Pangasinan State University

Institute of Nursing
Bayambang Campus
Bayambang Pangasinan

COMMUNITY HEALTH
NURSING II

CASE
FINDING
Submitted by:

Mary Grace D. Penoliar

(BSN III-2)

Submitted to:

Susana S. Macabulos, MAN

(Clinical Instructor)
 Pangasinan State University
Institute of Nursing
Bayambang Campus
Bayambang Pangasinan

COMMUNITY HEALTH NURSING II

FAMILY ASSESSMENT GUIDE

Family Name: Mary Jane S. Penoliar Address: Macabito Calasiao Pangasinan

No. of Visit: 1 Date: November 6, 2020

I. Family Member’s Chart

W H
A E E S Civil Position in Relationship Educational Occupation
Family Members G I I E Status the family to Family attainment
E G G X Head
H H
T T

College Brand
Richard I. Penoliar 42 82 5’7 M M Family Head Family head
Grad Manager
Mary Jane S. 3rd year
41 66 5’6 F M Mother Wife Housewife
Penoliar college
2nd year
Marichar S. Penoliar 20 50 5’3 F S 1st child Daughter N/A
college
1ST year
Johnary S. Penoliar 19 51 5’5 M S 2nd child Son N/A
college
Joriz Miguel S.
18 55 5’5 M S 3rd child Son SHS grad N/A
Penoliar

II. Family Characteristics

Type of family structure
A. Extended ______ D. Nuclear __ ✅__
B. Matriarchal ______ E. Patriarchal ______
C. Dominant Family Member ______

Family Dietary Habits

What did you eat yesterday? (24 hours recall)
Breakfast: egg and longganisa
Lunch: adobo
Supper: hotdog and salted egg
Monthly Income Source
Husband: ₱12,000
Wife: ______
 Others : ______
Monthly Family Income Source
Total (check bracket)
Below P 5,000 ______ 20,001-30,000 ______
5,000-10,000 ______ 30,001-40,000 ______
10,001-15,000 __✅__ 40,001-50,000 ______
15,001-20,000 ______ more than 50,000 ______
Family Health Status/Health History
__✅__ Heart disease ______ Breast cancer
__✅__ HPN ______ Cervical cancer
______ PTB ______ Colon cancer
______ Asthma __ ✅__ others (specify) Kidney Failure
__✅__ Diabetes Mellitus
Father: Hypertension and Diabetes Mellitus
Mother: Kidney Failure
Children: None

III. Home and Environment

A. Is the living space adequate Yes __ ✅__ No ______
B. What are the appliances owned by the family?
Television, speaker, aircon, electric fans, rice cooker, stove
C. Type of garbage disposal
__✅__ Collected ______Burning ______ Feeding to animals
______ Waste segregation ______ Burying ______ Open dumping
______ Throw in the river/sewer ______ others (specify)
D. Type of waste disposal
______ Flush __ ✅__ Water-sealed
______ Wrap and throw ______Pit-privy
______ Others (specify) _____________________________________________
E. Type of drainage system
__✅__ Open ______ Closed
F. Source of water supply
__✅__ Owned ______ Shared
______ Bought ______ others (specify) ____________
G. Drinking water storage
__✅__ Refrigerated ______Covered
______ Uncovered
H. Containers used
______ Plastic pitchers ______ Jars, clay pots
__✅__ Bottles __✅__ others (specify) gallon
I. Food storage/cooking facilities
__✅__ Covered ______ Uncovered __ ✅__ Stove
__✅__ Refrigerator ______ Cabinet ______Pots/pans
J. Common household pets found at home
dog
K. Are there breading sites of insects, rodents, etc. present?
______Yes __✅__ None
L. Pets and animals kept in the yard/home
dog
M. Are there accident hazards present?
 ______ Yes __✅__ None

IV. Health and Health Practices

A. Common illness encountered for the last 6 months
__✅__ Hypertension ______ Asthma
______ URTI ______ Otitis media
__✅__ DM ______ Depression
______ Sinusitis
______ Bronchitis
______ Arthritis
B. Gastro Intestinal Problem
__✅__ Diarrhea
______ Gastroenteritis
______ Cholera
C. Genitourinary Problem
______ Gonorrhea ______ Pubic lice
______ Pelvic inflammatory disease ______ Genital herpes
______ Cystitis ______ Genital warts
D. Male Reproductive Problem
______ Impotence ______ Sexually transmitted
______ Premature ejaculation ______ others (specify) ___________
______ Prostate cancer
E. Upper Respiratory Tract Infection (URTI)
______ Rhinitis ______ Pharyngitis
______ Sinusitis ______ Laryngitis
______ Nasopharyngitis
F. Lower Respiratory Tract Infection
______ Pneumonia ______ Asthma
______ Pulmonary tuberculosis ______ Pleural effusion
G. Who do you consult for health related problems?
______ Manghihilot ______ Albularyo ______ Nurse
______ Midwife __✅__ Health Center ______ BHW
__✅__ Doctor ______ others (specify) __________________
H. Immunization Status of Family Members
Complete
I. Have you had adequate
1. Rest and sleep __ ✅__ Yes ______No
2. Exercise __ ✅__ Yes ______ No
3. Relaxation activities __ ✅__ Yes ______ No
4. Stress management activities __ ✅__ Yes ______No

V. Awareness of community organization

A. Are you aware of existing organizations in the community?
__✅__ Yes ______ No
B. Name all the organizations you know.
__✅__ 4Ps __✅__ Phil Health __ ✅__ other (specify) GSIS, SSS

Next Appointment Date: November 13, 2020

 Mary Jane S. Penoliar
Signature Over Printed Name

Pangasinan State University

Institute of Nursing
Bayambang Campus
Bayambang Pangasinan
 Name of Client: Mary Jane S. Penoliar Age: 41 Case: Hypertension
Address: Macabito Calasiao Pangasinan Birthday: May 29, 1979

Date: November 6, 2020 No. of Visit: 1

Objective of the visit:

1. To assess the client's condition and health status.

2. To get the vital signs of the client.
3. To check and monitor the client’s blood pressure.
4. To conduct health teachings.

Vital Signs: T: 36.3°C RR: 22/min. PR: 98 bpm BP: 140/100

Health Teaching

Advised the client to: Rationale:

1. Adhere to treatment regimen and keep
follow-up appointments.
2. Monitor blood pressure and keep diary or
pressure readings.
3. Avoid stressors and continue exercising.
Lack of cooperation is a common reason for failure
of antihypertensive therapy. Therefore, ongoing
evaluation for client cooperation is critical to
successful treatment. Compliance usually improves
when client understands causative factors and
consequences of inadequate intervention and health
maintenance.
Monitoring bp at home is reassuring to patient
because it provides visual/positive reinforcement for
efforts in following the medical regimen and
promotes early detection of deleterious changes.
This can reduce stressful stimuli, produce calming
effect, thereby reducing bp.

Individualizing medication schedule to fit patient’s

4. To develop a simple, convenient schedule personal habits/needs may facilitate cooperation
for taking medications. with long-term regimen.

Next Appointment Date: November 13, 2020

NURSING CARE PLAN

NURSING
ASSESSMENT OUTCOMES INTERVENTION EVALUATION
DIAGNOSIS
Subjective: Risk for Unstable The client will: •Ascertain client’s At the end of the
“Umiinom lang Blood Pressure •Verbalize current and nursing
ako ng gamot related to understanding of ongoing blood interventions, the
kapag Inconsistency condition, pressure client verbalized
nararamdaman with Medication medication measurements, understanding of
kong nanghihina Regimen. regimen and noting trends and condition,
or nahihilo na preventive sudden changes. importance of
ako” measures. taking
•Measure blood
medications and
pressure using
Objective: acknowledge the
the appropriate
-V/S are taken as preventive
size and type of
follows: measures given.
equipment,
T: 36.3°C
proper position
RR: 22/min.
(e.g., seated, legs
PR: 98 bpm
uncrossed, feet
BP: 140/100
flat on floor), and
free of
contributing
factors such as
recent
consumption of
caffeine, recent
administration of
influential
medications,
agitation).
Incorrect
readings nay
result in
inappropriate or
lack of needed
treatment.
•Note client
reports of
headaches,
blurred vision,
chest pain,
weakness or
numbness in
arms, legs, or
face which kay
indicate that
blood pressure
is elevated.
•Note client
reports of
dizziness or
gaining, blurred
vision, nausea,
shortness of
breath, and
thirsty, which
may indicate
that blood
pressure is
fluctuating
downward.
•Emphasize
importance of
regular and long-
term medical
follow-up
appointments for
monitoring
blood pressure
and
disease/conditio
n trends, and to
provide for early
intervention to
reduce risk of
complications.
•Teach home
monitoring of
blood pressure.
•Emphasized the
importance of
taking prescribed
medications.
•Instruct client in
healthy eating
and adequate
fluid intake.
•Advise the client
to avoid stressors
and continue
exercising.
•Explain
prescribed
medications along
with their
rationale, dosage,
expected and
adverse side
effects, and
idiosyncrasies.
Adequate
information and
understanding
that side effects
(e.g., mood
changes, initial
weight gain, dry
mouth) are
common and
often subside
with time can
enhance
cooperation with
treatment plan.
 Pangasinan State University
Institute of Nursing
Bayambang Campus
Bayambang Pangasinan

COMMUNITY HEALTH NURSING II

FAMILY ASSESSMENT GUIDE

Family Name: Aguilar Address: Macabito Calasiao Pangasinan

No. of Visit: 1 Date: November 6, 2020

VI. Family Member’s Chart

W H
A E E S Civil Position in Relationship Educational Occupation
Family Members G I I E Status the family to Family attainment
E G G X Head
H H
T T

Lechon
Head of the
Mark Dennis Aguilar 27 44 5’3 M Live-in Family Head HS Grad manok
Family
seller
Cherry Gutanggogan 22 39 5’4 F Live-in Mother Wife HS Grad Housewife
79
Daniel Aguilar 1 10 M 1st child Son N/A N/A
cm

VII. Family Characteristics

Type of family structure
D. Extended ______ D. Nuclear __✅__
E. Matriarchal ______ E. Patriarchal ______
F. Dominant Family Member ______

Family Dietary Habits

What did you eat yesterday? (24 hours recall)
Breakfast: ________
Lunch: chicken
Supper: BBQ
Monthly Income Source
Husband: ₱5,000
Wife: ______
Others : ______
Monthly Family Income Source
 Total (check bracket)
Below P 5,000 ______ 20,001-30,000 ______
5,000-10,000 __✅__ 30,001-40,000 ______
10,001-15,000 ______ 40,001-50,000 ______
15,001-20,000 ______ more than 50,000 ______
Family Health Status/Health History
______ Heart disease ______ Breast cancer
______ HPN ______ Cervical cancer
______ PTB ______ Colon cancer
______ Asthma ______ others (specify)
______ Diabetes Mellitus
Father: ________________
Mother: ________________
Children: ________________

VIII. Home and Environment

N. Is the living space adequate Yes __✅__ No ______
O. What are the appliances owned by the family?
Refrigerator, freezer, speaker, aircon, electric fan
P. Type of garbage disposal
__✅__ Collected ______Burning ______ Feeding to animals
______ Waste segregation ______ Burying ______ Open dumping
______ Throw in the river/sewer ______ others (specify)
Q. Type of waste disposal
______ Flush __✅__ Water-sealed
______ Wrap and throw ______Pit-privy
______ Others (specify) _____________________________________________
R. Type of drainage system
__✅__ Open ______ Closed
S. Source of water supply
__✅__ Owned ______ Shared
______ Bought ______ others (specify) ____________
T. Drinking water storage
__✅__ Refrigerated ______Covered
______ Uncovered
U. Containers used
______ Plastic pitchers ______ Jars, clay pots
__✅__ Bottles __✅__ others (specify) gallon
V. Food storage/cooking facilities
__✅__ Covered ______ Uncovered __✅__ Stove
__✅__ Refrigerator ______ Cabinet ______Pots/pans
W. Common household pets found at home
Dog and cat
X. Are there breading sites of insects, rodents, etc. present?
______Yes __✅__ None
Y. Pets and animals kept in the yard/home
Dog, cat and chicken
 Z. Are there accident hazards present?
______ Yes __✅__ None

IX. Health and Health Practices

J. Common illness encountered for the last 6 months
______ Hypertension ______ Asthma
__✅__ UTI ______ Otitis media
______ DM ______ Depression
______ Sinusitis
______ Bronchitis
______ Arthritis
K. Gastro Intestinal Problem
__✅__ Diarrhea
______ Gastroenteritis
______ Cholera
L. Genitourinary Problem
______ Gonorrhea ______ Pubic lice
______ Pelvic inflammatory disease ______ Genital herpes
______ Cystitis ______ Genital warts
M. Male Reproductive Problem
______ Impotence ______ Sexually transmitted
______ Premature ejaculation ______ others (specify) ___________
______ Prostate cancer
N. Upper Respiratory Tract Infection (URTI)
______ Rhinitis ______ Pharyngitis
______ Sinusitis ______ Laryngitis
______ Nasopharyngitis
O. Lower Respiratory Tract Infection
______ Pneumonia ______ Asthma
______ Pulmonary tuberculosis ______ Pleural effusion
P. Who do you consult for health related problems?
______ Manghihilot __✅__ Albularyo ______ Nurse
______ Midwife ______ Health Center ______ BHW
______ Doctor ______ others (specify) __________________
Q. Immunization Status of Family Members
Not yet complete
R. Have you had adequate
5. Rest and sleep ______ Yes __✅__No
6. Exercise ______ Yes __✅__ No
7. Relaxation activities __✅__ Yes ______ No
8. Stress management activities __✅__ Yes ______No

X. Awareness of community organization

C. Are you aware of existing organizations in the community?
__✅__ Yes ______ No
D. Name all the organizations you know.
__✅__ 4Ps __✅__ Phil Health ______ other (specify) GSIS, SSS
Next Appointment Date: November 13, 2020

Cherry Gutanggogan
Signature Over Printed Name

.
 Pangasinan State University
Institute of Nursing
Bayambang Campus
Bayambang Pangasinan

Name of Client: Daniel Aguilar Case: Underweight

Age: 1 Address: Macabito Calasiao Pangasinan

Date: November 6, 2020 No. of Visit: 1

Objective of the visit:

1. To establish rapport.
2. To assess the condition and health status of the child.
3. To conduct health teaching to the parents on sufficient nutrient intake.
Height: 79 cm
Weight: 10 kg
BMI: 16 (severely underweight)

Health Teaching

Advised the client to: Rationale:

1. Avoid “grazing” or excessive snacking.
2. Avoid use of electronics and toys while
eating.
3. Avoid fruit juices and soft drinks especially
those with added sugar.
4. Serve their child with wide variety of root
crops such as sweet potatoes (kamote),
cassava (kamoteng kahoy) and potatoes.
5. Include egg, milk, nuts, yogurt, breads and
pastas to the child’s intake.
So that the child has time to get hungry before
sitting down to a nutritionally balanced meal.
It will distract the child from eating.
Juices and other sugary beverages will fill kids up
without providing them with any energy, fat or
protein.
Root crops are excellent sources of carbohydrates
that will provide child’s body with the energy that it
needs.
•Eggs are known for being a great source of high
quality protein and also provide vitamin A, vitamin D,
choline and selenium.
•Milk has long been known to be good for growing
kids. It is a good high-calorie source of calcium,
protein and vitamin D.
•Nuts are excellent sources of good fats, calcium,
protein, vitamins, and minerals.
•Yogurt can help in weight gain because of the high
calories it provides.
•Breads and pastas are great sources of calories
which are necessary if your child needs to gain
weight.
Next Appointment Date: November 13, 2020
 NURSING CARE PLAN
NURSING
ASSESSMENT OUTCOMES INTERVENTION EVALUATION
DIAGNOSIS
Subjective: Imbalanced The parents of •Ascertain At the end of the
Nutrition: Less the child will: parents' nursing
“Mahilig siyang
than Body •Verbalize understanding of interventions, the
kumain ng mga
Requirements understanding of theor child’s parents
snacks pero
related to the sufficient nutritional needs verbalized
pagdating sa
Insufficient nutrient intake and ways child is understanding of
kanin at ulam, di
Dietary Intake needed by the meeting those the health
ganon karami
child. needs to teachings about
kinakain”
•Demonstrate determine sufficient nutrient
“Trabaho ni behaviors and informaional intake.
Dennis ay taga- lifestyle changes needs.
benta at taga- to achieve the
•Note availability
lechon ng manok appropriate
and use of
kaya di weight for their
resources and
mawawala ang child.
support systems.
lechon manok sa
These factors
kinakain niya
affect or
araw-araw” as
determine ability
verbalized by the
to acquire,
mother.
prepare and
Objective: store food. Lack
of support may
-Food intake less impact the
than child’s desire to
recommended eat.
daily allowances.
•Explore lifestyle
-V/S are taken as factors such as
follows: specific eating
T: 36.2 habits (e.g., never
RR:19 eats breakfast,
snacks
Height: 79 cm throughout entire
Weight: 10 kg day) and child's
BMI: 16 (severely food preferences
underweight) and
intolerances/aver
sions. Identifies
eating practices
that may need to
be corrected and
provides insight
into dietary
interventions
that may appeal
to client.
•Encourage the
the mother to
choose foods or
have family
member bring
foods that seem
appealing to
stimulate
appetite.
•Advise the
parents to avoid
foods that cause
intolerances or
increase gastric
motility (e.g.,
foods that are gas
forming, hot/cold,
or spicy;
caffeinated
beverages; milk
products). Also,
limit fiber or bulk
because it may
lead to early
satisfy.
•Encourage the
parents to
promote pleasant
and relaxing
environment to
enhance food
intake.
•Advise the
parents to
promote
adequate and
timely fluid intake.
Also, avoid giving
snacks and limit
fluids 1 hr prior to
meal to reduce
possibility of
early satiety.
•Emphasize
importance of
well-balanced,
nutritious intake.
•Instruct that the
child should be
positioned so that
the head is up
and the child is
comfortable. The
child should be
allowed to feed
him/herself(e.g.,
by holding a
bottle or eating
finger foods) but
may need to be
fed soft foods with
a spoon.
•Advise the
parents to avoid
meal time
distractions, such
as television,
phone calls and
loud music.
 Pangasinan State University
Institute of Nursing
Bayambang Campus
Bayambang Pangasinan

COMMUNITY HEALTH NURSING II

FAMILY ASSESSMENT GUIDE

Family Name: Evangeline A. Laforteza Address: Macabito Calasiao Pangasinan

No. of Visit: 1 Date: November 6, 2020

XI. Family Member’s Chart

W H
A E E S Civil Position in Relationship Educational Occupation
Family Members G I I E Status the family to Family attainment
E G G X Head
H H
T T

Mango
Ronald C. Lopez 42 54 5’7 M Live-In Family Head Family Head Gr. 2 Sprayer/
Contractor
Evangeline A.
39 50 5’5 F Live-In Mother Wife Elem. Grad
Laforteza
Mango
Raymart Diaz 15 N/A N/A M S 2nd child Son N/A Sprayer/
Contractor
Ranger L. Lopez 9 23 4’0 M S 3rd child Son Gr. 3
Ronaldo L. Lopez 4 16 3’6 M S 4th child Son N/A

XII. Family Characteristics

Type of family structure
G. Extended ______ D. Nuclear __✅__
H. Matriarchal ______ E. Patriarchal ______
I. Dominant Family Member ______

Family Dietary Habits

What did you eat yesterday? (24 hours recall)
Breakfast: pritong bangus
Lunch: pritong bangus
Supper: pritong bangus
Monthly Income Source
Husband: ₱2,000
Wife:. ______
Son: : ₱2,000
Monthly Family Income Source
Total (check bracket)
Below P 5,000 __✅__ 20,001-30,000 ______
5,000-10,000 ______ 30,001-40,000 ______
10,001-15,000 ______ 40,001-50,000 ______
15,001-20,000 ______ more than 50,000 ______
Family Health Status/Health History
______ Heart disease ______ Breast cancer
______ HPN ______ Cervical cancer
______ PTB ______ Colon cancer
______ Asthma ______ others (specify)_____________
______ Diabetes Mellitus
Father: __________________________________________________________
Mother: __________________________________________________________
Children: __________________________________________________________

XIII. Home and Environment

AA. Is the living space adequate Yes ______ No __✅__
BB. What are the appliances owned by the family?
None
CC.Type of garbage disposal
______ Collected __✅__ Burning ______ Feeding to animals
______ Waste segregation ______ Burying ______ Open dumping
______ Throw in the river/sewer ______ others (specify)
DD.Type of waste disposal
______ Flush ______ Water-sealed
______ Wrap and throw __✅__ Pit-privy
______ Others (specify) _____________________________________________
EE. Type of drainage system
__✅__ Open ______ Closed
FF. Source of water supply
__✅__ Owned ______ Shared
______ Bought ______ others (specify) ____________
GG. Drinking water storage
______ Refrigerated __✅__ Covered
______ Uncovered
HH.Containers used
______ Plastic pitchers ______ Jars, clay pots
______ Bottles __✅__ others (specify) gallon
II. Food storage/cooking facilities
______ Covered ______ Uncovered ______ Stove
______ Refrigerator ______ Cabinet __✅__ Pots/pans
JJ. Common household pets found at home
 _____________________________________________________________
KK. Are there breading sites of insects, rodents, etc. present?
__✅__ Yes ______ None
LL. Pets and animals kept in the yard/home
Duck and dog
MM. Are there accident hazards present?
______ Yes __✅__ None

XIV. Health and Health Practices

S. Common illness encountered for the last 6 months
______ Hypertension ______ Asthma
______ URTI ______ Otitis media
______ DM ______ Depression
______ Sinusitis
______ Bronchitis
______ Arthritis
T. Gastro Intestinal Problem
______ Diarrhea
______ Gastroenteritis
______ Cholera
U. Genitourinary Problem
______ Gonorrhea ______ Pubic lice
______ Pelvic inflammatory disease ______ Genital herpes
______ Cystitis ______ Genital warts
V. Male Reproductive Problem
______ Impotence ______ Sexually transmitted
______ Premature ejaculation ______ others (specify) ___________
______ Prostate cancer
W. Upper Respiratory Tract Infection (URTI)
______ Rhinitis ______ Pharyngitis
______ Sinusitis ______ Laryngitis
______ Nasopharyngitis
X. Lower Respiratory Tract Infection
______ Pneumonia ______ Asthma
______ Pulmonary tuberculosis ______ Pleural effusion
Y. Who do you consult for health related problems?
______ Manghihilot ______ Albularyo ______ Nurse
______ Midwife __✅__ Health Center ______ BHW
______ Doctor ______ others (specify) __________________
Z. Immunization Status of Family Members
________________________________________________________________
AA. Have you had adequate
9. Rest and sleep ______ Yes __✅__ No
10. Exercise __✅__ Yes ______ No
11. Relaxation activities __✅__ Yes ______ No
12. Stress management activities ______ Yes __✅__ No

XV. Awareness of community organization

E. Are you aware of existing organizations in the community?
 __✅__ Yes ______ No
F. Name all the organizations you know.
__✅__ 4Ps __✅__ Phil Health ______ other (specify) _________

Next Appointment Date: November 13, 2020

Evangeline A. Laforteza
Signature Over Printed Name
 Pangasinan State University
Institute of Nursing
Bayambang Campus
Bayambang Pangasinan

COMMUNITY HEALTH NURSING II

Name of Client: Evangeline A. Laforteza Age: 39

Address: Macabito Calasiao Pangasinan Birthday: January 31, 1981
Case: Pre-natal

Objective of the visit:

1. To establish rapport to the pregnant woman.
2. To assess her condition and health status.
3. To get the vital signs of the pregnant.
4. To know the obstretical history of the client.
5. To get the LMP, EDC and AOG.
6. To conduct health teachings.

Date: November 6, 2020 NURSES NOTES

No. of visit: 1
I. Condition of client when found:
When we arrived at their house, she's taking care of her drunk
husband.

II. G: 6
T: 5
P: 0
A: 1
L: 5

III. LMP: March 4, 2020

EDC: December 11, 2020
AOG: 8 months

IV. General Appearance:

Skin: striae gravidarum and Hair: not dry

melasma are visible
Breast: no tenderness
Mouth: no swollen gums and
dental carries Conjunctiva: normal

Head: normal in shape

Upper Extremities: normal

Chest: normal
 Lower Extremities: swelling of Neck: normal
ankle
Teeth: no dental carries found
Eyes: clear and normal
Ears: normal
Nose: normal
DEVELOPMENTAL MILESTONES:

V. Nursing Activities:

Vital Signs: T: 35.7°C RR: 24/min PR: 89 bpm BP: 120/70

VI. Health Teaching

Advised the client to: Rationale:

1. Have check-ups and monitoring at the This reinforces the relationship between health
health center. Take the vitamins given assessment and positive outcomes for mother and
by the health center. baby.
2. To eat more fruits and vegetables. Fruits and vegetables provide vitamins and fiber.

3. To avoid drinking coffee, alcoholic
beverages and softdrinks.
4. Go for a walk and some non-weight-
bearing activities..
5. Have a consistent sleep and rest
schedule (1- to 2-hour daytime nap and
8 hours of sleep each night).
6. To eat high-fiber foods and drinks more
water.
Caffeine and drinks sweetened with sugar may
cause difficulty sleeping and can be harmful to
pregnancy if intake is too much.
Exercise tends to shorten labor, increases likelihood
of a spontaneous vaginal delivery and decreases
need for oxytocin augmentation
This provides rest to meet metabolic needs
associated with growth of maternal and fetal tissues.
This maay help prevent constipation.

VII. Reaction of the Client:

As we reached her house, we saw that she is caring for her drunk husband. She
is surprised to see us and immediately ask for our understanding on seeing them in that
state. As we bid our goodbye, she expressed her gratitude for checking her condition
and for the health teachings that we provided.

VIII. Next Appointment Date: November 13, 2020

 Evangeline A. Laforteza
Signature Over Printed Name

NURSING CARE PLAN

NURSING
ASSESSMENT OUTCOMES INTERVENTION EVALUATION
DIAGNOSIS
Subjective: Risk for The mother will: •Evaluate current At the end of the
“Ung ulam namin Ineffective •Acknowledge knowledge nursing
ng umaga, yun na Childbearing and address regarding interventions, the
din ung ulam Process related to individual risk physiological and mother was able
hanggang gabi.” Inadequate factors of psychological to understand the
Maternal Nutrition childbearing. changes importance of
“Hindi na ako associated with nutrition and care
umiinom nung •Demonstrate pregnancy. This requirements to
mga vitamins.” healthy provides promote healthy
pregnancy free of information to childbearing
Objective: preventable assist in process.
-Weak in complications. identifying
appearance needs and
-Insufficient •Engage in creating an
access of support activities to individual plan
system prepare for birth of care.
-Decreased proces.
subcutaneous fat •Determine family
or muscle mass •Verbalize stressors,
-Food intake less understanding of economic
than care requirements situation/fiancial
recommended to promote health needs, and
daily allowances of self and infant. availability/use of
resources.
-V/S are taken as Impact of
follows: pregnancy n
T: 35.7°C family with
RR: 24/min limited
PR: 89 bpm resources can
BP: 120/70 create added
stress and result
Height: 50 in limited Pre-
Weight: 5’5 natal care and
BMI: 17.8 preparation for
(underweight) newborn.

•Verify
environmental
well-being and
safety of
client/family.
Women
experiencing
intimate partner
violence both
prior to and/or
during
pregnancy are at
higher risk for
multiple poor
maternal and
infant health
outcomes.

•Review nutrition
requirements and
optimal pre-natal
weight gain to
support maternal-
fetal needs.
Inadequate
prenatal weight
gain and/or elow
normal
prepregnacy
weight increases
the risk of
intrauterine
growth
retardation
(IUGR) in the
fetus and
delivery of a
low-birth-weight
(LBW) infant.

•Encourage
moderate
exercise such as
walking or non-
weight-bearing
activities in
accordance with
the client’s
physical condition
and cultural
beliefs. Exercise
tends to shorten
labor, increases
likelihood of a
spontaneous
vaginal delivery
and decreases
need for
oxytocin
augmentation.

•Recommend a
consistent sleep
and rest schedule
(1- to 2-hour
daytime nap and
8 hours of sleep
each night). This
provides rest to
meet metabolic
needs
associated with
growth of
maternal and
fetal tissues.

•Explain
psychological
reactions
including
ambivalence,
introspection,
stress reactions
and emotional
lability as
characteristics of
pregnancy. Helps
client/couple
understand
mood swings
and may provide
opportunity for
partner to offer
support and
affection at
these times.

•Explain the
importance of
check-ups and
close monitoring
such as blood
pressure
monitoring,
weight and fetal
growth. This
reinforces the
relationship
between health
assessment and
positive
outcomes for
mother and
baby.

•Advise the
mother to eat
fruits and
vegetables to
provide vitamins
and fiber.

•Instruct the
mother to eat
high-fiber foods.
Eating high-fiber
foods, drinking
water and getting
daily physical
activity may help
prevent
constipation.