INITIAL DATA BASE FOR FAMILY NURSING PRACTICE A.

Family Structure, Characteristics, and Dynamics Member of the household Relationship to the head of the family Father/ husband wife 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

Leland N. de Leon Marciana S. de Leon Mark Leland S. Son de Leon Elaine S. de daughter Leon Member of the household

Place of residence of each member of the family Leland N. de Living Leon independently Marciana S. de Living Leon independently Mark Leland S. Living with de Leon parents Elaine S. de Living with Leon parents

Type of family structure Patriarchal/ nuclear Patriarchal/ nuclear Patriarchal/ nuclear Patriarchal/ nuclear

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 household work each working member Leland N. de Leon Marciana S. de Leon Mark Leland S. de Leon Elaine S. de Leon Production manager Landlady BTM student BSN student Bulacan Manila PUP UERMMMC

Adequacy to meet basic necessities P15,000.00/mo Adequate P4,000.00/mo Adequate

Who makes decisions about money

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

de Leon Mark Leland S. de Leon Rest/ 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. Maintenance and Disease Prevention Member of the Immunization Healthy lifestyle Practices household status of family members Leland N. de Leon Mark Leland S. de Leon Marciana S. de Leon Marciana S. and handkerchiefs . Practices on Health Promotion. de Leon Elaine S. Value.E. Habits. Walking and eating fruits 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. de Leon Adequacy of : Member of the household Leland N. de Leon Elaine S.

3. because now that I’m in college. 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.FIRST LEVEL ASSESSMENT SMOKING Structured Questions: 1. STRESS Structured Questions: 1. I tried to rest for an hour or just lay back and watch TV . 2. 3. 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. I usually sleep only for about 5 or 6 hours. 2. Did you try to stop smoking? • I did not try to stop smoking. How do you relieve stress? • Whenever I came home from school. Why do you smoke? • I smoke because it relieves my stress and it’s already been a habit and a part of my everyday practice. Do you have enough rest or sleep? • No.

What do you do to improve your health? • I drink my medicine on time and eat right amount of food. 2. I also drink multivitamins and vitamin C tablets.RHEUMATIC HEART DISEASE Structured Questions: 1. . 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. 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.

Salience of the Problem 3/3 x 1 2 1 1/2 x 1 0.66 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. Modifiability of the Problem 3. Preventive Potential 4. Modifiability of the Problem 3.16 2.66 Justification It is a health threat that does not demand immediate action Resources are available and interventions are feasible.PRIORITIZATION SMOKING Criteria 1. Preventive Potential 3/3 x 1 2 1 . 2/2 x 2 2. STRESS Criteria 1.5 TOTAL SCORE 4. Stress can be reduced or minimized 2/2 x 2 2. Nature of the Problem Computation 2/3 x 1 Actual Score 0. Nature of the Problem Computation 2/3 x 1 Actual Score 0. It does not seem the problem as needing immediate action.

The family perceives it as a serious problem needing attention. interventions and resources are available to solve the problem Disease can be prevented.5 The family recognizes it as a problem but does not required immediate action TOTAL SCORE 3.4.16 . 2/2 x 1 1 5 RANK 1 RANK 2 RANK 3 RHEUMATIC HEART DISEASE SMOKING STRESS 5 4.16 4. Salience of the Problem TOTAL SCORE THE PRIORITIZED HEALTH PROBLEMS: 3/3 x 1 2 1 Justification It is a health deficit that requires immediate attention and adequate management. Nature of the Problem Computation 3/3 x 1 4. Current knowledge. Modifiability of the Problem 3. RHEUMATIC HEART DISEASE Criteria 1. Preventive Potential 4. Salience of the Problem 1/2 x 1 0.16 Actual Score 1 1/2 x 2 2.

2. the patient will be able to eliminate 2. 3. magnitud e and scope of OBJECTIVES NURSING INTERVENT ION EVALUATI ON General: To eliminate or minimized smoking habits. Health smoking. inability to make decisions with respect to taking appropri ate health action due to: failure to compreh end the nature. Teaching 2. strategy. the client will be able to recogniz e the bad effects of 1. Guide the or family as minimize motivation d al smoking. to educate about the cause and effects of smoking. discus with the family the cause and effects of smoking and how does it affects one’s health . 3.FAMILY NURSING DIAGNOSIS forget HEALTH GOAL OF PROBLEM CARE FAMILY DIAGNOSIS Smoking To improve the 1. to provide activities that will disregard from smoking. Specific: 1. to give appropriate medication and counseling for the client 1. inability condition of to the client recogniz e the presence of the condition or problem due to: attitude/p hilosoph y in life which hinders recogniti on/accep tance of a problem 2.

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

e to health maintena nce and personal develop ment 5. Failure to utilize communi ty resources for health care due to: lack of inadequa te 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 GOAL OF CARE OBJECTIVES EVALUATION .

5. disabled. dependent or vulnerable/atrisk member of the family due to: 4.appropriate health action due to: failure to comprehend the nature/magnitu de of the problem/condi tion 3. 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 GOAL OF OBJECTIV CARE ES NURSING INTERVENTI ON EVALUATION . Inability to provide adequate nursing care to the sick. inability to provide a home environment conducive to health maintenance and personal development due to.

3. dependent or vulnerable/atrisk member of the family due to: 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: . disabled.2. 4. condition or problem due to: inability to make decisions with respect to taking appropriate health action due to: Inability to provide adequate nursing care to the sick.