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FAMILY CASE STUDY

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IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

IN CHN ± RLE 101

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SUBMITTTED TO:

Mr. Donn N. Cariaga,St.N

PRACTICING CLINICAL INSTRUCTOR

Mrs. Bevan B. Balbuena,RN,MN

CLINICAL INSTRUCTOR

SUBMITTED BY:

Jhonna Lyn N. Gallardo,St.N

Roxy Mae A. Melgar,St.N

Roselle Carmi L Lego,St.N

Phil Anthony P. Jimena,St.N

Winston B. Credo,St.N

BSN ± 2K

OCTOBER 13, 2009

CRITERIA

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CONTENTS

Ñ Introduction and objectives 5%

Ñ Family developmental task by Duvall 10%

INITIAL DATA BASE 15%

FAMILY COPING INDEX 10%

FAMILY ECOMAP 5%

PRENATAL ASSESSMENT 10%

PROIRITIZING OF PROBLEMS 10%

FAMILY NURSING CARE PLAN 30%

IMPLICATIONS 5%

PROMPTNESS 5%

NEATNESS 5%

FORMAT 5%

TABLE OF CONTENTS

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CRITERIA

TABLE OF CONTENTS

INTRODUCTION

INITIAL DATA BASE

FAMILY COPING INDEX

FAMILY ECOMAP

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 A case study illustrates how a nurse selects a client for health supervision based
on the clinic appointment registry. It also shows how she prepares for a family follow-up.
Note that assessment questions are clearly specified based on review of record done
before a home visit is made is made. This preparation facility the assessment interview
with the family and makes the home visit an efficient method of nurse-family contact.

Community health nursing ³! !  


  ! 
 It¶s uniqueness
lies in its emphasis on the health of the population as a whole. Community health
nurses address both the personal and the environmental aspects of health and deal
with community factors which either inhibit or facilitate healthy living. In community
health nursing nurses enter the environment which people live and practice within that
environment, in sharp contrast with the situation where the client nurse¶s environment in
a hospital or clinic.

Family definitions are changing as the society changes. Defined as a small group

of people who consider themselves to be bound by ties and who accept the

responsibility for bearing children. It is also an open and developing system of

interacting personalities with a structure and process enacted in relationship among the

individual members regulated by resources and stressors, and existing within the larger

community.

On September 24, 2009, the student nurses of BSN ± 2K (group 2) in their first

community rotation assigned at MINIFOREST HEALTH CENTER located in Boulevard,

Davao City. The students were tasked to conduct a home visit to be able to interview

and know better the family whom they chose for their case presentation.

The family belongs to a NON - TRADITIONAL FAMILY specifically the COMMON

LAW which consists of unmarried couple living together; also known in the Phiilippines

as ³
!

 As the student nurses conducted their home visit, the family seemed to be very

hospitable and cooperative. The family¶s willingness to be provided nursing care made

them to decide to have them as client of their case study.

 
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At the end of 5 weeks duty of Community Health Nursing especially in Mini

Forest Health Center, the student nurses will be able to research on their client¶s

current and possible health problems, threats and deficits with its respective causative

factors that leads to the deterioration of the family¶s health condition to be able to

provide appropriate actions for the family¶s betterment through obtaining data, training

the root of current and possible observable disease/s and eventually implement nursing

care.

V || | V

At the end of this case study, the student nurses should be able to:

ù Choose a family with newborn or a pregnant woman to render

nursing care and be the subject of the case study;

ù Establish rapport with the family to have a good working


relationship;
ù obtain demographic data and other pertinent information about the
client as well as the family to support the case study;
ù State why the family was chosen by the group and how can they be
an attractive and proponent of the study;
ù Make a comprehensive case study content that contains the
introduction, objectives (general & specific) and present the initial
data base of the client;
ù present the client¶s Family Developmental Task based on Evelyn
Duvall¶s theory family development
ù trace the client¶s genogram, family diseases and health conditions
in a diagram format with a corresponding legend
ù Come up with a family coping index through religious assessment
of the family from the first meeting up to the last meeting of their
home visit;
ù illustrate the family eco map
ù present the Prenatal/Newborn Assessment of one of the members
of the chosen family
ù present the Prenatal/Newborn Assessment of one of the members
of the family
ù list down 10 problems noted in the family;
ù prioritize problems based on the Scale for Ranking Health
Conditions and Problems According to Priorities;
ù select the Top 5 problems in the family;
ù formulate 5 Family Nursing Care Plans for the family;

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> objective and subjective cues that give hints about the
client¶s problem;
> the category of the health and family nursing problem;
> general goal of care;
> specific objectives of care;
> nursing interventions implemented geared towards the
solution of the specified problem;
> method of nurse-family contacts;
> resources needed for the implementation of nursing
interventions;
> evaluation of the impact of the nursing care and
management given towards the family;
ù Provide implications which would be a summary of how is this case
study would be of a great contribution for nursing practice and
research;




 

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Ms. Cathy Beth resides in Davao City since birth while Mr. Jefrey was at

Padada, Davao del Sur. When both couple lives together, the family is living at

Governor Salis, Purok-4, Barangay 28-C, Davao City for 1 year. There are only 2

members of the family since they are only starting to build one. Both of them were raise

as Pentecostal religion. The tribe of the husband was Ilonggo while the wife was a pure

Visayan.

Mr. Jeffrey Casiple, the head of the family, a college graduate of BSMT in Holy

Cross of Davao and working as a dicer at PROCTER AND GAMBLE in Bolton, Davao

City to support his family. While Ms. Cathy Beth Parolinog, the wife, a 3rd year college

student at Holy Cross of Davao and a plain housewife who focuses in family issues and

in her pregnancy.

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1.Observable conflicts None As the student nurses have visited the family
between family members they have not observed from them any conflicts
within the family.
2.Characteristics of informal The family calls each other ³babes´. They
communication served are open with each other as what have
also said to us by the wife
3.Interaction patterns informal They have time with each other they make
among the members sure that they are going to the Church every
Sunday.


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Casiple Family is an extended in terms of its family structure. They are living together

with other relatives on one roof but independent by each other like in budget. Upon

visiting to the family, student nurses have not observed any conflicts within the couple.

And the characteristics of their communication are informal where they call each other

³babes´. They are open to each other in terms of problems and other personal matters

as stated by the wife. The interaction of the family was also informal for as the wife had

also stated to that they make sure that they have time with each other especially during

Sunday which is the day off of the husband. Sunday is the day were the family go to

Church to attend mass.

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V rice and fried fish noodles *sinigang´

  rice, egg and ³Sinabawang gulay´ barbeque

noodles

|  rice, sardines sardines #+(

 As shown in the table, the diet of the family is consists of foods with
preservatives, cholesterol, carbohydrates and nutrients. Family usually eats foods with
preservatives such as canned goods and noodles where they buy at the store near their
house and serve it usually during their breakfast and lunch which may compromise
nutritional adequacy and lead to lack of variations in their diet.

They seldom eat foods like vegetables and fruits which gives nutrients for growth
and development of the family especially to Ms. Cathy who is pregnant to help and her
baby to be healthy.

Sleeping Pattern

The couple¶s regular hours of retiring is 11:00 pm. And their regular hour for

getting up is at 6:30 am which we find as an unhealthy lifestyle and as a health threat

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especially to Ms. Cathy Beth Parolinog who is pregnant. The retiring and getting up

does not depend on the whims of each other.

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Mr. Casiple earns š265.00 per day wherein he is the dicer at PROCTER AND
GAMBLE located in Bolton, Davao City. While Ms. Parolinog, a plain housewife who
receives š1,000.00 per month that was given by her aunt. The total estimated income if
the family is 9,500 pesos a month.

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The house and lot is owned by Parolinog family that is why Mr. Jeffrey Casiple
and Ms. Cathy Beth Parolinog are allowed to live together with their relatives but
provided with different budget and housing needs.
They are just occupying small room in the house where they live. The house was
made of combined cement and wood materials which may result to fire hazard. Some
area in the house may also result of accident such as fall hazard like extra woods
hanging up the stairs. The family¶s residence is situated inside which other houses are
at the back situated next to them.

They cook their food using gas stove beside the kitchen sink . The family doesn¶t
share eating utensils with each other. There is a common comfort room used for
washing clothes, taking a bath, and peeing or defecating. The waste disposal is a flush
type with a closed drainage system. The drinking water is stored in the refrigerator put
in plastic pitchers and bottles. While food storage facility like their mini cabinet where
they foods is put and covered.

The source of water is /,!&$'$% and their electricity¶s source is


/, 0# -. ,1&$ ,2-. They complain often about mosquitoes at night,
and reports of flies as common household pests. Their garbage is not being segregated
and only placed in big cellophane found at the kitchen; this may be a factor that
contributes to the presence of vectors and pests in their house. One factor also was the
improper drainage system. The student nurses have also observed an open canal on
side of their house with obstructions like garbages which may result to presence of
breeding sites of vectors of diseases.

The student nurses also observed that there were appliances like the TV set with
DVD player, sound system component, refrigerator and computer which owned by her
grandmother.

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1. Cough Medicines None none
2. Colds medicines none none
3. Fever medicines none none


 As observed in the table, the family encountered most of the common illnesses
which are cough, colds, and fever. These are common in the community which is easily
acquired in having an unusual climate change and unhealthy environment like the
presence of uncovered and obstructions of garbage at the canal. As reported by Ms.
Cathy they usually experience these for couple of weeks. They usually visit the clinic
near their house to have a consultation on what medicines they will take because that
could harm her and the baby.

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The family is aware of the existing organizations in the community and was able
to name those organizations, namely; Barangay Day and Senior Citizen. The family
does not engage their selves to those organizations, but then, they are aware of the
activities conducted by the said organizations.

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As the student nurses interviewed Ms. Cathy Beth Parolinog, she reported that

they have good relationship with their neighbors. And added, that some of them are

fond of gossiping.

She said that the only health facility available in the community is the Health

Center. They use bicycle, motorcycle, and jeep as their way of transportation.

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 $ Ms. Cathy Beth Parolinog 
$ Mr. Jefrey Casiple
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Ms. Cathy Beth Parolinog and Mr.Jeffrey Casiple were not married.

Jeffrey works as a dicer and regularly goes to work except Sunday. But since Mr. Jefrey

does not have work during Sunday, both of them go to Church together with their

relatives. After attending mass, Mr. Jefrey usually go to the basketball court near to their

house to play basketball together with his friends.

Regularly they go together to their neighbor¶s house to socialize since their

neighbors are also their relatives. During salary days, both of them usually go to mall to

shop for those things they will need most especially their basic needs like food or in

DCLA at uyanguren to buy clothes. When both of them want to have a vacation, they

usually decide to go to Padada where Mr. Jefrey lived before, to visit his relatives and

his family.

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The name of our client is Cathy Beth, a 21 year-old pregnant woman living in
634- 1 Governor Salis, Prk. 4, Brgy. 28- C. She has a weight of 44 kilograms and with a
height of 4 feet and 9.5 inches. She is already 4 months pregnant. In terms of her
pregnancy status her last menstrual period was May 30, 2009. The estimated date of
her confinement is on March 9, 2010. Upon assessment, it revealed that she had
normal vital signs with a blood pressure of 80/70 mmHg, this is normal based on his
previous Bp result. Ms. Cathy has a cardiac rate of 89 beats per minute, pulse rate of 89
beats per minute, respiratory rate of 19 cycles per minute. The age of gestation is 16
weeks and 8 days.

Neurologic System

Neurologic complications and findings were present in our client. She did
experience headache, blurring of vision, and syncope.

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There is manifestation of anemia in our client. She has no varicosities and is


negative for edema. Cardiac rate is found to be normal within a range of 89-91 bpm, her
blood pressure is also normal having results of 80/70 mmHg. The fetal heart rate of her
child could not yet be appreciated.

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Our client verbalized that she does not experienced shortness of breathing after
doing certain activities like household chores. When not doing any strenuous work, she
is not experiencing respiratory distress. Upon assessment, presence of colds is noted.

Gastrointestinal System

As far as her appetite and food consumption are concerned, she is having loss of
appetite. She is able to eat 2 to 3 full meals a day and is eating a variety of food each
day but it depends on her budget. Upon assessment of the mouth, she has no dental
complications such as swollen gums and halitosis. She is not experiencing constipation
or other gastrointestinal problems.

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As we conducted a urine test, the test revealed a negative result of having


glucose and albumin traces which fortunately indicates that she is not in the risk of
having gestational diabetes and pregnancy induced hypertension.

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Our client does not have any family history of any endocrine complications.

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The client verbalized that she does not have any discharges such as vaginal
secretions, blood, and pus. Her genitals were in uniform color with her skin as she
verbalized.

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Upon assessment of the skin we noted that she has fair, white complexion. Her
extremities however had marks of mosquito bites especially on her legs. On her
abdominal area, the presence of |
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was noted; Striae Gavidarum is not yet
evident.

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The client verbalized that her breasts were tender and were free from masses.
She stated that her nipples were darker in color when compared with the color before
pregnancy. Lesions, redness and dimpling on and of her breasts were not noted as she
verbalized

Skeletal System

Our client has no bone deformities and fractures. She has good posture and gait.
She can move about with a full range of motion although limitations are observed due to
the pregnancy.

Nutritional Status

As in terms with our client¶s diet, she considers rice as the major source of
carbohydrates. It is always part of her meals. She also has fruits and vegetables along
with her meals sometimes especially banana and also eats a variety of food each day.
She drinks milk everyday especially before she sleeps. She doesn¶t prefer meals that
are high in fat and oil. She takes in a lot of water each day and thus she is well
hydrated. Her food intake and selection is according to the capability of her budget.

Lifestyle Habits

Our client has no history of smoking. She is also not an alcoholic. As she got
pregnant, she only walks only when it is necessary like buying items for their food and
other needs in the house every salary day of her husband. She doesn¶t do strenuous
activities because she feels fatigue and shortness of breath.

Post Partum Plans

For our client¶s first baby, she is planning to provide breastfeeding for she knows
the different advantages and benefits of breast milk over formula milk. She also plans to
have her child immunized.

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The vagina is a muscular, hollow tube that extends from the vaginal opening to
the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is
about three to five inches long in a grown woman. The muscular wall allows the vagina
to expand and contract. The muscular walls are lined with mucous membranes, which
keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the
hymen, partially covers the opening of the vagina. The vagina receives sperm during
sexual intercourse from the penis. The sperm that survive the acidic condition of the
vagina continue on through to the fallopian tubes where fertilization may occur.
The vagina is made up of three layers, an inner mucosal layer, a middle
muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae
that stretch and allow penetration to occur. These also help with stimulation of the
penis. The middle layer has glands that secrete acidic mucus (pH of around 4.0.) that
keeps bacterial growth down. The outer muscular layer is especially important with
delivery of a fetus and placenta.
Purposes of the Vagina

h Receives a males erect penis and semen during sexual intercourse.


h Pathway through a woman's body for the baby to take during childbirth.
h Provides the route for the menstrual blood (menses) from the uterus, to leave the
body.

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h May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or
female condom.

The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins
with the top end of the vagina. Where they join together forms an almost 90 degree
curve. It is cylindrical or conical in shape and protrudes through the upper anterior
vaginal wall. Approximately half its length is visible with appropriate medical equipment;
the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri",
or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow
the endometrium to be shed. This stretching is believed to be part of the cramping pain
that many women experience. Evidence for this is given by the fact that some women's
cramps subside or disappear after their first vaginal birth because the cervical opening
has widened. The portion projecting into the vagina is referred to as the portio vaginalis
or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide.
It has a convex, elliptical surface and is divided into anterior and posterior lips. The
ectocervix's opening is called the external os. The size and shape of the external os and
the ectocervix varies widely with age, hormonal state, and whether the woman has had
a vaginal birth. In women who have not had a vaginal birth the external os appears as a
small, circular opening. In women who have had a vaginal birth, the ectocervix appears
bulkier and the external os appears wider, more slit-like and gaping. The passageway
between the external os and the uterine cavity is referred to as the endocervical canal. It
varies widely in length and width, along with the cervix overall. Flattened anterior to
posterior, the endocervical canal measures seven to eight mm at its widest in
reproductive-aged women. The endocervical canal terminates at the internal os which is
the opening of the cervix inside the uterine cavity. During childbirth, contractions of the
uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through.
During orgasm, the cervix convulses and the external os dilates.

The uterus is shaped like an upside-down pear, with a thick lining and muscular
walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or
fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build
up until a fertilized egg is implanted, or it is sloughed off during menses.

The uterus contains some of the strongest muscles in the female body. These
muscles are able to expand and contract to accommodate a growing fetus and then
help push the baby out during labor. These muscles also contract rhythmically during an
orgasm in a wave like action. It is thought that this is to help push or guide the sperm up
the uterus to the fallopian tubes where fertilization may be possible.

The uterus is only about three inches long and two inches wide, but during
pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the

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fundus and is a landmark for many doctors to track the progress of a pregnancy. The
uterine cavity refers to the fundus of the uterus and the body of the uterus.

Helping support the uterus are ligaments that attach from the body of the uterus to
the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the
growing uterus, but retract after childbirth. In some cases after menopause, they may
lose elasticity and uterine prolapse may occur. This can be fixed with surgery.

Some problems of the uterus include uterine fibroids, pelvic pain (including
endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal
menstrual bleeding, and cancer. It is only after all alternative options have been
considered that surgery is recommended in these cases. This surgery is called
hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal
of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy,
many women begin a form of alternate hormone therapy due to the lack of ovaries and
hormone production.

At the upper corners of the uterus are the fallopian tubes. There are two fallopian
tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a
side of the uterus and connects to an ovary. They are positioned between the ligaments
that support the uterus. The fallopian tubes are about four inches long and about as
wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a
sewing needle. At the other end of each fallopian tube is a fringed area that looks like a
funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not
attached. The ovaries alternately release an egg. When an ovary does ovulate, or
release an egg, it is swept into the lumen of the fallopian tube by the frimbriae.

Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down
the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes
four to five days to travel down the length of the fallopian tube. If enough sperm are
ejaculated during sexual intercourse and there is an oocyte in the fallopian tube,
fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue
down to the uterus and implant itself in the uterine wall where it will grow and develop.

If a zygote doesn't move down to the uterus and implants itself in the fallopian
tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to
be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage
and possible death of the mother.

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Mammary glands are the organs that produce milk for the sustenance of a baby.
These exocrine glands are enlarged and modified sweat glands.

The basic components of the mammary gland are the alveoli (hollow cavities, a
few millimetres large) lined with milk-secreting epithelial cells and surrounded by
myoepithelial cells. These alveoli join up to form groups known as lobules, and each
lobule has a lactiferous duct that drains into openings in the nipple. The myoepithelial
cells can contract, similar to muscle cells, and thereby push the milk from the alveoli
through the lactiferous ducts towards the nipple, where it collects in widenings (sinuses)
of the ducts. A suckling baby essentially squeezes the milk out of these sinuses.

The development of mammary glands is controlled by hormones. The mammary


glands exist in both sexes, but they are rudimentary until puberty when - in response to
ovarian hormones they begin to develop in the female. Estrogen promotes formation,
while testosterone inhibits it. At the time of birth, the baby has lactiferous ducts but no
alveoli. Little branching occurs before puberty when ovarian estrogens stimulate
branching differentiation of the ducts into spherical masses of cells that will become
alveoli. True secretory alveoli only develop in pregnancy, where rising levels of estrogen
and progesterone cause further branching and differentiation of the duct cells, together
with an increase in adipose tissue and a richer blood flow.

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Colostrum is secreted in late pregnancy and for the first few days after giving
birth. True milk secretion (lactation) begins a few days later due to a reduction in
circulating progesterone and the presence of the hormone prolactin. The suckling of the
baby causes the release of the hormone oxytocin which stimulates contraction of the
myoepithelial cells.

The cells of mammary glands can easily be induced to grow and multiply by
hormones. If this growth runs out of control, cancer results. Almost all instances of
breast cancer originate in the lobules or ducts of the mammary glands.

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Labor is defined as the sequence of events by which the uterus expels the
products of conception into the vagina and into the outer world. Another definition of
labor is that it is the normal process of coordinated, effective involuntary cervical
effacement and dilatation and descent and delivery of the newborn and placenta. The
term is reserved for pregnancies of more than 20 weeks¶ duration.

A primigravida is a woman pregnant for the first time, while a mulitigravida is a


pregnant woman who had more than one previous pregnancy.

Primary and secondary forces work together to achieve birth of the fetus, the
fetal membranes, and the placenta. The primary force is uterine muscular contractions,
which cause the complete effacement and dilatation of the cervix.

The secondary force is the use of abdominal muscles to push during the second
stage of labor. The pushing adds to the primary force after full dilatation.

Each contraction has three phases: (1) increment, the building up of the
contraction (the longest phase); (2) acme or the peak of contraction; and (3) decrement,
or the letting up of the contraction. The terms frequency, duration, and intensity are
used to describe uterine contractions during labor. $&7+&-% refers to the time
between the beginning of one contraction and the beginning of the next contraction.
+$,- is measured from the beginning of a contraction to the completion of that
same contraction. |-&-' refers o the strength of the contraction during acme.

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The process of labor usually begins between the 38th and 42nd week of gestation,
when the fetus is mature and ready for birth. The exact cause of labor onset is not
clearly understood. However, some important aspects have been identified:
progesterone relaxes smooth muscle tissue, estrogen stimulates uterine muscle
contractions, and connective tissue loosens to permit the softening, thinning, and
eventual opening of the cervix. Currently, researchers are focusing on several promising
areas of research about labor onset.

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Progesterone, produced by the placenta, relaxes uterine smooth muscle by


interfering with the conduction of impulses from one cell to the next. During pregnancy,
progesterone exerts a quieting effect and the uterus generally does not have
coordinated contractions. Toward the end of gestation, biochemical changes decrease
the availability of progesterone to myometrial cells and may be associated with an
antiprogestin that inhibits the relaxant effect but allows other progesterone actions such
as lactogenesis. With the decreased availability of progesterone, estrogen is better able
to stimulate contractions.

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Although the exact relationship between prostaglandin and the onset of labor is
not yet known, the effect is clinically demonstrated by the successful induction of labor
after vaginal application of prostaglandin E. Preterm labor may be stopped by using an
inhibitor of prostaglandin synthesis.

The amnion and deciduas are the focus of research on the source of
prostaglandins. Once prostaglandin is produced, stimuli for its synthesis may include
rising levels of estrogen, decreased availability of progesterone, and increased levels of
oxytocin, platelet-activating factor, and endothelin-I.

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Corticotrin-releasing hormone ha a possible role in labor. It increases during


pregnancy, with a sharp increase at term. Plasma CRH increases prior to preterm labor,
and CRH levels are elevated multiple gestation. CRH is also known to stimulate the
synthesis of prostaglandin F and prostaglandin E by amnion cells.

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In true labor the muscles of the upper uterine segment shorten and exert a
longitudinal pull on the cervix with each contraction, causing effacement. 33%&&-is
the drawing up of the internal os and the cervical canal into the sidewalls of the uterus.
The cervix changes progressively from a long, thick structure to one that is tissue paper
thin. In primigravidas, effacement usually occurs before dilatation.

The uterus elongates with each contraction, decreasing the horizontal diameter.
This elongation causes a straightening of the fetal body, pressing the upper portion
against the fundus and thrusting the presenting part down toward the lower uterine
segment and the cervix. The pressure exerted by the fetus is called the fetal axis
pressure. As the uterus elongates, the longitudinal muscle fibers are pulled upward over
the presenting part. This action and the hydrostatic pressure of the fetal membranes
cause cervical dilation. The cervical os and cervical canal widen from less than 1 cm to
approximately 10 cm, allowing birth of the fetus. When the cervix is completely dilated
and retracted up into the lower uterine segment, it can no longer be palpated. At the
same time, the round ligament pulls the fundus forward, aligning the fetus with the bony
pelvis.

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 The elevator ani muscle and fascia of the pelvic floor draw the rectum and the
vagina upward and forward with each contraction, along the curve of the pelvic floor. As
the fetal head descends the pelvic floor the pressure of the presenting part causes the
perineal structure, which was once 5 cm in thickness, to thin to less than 1 cm. the anus
everts, exposing the interior rectal wall as the fetal head descends forward.

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Before labor, the woman often experiences following signs that can signal the onset of
the labor.

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h It is the descent of the fetal presentation part into the pelvis, occurs
approximately 10-14 days before labor begins

h For the 1st pregnancy, lightening may occur weeks or days before labor begins.
For subsequent pregnancies, it may not happen ahead of time. For some
women, the changes are obvious. Others may not notice a thing.

h Lightening gives the women relief from the diaphragmatic pressure and
shortness of breath she has been experiencing and thus ³lightens´ her load.

h The baby¶s new position may give the woman¶s lungs more room to expand,
making it easier to breathe. On the other side, increased pressure on the bladder
may send her to the bathroom more often.

In lightening, abdominal pressure increases and this may result in reports of


shooting leg pains from the pressure on the sciatic nerve, increased amounts of vaginal
discharge and, urinary frequency from pressure on the bladder.

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This increase in activity is due to an increase in epinephrine release that is


initiated by decrease in progesterone produced by the placenta. This happens
approximately 24-48 hours before labor.

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Braxton Hicks Contractions are uterine contractions occurring prior to the onset
of labor. They are normal and can be demonstrated with fetal monitoring techniques
early in the middle trimester of pregnancy. These innocent contractions can be painful,
regular, and frequent, although they usually are not. Women may be admitted to the
labor unit of a hospital because false contractions so closely simulate true labor.

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The cervix changes from firm and rigid into soft and dilates so it can stretch and
dilate to allow the passage of the fetus. This softening is called ripening.

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Pink-tinged secretions that begins within 24 to 48 hours. These are cervical


secretions that accumulate in the cervical canal to form a barrier called a mucous plug.

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With softening and effacement of the cervix, the mucous plug is often expelled resulting
in a small amount of blood loss from the exposed cervical capillaries.

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Rupture of the amniotic membranes before the onset of labor. After the rupture
the onset of labor begins within 24 hours. If membranes rupture and labor does not
begin spontaneously within 12 to 24 hours, labor may be induced to decrease the risk
for infection.

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Weight loss of 1 to 3 lb due to fluid loss and electrolyte shifts produced by


changes in estrogen and progesterone levels.

Diarrhea, indigestion, or nausea and vomiting just before onset of labor.

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FALSE CONTRACTIONS TRUE CONTRACTIONS

Begin and remain irregular Begin irregularly but become regular and
predictable; regular intervals

Felt first abdominally and remain Felt first in lower back and sweep
confined to the abdomen and groin around to the abdomen in a wave

Often disappear with ambulation and Continue no matter what the woman¶s
sleep level of activity

Do not increase in duration, frequency or Increase in duration, frequency or


intensity intensity

Do not achieve cervical dilatation Achieve cervical dilatation

The beginning of true labor is marked by increasingly frequent, forceful,


prolonged, and finally, regular uterine contractions. Low backache may precede or
accompany the uterine contractions. Each contraction starts with a gradual buildup of
intensity and a similar dissipation follows the peak.

False labor is defined as a period of fairly regular, painful contractions that are
not accompanied by effacement or dilatation of the cervix and that may either stop,
completely or be followed either promptly or ultimately, by the onset of true labor. False
labor is a form of disordered uterine contractions.

 
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h · It is important to document presentation and position because the presentation
of a body part other than the vertex puts the fetus at risk. It implies a proportional
difference between the fetus and pelvis, making a cesarean birth necessary.

h · Four methods are used to determine fetal position, presentation and fetal lie: 1.)
combined abdominal inspection and palpation 2.) Vaginal examination 3.)
Auscultation of fetal heart tones and 4.) sonography

+.&. Attitude describes the degree of flexion the fetus assumes during labor or the
relation of the fetal parts of each other.

h · A fetus is in good attitude if it is the complete flexion: the spinal column is


bowed forward; the head is flexed forward so much that chin touches the
sternum. This presents the smallest anteroposterior diameter of the skull to the
pelvis

h · A fetus is in moderate flexion if the chin is not touching the chest but is in alert
or ³military position. This position causes the next-widest anteroposterior
diameter, the occipital frontal diameter to present to the birth canal.

h · The fetus impartial extension presents the ³brow: of the head to the birth canal.
If a fetus is in poor flexion, the back is arched, the neck is extended, and the
fetus is I complete extension, presenting the occipitomental diameter of the head
to the birth canal. This is an unusual presentation

-00&&-. Engagement refers to the settling of the presenting part of the fetus far
enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis.

h · in primipara, nonengagement of the head a t the beginning of labor indicated a


possible complication s such as an abnormal presentation or positron,
abnormality of the fetal head or cephalopelvic disproportion

h · in multiparas engagement may or may nit be present at the beginning of the


labor

h · a presenting part that is not engaged is said to be ³floating´. One that is


descending but has not yet reached the iliac spines can be said to be ³dipping´.

h · The degree of engagement is assessed by vaginal and cervical examination

V,-. Station refers to the relationship of the presenting part of the fetus to the level
of the ischial spines

h Station refers to the level of the head in the pelvis. When the most dependent
part of the head is at the level of the ischial spines, the station is referred to as
zero. Levels 1, 2, or 3 cm above or below the level of the spines are referred to
as -1, -2, -3 or +1, +2, +3, respectively. Station 0 is generally considered exact
engagement, indication that the biparietal diameter is the level of the inlet.

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&&Lie is the relationship between the long axis of the fetal body and the long axis
of the woman¶s body.

h · 99% of fetuses assume a longitudinal lie. longitudinal lies are further classified
as cephalic and breech.

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Fetal presentation denotes the body part that well first contact he cervix or deliver
first. This is determined by fetal lie an the degree of flexion

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a. it means that the head is the body part that first contacts the cervix

b. it is the most frequent type of presentation occurring as often as 95% of


the time

c. Cephalic presentation occurs


when the head is completely
flexed onto the chest;
smallest diameter presents.
The occiput is the presenting
part. This is determined by
the relation of the fetal occiput
to the mother¶s right side or
left side. This is expressed as OA (occiput directly anterior), LOA (left
occiput anterior), LOP (left occiput posterior), and so on.

d. the four types of cephalic presentations are vertex brow , face and
mentum

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a. it means that either the buttocks or feet are the first body parts to contact
the cervix

b. it occurs approximately 3% of births and are affected by fetal attitude

c. Breech presentation is determined by the position of the infant¶s sacrum in


relation to the mother¶s right or left side. This expressed as SA (sacrum
directly anterior), LSA (left sacrum anterior), LSP (left sacrum posterior),
and so on.

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a. The fetus is lying horizontally in the pelvis so that its long axis is
perpendicular to that of the mother.

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b. The presenting part usually becomes one of the shoulders, an iliac crest, a
hand or an elbow

c. Fewer than 1% of fetuses lie transversely. This may be caused by relaxed


abdominal walls from grand multiparity, allowing the uterus to be
unsupported and fall forward.

d. Transverse presentation occurs when the long axis of the fetal body is
perpendicular to that of the mother. One shoulder will occupy the superior
strait, but it will be considerably to the right or left of the midline.
Transverse presentation is designated by relating the infant¶s inferior
shoulder and back to the mother¶s back or abdominal wall.

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The head id sharply flexed, making


the parietal bones or the space
between the fontanelles the vertex)
Vertex Longitudinal Good (full flexion) the presenting part. This is the most
common presentation and allows
the suboccipitobregmatic diameter
to present to the cervix

Because the head is only


Brow Longitudinal Moderate (military) moderately flexed, the brow or
sinciput becomes the repenting part

The fetus has extended the head to


make the face the presenting part.
From this position, extreme edema
Face Longitudinal Poor and distortion of the face may
occur. The presenting diameter
(occipitomental) is so wide birth
may be impossible.

The fetus has completely


hyperextend the head to present
the chin. The widest diameter
Mentum Longitudinal Very poor
(occipitomental) is presenting. As a
rule, the fetus cannot enter the
pelvis in this presentation

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h it is the relationship f the presenting part to the specific quadrant of the woman¶s
pelvis

h The maternal pelvis is divided into four quadrants according g to the mother¶s
right and left: 1.) right anterior 2.) left anterior 3.) right posterior 4.) left posterior

h Fetal position refers to the relation of the point of direction to one of the 4
quadrants or to the transverse diameter of the maternal pelvis. The point of
direction may lie in either of the 2 posterior quadrants (right or left posterior), in
either of the 2 anterior quadrants (right or left anterior), or in the direct transverse
diameter (right or left transverse). It may also lie either directly to the front of the
pelvis or directly to the back (direct anterior or direct posterior).

h In defining the positions, the following primary abbreviations are used: O for
occiput in the cephalic presentation, M for mentum in the face presentation, Sc
for scapula in transverse presentation, and S for sacrum in breech presentation.

h Position is important because it influences the process and efficiency of labor.


typically, a fetus delivers fastest from an ROA or LOA position. Labor is
considerably extended of the position is posterior (ROP or LOP).



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Lightening Braxton Hicks Contraction Ripening of the cervix


(false labor)
(descent of the fetal head >begin and remain irregular (Goodell¶s Sign wherein the
into the pelvis) >1st felt abdominally cervix feels softer like
>pain disappears with consistency of the earlobe)
ambulation
>do not increase in duration
and intensity
>do not achieve cervical
dilatation

 


Uterine Contractions SHOW Rupture of Membranes
>increase in duration and (pink-tinge of blood, a (rupture of the amniotic
intensity mixture of blood and fluid) sac)
>1st felt at the back &
radiates to the abdomen 

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>pain is not relieved no
matter what the activity
>achieve cervical dilatation

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(due to Large baby)

increase risk for fetal distress


(meconium staining, hypoxia)
I

Increase risk of fetal death

Emergent cesarean delivery


(the incision made on the lower part of the abdomen)

Expulsion of the fetus

Expulsion of the placenta


(accompanied by blood approximately 500-1000 mL)

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V)

Stages of family Stage- critical Achieved Justification


life cycle family or not
developmental achieved
task

Family 1. Providing for Achieved The family provides the children¶s


developmental children¶s activity activity in school if there are affairs
tasks at school- and parents¶ like joining kids scout, and playing
age stage privacy basketball. During this school age
period children are fond of playing
with their peers after their class
session. Parents are letting the child
roam the streets and play in the
alley.

According to Duvall, encouraging


the child¶s growth involves letting
him go. The child is away from
home throughout the school hours,
which often include the lunch period
as well as morning and afternoon
sessions. If he or she is getting
normally involved in sports, clubs,
and friendship groups, the after-
school hours are increasingly given
to these interests, so the youngsters
come home tired and bedraggled
just in time for the evening meal.

2. Keeping Achieved As a family, they focus their


financially solvent financial expenses to their basic
needs like food, clothing and school
expenses of their son. They are
also preparing for the coming of
their new angel. Their monthly
income is just enough for their daily
living.

According to Duvall, the


developmental task of school age is
that they develop practicing of the
use of money. They learn how to
buy wisely the things they want
most and to stay within their
available resources. They learn also
the value of saving for postponed
satisfactions.

3. Furthering Achieved Responsibilities have always behind


socialization of every man¶s back. And as a family,
family members everyone must have a new role in
performing individual tasks as the
level of everyone¶s capacity. They
make sure that whatever needs of

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their child must be well managed
and kept in balance. The child must
be well-groomed and the wife must
be concerned about her husband.

According to Duvall, cooperative


efforts in the family like medical
preparation, cleaning up, dividing
daily responsibilities that would
somehow learned the child and to
be involved in the household with
the parents. In that, the child
develops learning and acquire
willingness and discipline to his
assigned work both in school and
home. Thus, he and his family
continue their socialization
throughout the year.

4. Upgrading Achieved The family has an open


communication in communication to each other
the family especially to their school-age child.
He can share his own feelings of
happiness, sadness, or
embarrassment about his
experience to a first available family
member either his mother or father.
The parents also discuss their own
problem with each other, but the
wife reported having such negative
emotion and she just want to be
alone. According to Duvall, the child
can grow in his ability to cope with
simple frustration. Exploring socially
acceptable ways of releasing
negative emotion effectively. The
child gained his skill in sharing his
feelings with those who can help
him like his parents, teachers,
friends, etc.

Establishing ties Achieved Ties between the family plays a


beyond the great role in maintaining a good
immediate family working relationship among family
members. As a family, they find
time with each other by having fun
and leisure. They find ways on how
to make every moment an
unforgettable one despite of the fact
that they usually do it at home.
Being with an immediate family
keeps them stronger and contented.
According to Duvall, he explained

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that a feeling of closeness among
family and relative are achieved
over a years of gift-giving vacation
sharing and by all means that will
help the members of the family
maintain the contact with each
other. They have a loyalty that bind
them together regardless of what
any member may or may not do.

6. Developing Achieved Parents become especially


morally and concerned about the moral
building family development of their child when
morale they are exposed, as school
children, to wide variations in the
conduct of people outside the
family. They teach their son
character traits over the years and
they will be able to achieve it. The
child has full of respect to his
parents and other members of his
family.

According to Duvall, the morale of


families with school children
appears to be related to how
effectively they are able to cope
with community pressures and to
give clear interpretation of their own
values to their children.

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Narrative Genogram

The Parolinog family has a history of Breast Cancer. And only Filipina Parolinog
has been suffering from this health problem. All Cathy Beth grandparents died except
for her grandmother on the father side. They all died due to old age.

The Casiple family has a history of Hypertension and pulmonary problem


(asthma). The brother of Jefrey is the one who is in agony of acquiring a pulmonary
problem (asthma). And Jefrey¶s mother is the one who has hypertension.


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9 Areas Admission Discharge

Ratin Justification Rating Justification


g

Physical 5 The chosen family is 5 No change in the


well enough to do level of
things and is able to dependence. All
Independence get about as far as of the members
possible within their can still meet their
physical abilities. own personal
They are not strained things to do. They
by any disability in were all able to
doing their household get as far as
chores, caring for possible within
others in times of their physical
sickness and able to abilities. In
meet their own care. accordance to
They are receiving household
resistance when chores, personal
needed without care and care for
interruption to their others.
own effort.

Therapeutic 3 Family carrying out 5 Family able to


Competence some but not all of demonstrate that the
the treatments. Ms. members can carry out
Torcende does not the prescribed
drink any medication procedures safely and
when she is having a efficiently, with the
fever but instead she understanding of the
just drinks plenty of principles involved and
water for therapeutic with confident and
recovery. Live-in willing attitude. They
partner and child were able to know the
may drink medicine purpose of a medicine,
in cases of on why is it important to
hyperthermia but take and are now very
they do not know any confident in taking
specific procedures medications. In cases of
like TSB for recovery. Hyperthermia, they
were able to perform
specific procedures like
TSB for immediate relief
of a sick member.

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Knowledge of 5 Family knows the 5 No changes in this
Health salient facts about area, family still knows
Condition the disease well the rationale of care
enough to take and is still able to report
necessary action at signs and symptoms
proper time as such as dengue rashes.
patient verbalized ³
Gkan man na sa
lamok ang dengue
diba? Mailhan man
kung gidengue kay
maluya na man.
Dalhun na dayon na
sa hospital.´

Application of 3 Our client fails to 3 Even if we explain to


Principles of apply some general them briefly the
Personal principles of personal immediate need for
Hygiene hygiene. They may cleaning their yard and
be able to secure drainage passageways,
initial immunizations, there is still no
but fails to clean their improvement. Still no
yard and drainage change in this area
passageways. They cause they show partial
were able to maintain competence in agreeing
good personal to this situation. There
hygiene like is still imbalanced family
brushing, bathing but nutrition because they
as a whole there are only depend on their
incompleteness of store for canned good.
necessities in Still there is a need for
accordance to complete understanding
personal hygiene to this situation.
such as imbalanced
family nutrition.

Health Care 5 When the family gets 5 No change in this area.


Attitudes seriously ill, they Very Competent in
always confine at the doctors for they know
UM multi test and that medical
diagnostic center to professionals know
have their check-up. what¶s best for their
They have the trust health. They accept
in medical every illness and
professionals to care disease calmly and
for themselves in recognize the limits it
times when they get imposes while doing all
sick or critically ill. possible measures to
They understand and effect recovery and
recognize the need

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for medical care in rehabilitation.
illness and for the
usual preventive
services and follows
recommendations
that the doctor has
given.

Emotional 5 All members of the 5 There were no changes


Competence family are able to in their emotional
maintain a competence. They still
reasonable degree of make decisions
emotional calmness. together and face
The family makes problems calmly and as
decisions together. partners. Vices are still
Can control their minimized or controlled.
vices such as
smoking and alcohol.
They face up to
illness realistically
and hopefully. The
family deals with
problems calmly.
They prefer to talk
about it rather than
fight about it because
they believe that
fighting can never
solve any of their
problems. They were
able to discuss
problems with their
members even they
have differences but
understand the part
of each member.

Family Living 3 The family cannot eat 3 The family still tries their
meals as one. They best to be together.
cannot go to mass They still respect each
together because Mr. other and think for
Hubert is a Baptist every member¶s best
but despite of not possible future. Family
spending enough gets along but has
time for God as a habits or customs that
whole family, they interfere with their
still try to work things effectiveness or
out such as buying coherence as a family
groceries for their such as Mr. Hubert as a
needs together. The Baptist and waking up

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family respects each late in the morning.
other and is
affectionate to one
another such as
caring for a sick
family member and
strongly face
problems as a whole.

Personal 3 Partially competent in 3 They were able to


Environment this area because as improve this area as
by evidence, the evidenced by the partial
house was clean but renovation of their
there were dark house. 2 family
places that may be a members also
place where rodents transferred to another
and other insects address to start on their
thrive. Not only that, own. There is still no
improper garbage proper garbage
disposal is also segregation.
noted. House may be
too small and
crowded for the 7 of
them but adjustments
can be made.

Use of 5 The family was able 5 The family continues to


Community to recognize the consult the center when
Facilities availability of in serious health
community facilities condition. They have
such as centers for the knowledge to go on
their own welfare and government facilities
safety. They use like centers and
facilities they need hospitals for their
appropriately and check- up.
promptly. They know
the things to do,
know who will call for
help. Feels secure
about the community
facilities that our
government provided
to its people. In
addition, confident to
professionals like
teaches, doctors and
others.

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