HANAN A.

ARABANI

NUR-FATIMA M. SANAAANI

CHN-2H

BSN-2H

HEALTH CONDITION AND PROBLEM SHEET

SUPPROTING DATA/CUES HEALTH CONDITION AND NURSING PROBLEM DATE:

PROBLEM IDENTIFIED RESOLVED
(PROBLEM1) HYPERTENSION AS A HEATH Inability To Recognized The November/10/2020 REFERRED TO
SUBJECTIVE CUES: DEFICIT Presence Of Health Problem Due To BNs FOR
“ napapagod na ako , bakit ba kasi : CONTINUTY
suma sakit ang ulo ko”, “dai  Lack Of Inadequate OF CARE
masakit din yung dibdib ko ” As Knowledge
Verbalized By The Client(NUR-  Inability To Make Decision
JAINA, PABUSTAN) With Respect Taking
Appropriate Health Action
OBJECTIVE CUES: Due To :
VITAL SIGNS Taken As -Failure To Comprehensive The
Following: Nature/Magnitude Of The
BP:130/90mmHg Problem
T:36.7 -Lack Of Adequate Knowledge
P:73b/mins As To Alternative Courses Of
RR:23b/mins Action Open To Them

WEIGHT: 69KG
HEIGHT: 5’0

(PROBLEM2) ASTHMA AS HEALTH DEFICIT Inability To Make Decision With

SUBJECTIVE: Respect To Appropriate Health
“Mas lumalala yung Asthma ko pag Action Due To Lack Of Knowledge.
nakakain ako ng mga pagkain na di
pala pwede sa akin” AS Inability To Provide Adequate
VERBALIZED BY THE Nursing Care To The Asthmatic
PATIENT Member Of The Family Related To:
 Inadequate Family Resources
“Hindi ako nakakapag trabaho ng For Care Specially Financial
maayos dahil konting galaw lang Contains
hinihika na ako at madaling
mapagod” AS VERBALIZED BY Failure To Utilize Community
THE PATIENT. Resources For Health Care Related
To:
OBJECTIVE:  Lack Of Trust In The
Slow wheezy breathing and dry Healthcare Personnel Due To
coughing Previous Experience
Family income is 2500-3000 a
month

SCALE RANKING HEALTH CONDITION AND PROBLEM

CRITERIA COMPUTATION ACTUAL JUSTIFIED

SCORE
1. NATURE OF THE 2/3X1 2/3 Inability to make decision with respect to taking
CONDITION OF appropriate health action due to lack of knowledge as to
PROBLEM PRESENTED alternative course of action open to family.
2. MODIFIABILITY OF 1/2X2 1 Problem can be partially modified since client has
THE CONDITION OR knowledge in how to reduce and increase problem by
 PROBLEM manifested utilization.
3. PREVENTIVE 2/3X1 2/3 If the quality and quantities of knowledge is adequate, it
POTETIAL reduce possible increase and chronic symptoms in client
4. SALIENCE 1/2X1 1/2 Family knows that this is a problem but perceives to
have no need to immediate action
TOTAL SCORE: 2.9
CRITERIA COMPITATION ACTUAL SCORE JUSTIFICATION
1. NATURE OF THE 2/3X2 4/3 It is health deficit because there are times that he feels
PROBLEM exhausted due to his work and also he doesn’t have the
ability to recognize his condition due to inadequacy of
knowledge
2. MODIFIABILITY OF 1/2X2 1 The problem is partially modifiable since he chooses to
THE PROBLEM rest whenever he feels exhausted
3. PREVENTIVE 1/3X1 1/3 Further complication will be avoided if this problem will
POTENTIAL be recognized and be given a careful attention
4. SALIENCE OF THE 1/2X1 ½ The family will recognize that this is a problem needing
PROBLEM immediate attention because it is not conductive to
health
TOTAL SCORE: 3.16
 (FAMILY)NURSING CARE PLAN

HEALTH CONDITION/S OBJECTIVE OF NURSING PLAN OF INTERVENTION EVALUATION PLAN

OR PROBLEMS AND CARE
FAMILY NURSING
OUTCOME METHODS/TOOLS
PROBLEM
CRITERIA/INDICATOR
S, STANDARDS
Hypertension as a heath deficit After nursing intervention the  Assess the level of the Partially met, after DIETARY HISTORY
Inability to recognized the family will be able to: family for applying nursing TAKING
presence of health problem -have an adequate knowledge a understanding regarding intervention client will
due to : good proper nutritional guide to to health problem verbalized and understood, SCALE OF
 Lack of inadequate reduce hypertension, and  Discussion with the disease process, and PHYSICAL
knowledge prevent occurrence of relative family regarding to treatment regiment as ACTIVITY
 Inability to make complication in the future times. nature signs and evidence by “maam , nur-
decision with respect symptoms of jaina s. Pabustan”, FAMILY HEALTH
taking appropriate -be able to determine the factors complication that might verbalization ”iiwasan ko HISTORY ASSESS
health action due to : that attribute to hypertension, arise hypertension na ang mga bawal na
-failure to comprehensive such as family history,  Discuss with the family bakain at chaka bibgyan ko RECORD REVIEW
the nature/magnitude of nutritional intake in salt, risk factors for na ng time ang sarili ko
the problem alcohol, and state of hypertension such as gmalaw ng konte kahit sa
-lack of adequate knowledge bmi(body/mass/index). family history, age , pag sayaw ng k-pop na
as to alternative courses of nutritional intake, level sayaw, para ng gumaaan
action open to them -practices of proper lifestyle of productivity of ang sakit na nararanasan ko
regarding to productive activity, activity, ”
and nutritional  Promote healthy
intake(macro&mico-nutrients). lifestyle such as
(A) Encourage proper food
intake such as salt, fatty,
and promote “dash” diet
plan
 (B) Prevent obesity through
proper nutritional and
exercises
(C) Encourage patient
reduce or eliminate
caffeine, cola, tea, and
chocolate
- Provide information
regarding
community
resources, support
patient in making
lifestyle changes
and initiate referral
to nutritional dietary
practitioner.

FAMILY NURSING CARE PLAN

HEALTH CONDITIOND/S
OR PROBLEMS and
FAMILY NURSING
PROBLEMS
ASTHMA AS HEALTH
DEFICIT
Inability to make decision with
respect to appropriate health
action due to lack of
knowledge.
Inability to provide adequate
nursing care to the asthmatic
member of the family related
to:
 inadequate family
resources for care
specially financial
contains
Failure to utilize community
resources for health care
related to:
 lack if trust in the
healthcare personnel
due to previous
experience
OBJECTIVE OF NURSING
CARE
After 1-3 days of nursing
intervention the client will be
able to:
1. Monitor the family’s
condition and take actions
which will improve their
health
2. Identify and avoid the
factors that will trigger the
asthma
3. Identify the preventive
measures and manage
when asthma triggers
4. Encouraging the family to
continue taking the
presumptive measures that
was given to them
PLAN OF INTERVENTION EVALIATION PLAN
OUTCOME CRITERIA/ METHOD/ TOOLS
INICATORS,
STANDARD
1. Broaden knowledge for the Achieved as the client Home visit
family about asthma. identify the problem and  Visual Aids
Rationale: Provide information the condition of the said  Pen
about health deficit problem and took necessary  Tape
action to prevent and
2. Discuss the effect of asthma manage when Asthma
in the body, preventive triggers
measures, proper
management and
treatments.
Rationale: to improve the health
of the family.
3. Discuss the factors causing
asthma, its signs and
symptoms.
Rationale: to prevent and
manage asthma
4. Discuss complications of
asthma in the body and
daily living.
Rationale: to maintain healthy
condition
5. Discuss for breath sounds
and adventitious sounds
such as wheezes and
strider.
Rationale: Adventitious sounds
may indicate a worsening
 condition or additional
developing complications such
as pneumonia. Wheezing
happens as a result of
bronchospasm.

6. Encourage positive attitude

Rationale: for continuing taking
the preventive measures.

7. Plan for periods of rest

between activities.
Rationale: Activity increases
metabolic rate and oxygen
requirements.

SERVICE AND PROGRESS NOTE

 DATE HEALTH NURSING OBSERVATION PRINTED NAME AND
CONDITION/NURSING TAKEN/RESPONSES AND SIGNATURE
PROBLEM EVALUATION OF
PROGRESSION/OUTCOME
November/10/2020 ASTHMA AS A HEALTH DEFICIT Note:
Write briefly and be diligent in HANAN A. ARABANI
corresponding form
Nurse will specify the nursing NUR-FATIMA M. SANAAANI
implementation every now and
then, in the form of “home visit”
 Assess the patient's
respiratory status by
monitoring the severity of the
symptoms.
 Assess for breath sounds.
 Monitor the patient's vital
signs.