes Resilient hair

Symmetry Without flakes Resilient hair

Normal

Face Eyebrows Eyelashes Eyelids Lower palpebral (conjunctiva) Sclera Cornea Pupils Iris

Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry

Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry

Normal and healthy

Eye movement Visual fields Visual acuity Ear canal Hearing acuity Internal nares Septum

Coordinated Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry

Coordinated Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry

Normal and healthy

Normal and healthy

Lips Gums Teeth Tongue Frenulum Cheeks, buccal mucosa Palate Uvula

Pinkish Pinkish 32, smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink

Pinkish Pinkish smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Normal and healthy

Tonsils Voice Muscular strength Areola Nipples Abdomen

Pink and smooth Can be heard Equal strength Round or oval Round and equal Unblemished skin, uniform in color

Pink and smooth Can be heard Equal strength Round or oval Round and equal Unblemished skin, uniform in color

Normal and healthy

Normal and healthy

Name of Client: NP Age: 28 years old

MEASUREMENTS RESULT Height Weight 5 2 119 lbs. (54.98 kg) NORMAL VALUES A small frame man with a height of 52 should have a weight range of 115-130 lbs. ANALYSIS Normal

VITAL SIGNS Temperature Pulse Rate Respiratory Rate Blood Pressure 37 degree celcius 70 19 100/80 36-37 degree celcius 60-100 bpm 16-20 bpm 120/80 Normal Normal Normal Normal

HEAD TO TOE ASSESSMENT AREAS TO BE ASESSED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Skull Scalp Hair Face Eyebrows Eyelashes Eyelids Lower palpebral (conjunctiva) Sclera Cornea Pupils Iris

Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry

Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry

Normal

Normal and healthy

Eye movement Visual fields Visual acuity

Coordinated Can see object in peripheral 20/20 vision

Coordinated Can see object in peripheral 20/20 vision

Normal and healthy

Ear canal

Uniform in color

Uniform in color

Hearing acuity Internal nares Septum Lips Gums Teeth Tongue Frenulum Cheeks, buccal mucosa Palate Uvula

Normal voice can respond Symmetry Symmetry Pinkish Pinkish 32, smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink

Normal voice can respond Symmetry Symmetry Pinkish Pinkish smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink

Normal and healthy

Normal and healthy

Tonsils Voice Muscular strength

Pink and smooth Can be heard Equal strength

Pink and smooth Can be heard Equal strength

Normal and healthy

Areola Nipples Abdomen

Round or oval Round and equal Unblemished skin, uniform in color

Round or oval Round and equal Unblemished skin, uniform in color Normal and healthy

Name of Client: MQP Age: 6 mos. old

MEASUREMENTS RESULT Height Weight 22 inches 15.43 lbs (7 kg) NORMAL VALUES An average weight of a 6 months old infant is 16.53 lbs. ANALYSIS Normal

VITAL SIGNS Temperature Pulse Rate Respiratory Rate 37.2 degree celcius 113 bpm 48bpm 37.2 degree celcius 120-140 bpm 30-50 bpm Normal Normal Normal

HEAD TO TOE ASSESSMENT

AREAS TO BE ASESSED Skull Scalp Hair Face Eyebrows Eyelashes Eyelids Lower palpebral (conjunctiva) Sclera Cornea Pupils Iris

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry

Symmetry Without flakes Resilient hair Symmetry Hair equal, intact Intact, with curl Aligned Pinkish White and clear Transparent, shiny Black, equal, round Symmetry

Normal

Normal and healthy

Eye movement

Coordinated

Coordinated

Normal and healthy

Visual fields Visual acuity Ear canal Hearing acuity Internal nares Septum Lips Gums Teeth Tongue Frenulum Cheeks, buccal mucosa Palate Uvula

Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry Pinkish Pinkish 32, smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink

Can see object in peripheral 20/20 vision Uniform in color Normal voice can respond Symmetry Symmetry Pinkish Pinkish smooth, shiny Smooth Smooth Uniform in color Soft and glistering Light pink Normal and healthy Normal and healthy

Tonsils

Pink and smooth

Pink and smooth

Normal and healthy

Voice Muscular strength Areola Nipples Abdomen

Can be heard Equal strength Round or oval Round and equal Unblemished skin, uniform in color

Can be heard Equal strength Round or oval Round and equal Unblemished skin, uniform in color Normal and healthy

ABNORMAL FINDING:

Skin

Smooth and unblemished

Rashes all over the body

Measles is an infection characterized by fever rashes and symptoms referable to upper respiratory tract, the eruption is preceded about 2 days coryza, during which stage grayish peck (Koplik Spots) may be found on the inner surface of the cheeks. A morbilliform rash appears on the 3rd or 4rth day affecting the face, body and extremities. ( Public Health Nursing pp. 267)

Nutritional Status

Name of Family Member DDP NP MQP

Height 5 10 5 2 22 inches

Weight 153lbs 119lbs 15.43 lbs

BMI 22 22 23

Interpretation Normal Normal Normal

All the family members have normal total body mass index because the ratio was 18.5-24.9.

Exercise Pattern Name of Family Member DDP NP MQP Hours of Exercise 30 minutes 30 minutes N/A Times per Week 7 times a week 7 times a week N/A Normal 30 minutes/day 30 minutes/day n/a

The father, DDP was not able to practice it everyday because of work. His wife on the other has a daily routine exercise in a form of dancing. Their child on the other hand was still too young to participate in the activity.

C.Values, Belief and Practices

Just like typical Filipinos they grow up to an environment wherein respect was being emphasized. The kind of environment they want their child to have and grow-up with. They do not want him to be

stubborn or disrespectful in front of people older than him. They want him to believe and have faith in God just like them. For them what they plant to their child is what they will also earn in the future.

II. ORGANIZATIONAL DATA

Cues Subjective: Nilagnat siya ng tatlong araw katawan.

Normal Standards Based on Reference

A healthy child must be free from diseases or illnesses like

bagolumabas yang mga pula-pula niya sa fever cough and colds, rashes and the like.

Subjective: Ang daming ipis dito pag umaga, yung pag binuksan mu yung ilaw, kanya kanyang takbo na sila. Minsan din malangaw at may magnilan-ngilang daga na naghaharutan sa may kisame. A healthy home must be free from rodents and pest, it is clean, well ventilate and free from threats.

Subjective: Nakakatakot lang ditto yung bukas na kanal dyan sa may labas. Lalo kapag umuulan at bumabaha, baka kasi di mapansin malusbot dun A healthy home must be free from rodents and pest, it is clean, well ventilate and free from threats.

III. CLUSTERED DATA

Cues/Data 6 mos old male infant with cough and rashes all over his body. Nilagnat siya ng tatlong araw bagolumabas Family Health Care Plan A. Measles and as a Health Deficit 1. Inability to provide adequate nursing care to the dependent member with measles and cough due to: Lack of knowledge on the nature and management of the

yang mga pula-pula niya sa katawan. Ang daming ipis dito pag umaga, yung pag binuksan mu yung ilaw, kanya kanyang takbo na sila. Minsan din malangaw at may magnilan-ngilang daga na naghaharutan sa may kisame. Nakakatakot lang ditto yung bukas na kanal dyan sa may labas. Lalo kapag umuulan at bumabaha, baka kasi di mapansin malusbot dun

health condition.

B. Presence of Vectors and Rodents as Health Threat 1. Inability to recognize the health threat due to lack of knowledge about the condition. 2. Inability to make decisions with regards to the management of the condition due to the failure on identifying what measures are appropriate. 3. Inability to provide home conducive to health maintenance and personal development due to ignorance in preventive measures.

C.Open Drainage as Health Threat 1. Inability to make decisions with respect to taking appropriate health actions due to lack of knowledge about alternative solutions.

IV. PRIORITIZATION OF THE PROBLEM

1. Measles with cough

CRITERIA Nature of the problem Modifiability of the problem

COMPUTATION 3/3 x 1 2/2 x 1

SCORE 1 1

JUSTIFICATION It is a health deficit that requires immediate intervention. Resources needed are available. With the compliance in the given instructions of

Preventive potential

3/3 x 2

appropriate health providers, disease will be manageable. The family considers this as a problem that needs

Salience

2/2 x 1 TOTAL

1 5

immediate attention.

2. Presence of Vectors and Rodents

CRITERIA Nature of the problem Modifiability of the problem

COMPUTATION 2/3 x 1 x2

SCORE 0.7 1

JUSTIFICATION It is a health threat that needs an immediate attention. The family has the necessary resources but does not utilize them properly.

Preventive potential

2/3 x 1

0.7

The susceptibility in acquiring other infections can be prevented if the problem will be solved. The problem was recognized by the family but they do

Salience TOTAL

1/2 x 1 2.9

0.5

not think it needs an immediate attention.

3. Open Drainage

CRITERIA Nature of the problem Modifiability of the problem

COMPUTATION 2/3 x 1 x2

SCORE 0.7 1

JUSTIFICATION It is a health threat for it could damage the health of the family. It is partially modifiable for the family alone cant solve the issue, referral to higher officials were still needed.

Preventive potential

2/3 x 1

0.7 Solving the problem lessen the risk of the family on acquiring infections brought about by an unpleasant environment

Salience

1/2 x 1

0.5 The family recognizes the problem but does not think it needs an immediate action.

TOTAL

2.9

PROBLEM PRIORITIZATION

Family Problems According to Priority

Measles and cough

Presence of Rodents and Vectors

2.9

Open Drainage

2.9

V.

FAMILY HEALTH CARE PLAN

INTERVENTION PLAN

HEALTH

FAMILY

GOAL OF

OBJECTIVES OF

Measles and cough

Inability to manage the condition due to the lack of knowledge regarding its manageme nt.

After nursing intervention, the family must be equipped with the necessary knowledge they need in dealing with the situation.

After nursing intervention, the family: -will be able identify the cause and effect of the disease. -Know the appropriate intervention to make.

1. Establish rapport. 2. Prepare the necessary equipments needed. 3. Inform the family about the visit. 4. Health education about the diseases and its management.

Home Visit

Material Resources: Visual Aids on Measles and cough. Human Resources: Time and effort of both the researchers and the family. Financial Resources: Money for the researchers transportation and food (if necessary).

FAMILY HEALTHCARE TEACHING PLAN

NURSING INTERVENTION METHOD OF RESARCHER-FAMILY CONTACT RESOURCES REQUIRED

1. Analyze with the family the problems measles and cough. 2. Discuss with the family the appropriate courses of action. 3. Enumerate to the family the danger signs they need to watch out for namely: inability of the infant to drink or breastfeed vomits everything convulsions

Home Visit

Material Resources: Visual Aids on Measles a cough. Human Resources: Time and effort of both the researchers and the family. Financial Resources: Money for the researchers transportation and food (if necessary).

abnormally sleepy or
difficulty to awaken

What to teach
What is measles? Measles is one of the most contagious viral diseases. It is caused by paramyxo virus and is the most unpleasant and the most dangerous of the children's diseases that result in a rash. This is due to the complications of the disease. How is measles transmitted?

Droplets transfer the infections. Although the sick person may be in isolation, the disease may still spread from room to room. Anybody who has not already had measles can be infected. Infants up to four months of age will not be infected if their mother has had measles herself because they will be protected by her antibodies. The incubation period - the time between infection and the outbreak of the condition - is usually one to two weeks. Patients are infectious from four days before the onset of the rash until five days after it appears.

What are the symptoms of measles? After about 14 days the following symptoms start showing:

A fever at about 39C. A cold. Coughing, possibly with a barking cough. Sore throat - the lymph nodes in the throat may swell. Reddish eyes. Sensitivity to light. Grayish spots, the size of grains of sand may appear in the mucous membrane of the mouth just around the molar teeth. These are called Koplik's spots and can be seen before the rash appears. After three to four days the temperature may fall, although it can run high again when the rash appears. The rash usually begins around the ears and spreads to the body and the legs within a day or two.

At first the spots are very small - a couple of millimeters - but they double in size quickly and begin to join together. The spots are a clear red color. The temperature, which may run as high as 40C, may stay that high for a couple of days. Then it disappears together with the rash, which may leave some brown spots. After a week the child will be fit again.

How are measles treated? The treatment is to stay in bed in a cool room without any bright lights. Medicines for coughing and reducing the temperature should only be given after consulting a GP.

www.nursingdepartment.blogspot.com