A CASE STUDY

IL L U S T R A T IN G N
U R S IN G A S S E S
SMENT
Situation:

on an afternoon of a
was go ing over th prenatal clinic da
e record files of y, th e co m m un ity
checked th is file wi th e patients se en health nurse
th the prenatal ap in the morning. Sh
37 year-old patient pointment bo ok an e cross
, on he r second d realized th at M
po intment for that trimester of he r pr rs . A, a
day. Th e nurse to egnancy, missed
record of previous ok he r family en ve lo he r ap-
follow-up. She ob pe and w en t over
patient's prenatal tained the followi her
check-up do ne a ng da ta taken du
w ee k ago: ring the
G aP 1
Age of Gestation
(AOG): 21 w ee ks
Blood Pressure: 14
0/ 90 ; Weight: 11 8
Abdominal Palpat lb s
ion:
• breech presenta
tion
• fu nd ic height:
14 cm .
• fetal he ar t tone
: 13 5 beats/minut
• regular bu t fa in e, right upper qu
t adrant,
O th er si gn ifi ca nt
fin di ng :
sl ig ht pedal ed em
Impression : Pr eg na a
nc y uterine, 21 w
R /0 Pr e- ec la m ps ee ks
M an ag em en t: ia
• lo w sa lt di et
• urinalysis
• to co m e ba ck
ne xt prenatal clin
ic da y
Since the nurse de
th e clinical record ci de d to do a hom
s of the ot he r m e follow-up on th e
em be rs of the fa patient, she read
clinic fo r consulta mily w ho have go
tion. She noted do ne to the
w n the following
data:
* Rina , three years
old, go t si ck of br
weight -1 0 kgs. onchopneumonia
three months ago;
* Lita, four and a half years old, an
to the clinic a mon d Andres, si x ye ar
th ag o fo r scabie s old were brough
hy gi en e and Be nz s; m an ag em en t in t
yl Benzoate in tw cluded personal
followed by a sh o applications 12
ow er after 12 -2 4 hours apart and
hours.
Th e A ss es sm en
t P ro ce ss
Th e available da
ta gathered durin
th e following poss g this first-level as
ible health conditi sessment reflected
on or problems:
1. Pre-ec la m ps ia
Supporting <?ues:
37 year-old m ot he f
ge st at io n , with BP r
14 0/ 90 and slight of seven at 21 ~ee~s ati~b~-
pedal edema; weig
ht. 11
74
 2. Scabies_ which may not have been fully cured
Supporting Cues: two preschoolers brought to the center for sca-
bies one month ago
3. Malnutri~ion whic~ may not have been successfully managed
Supporting Cues. 3 year-old daughter weighed 10 kgs., 3 months
ago
4. Family ~ize beyond what family resources can adequately provide
Supportin g Cues: A family with seven children; mother, 37 years
old and presently pregnant

The nurse decided to do a home follow-up on this family. As part of

her preparation for the home visit, she specified the important points that are
needed to be able to do an in-depth second-level assessment on the list of
possible health condition or problems gathered from the individual clinical records
of the family members. By going through the following questions, she aims to
determine the family's ability to perform the health tasks on the health condition
or problems identified earlier:

1. Why did Mrs. A fail to go to the clinic for check-up? What does
the family think about Mrs. A's condition? Does the family recog-
nize a possible complication of pregnancy? If no, why not? If yes,
what is the family doing about it?

2. How is Rina now? Does the family recognize the existence of mal-
nutrition in Rina? If no, why not? If yes, what has the family done
about it? Were the solutions effective?

To be able to do an adequate assessment on the other aspects of fam-

ily life, the nurse decided to also inquire about the following during the home
visit:

3. How are Lita and Andres? What has the family done about the sca-
bies? Were the solutions effective?

4. How are the three -family members? How do the members relate
with or affect each oth~r?

5. What are the goals or plans of the family for its members and/for
itself as a functioning unit?

6. How are the conditions in the home and the community environ-
ment?

The afternoon of the next day, the nurse made her home visit and ob-
tained the following data:

• The family lives in a two-room house of light materials situated in a

congested urban com~unity about 3 km from the health center

• Lita and Andres have varying degrees of infected and healed skin
eruptions and scabs on their hands and feet

75
 th tic• with scabies, too; markedly
I lethargic and apa e ,
• Rina loo_ks pa ~ undernourished .
underweight an
d · the community's market and earns a profit
• Mrs. A is a fish ~en ~ ~erbalized, "With the meager daily income of
of P200.00/day. b rsd. earns I need to help increase the family's in-
P300 ·00 my hhus an
selling fish. I 'am so busy that I cannot fiin d .th e t·1me to
come throu~ examined But I did not have problems during my pre-
have my urine .
. nci·es and even with my present pregnancy. Th at,s why I
v1ous pregna . . ·
seldom go for a check-up at the chmc. _It Just happened that I passed
b the health center on my way to my in-laws last week, so I thought
oi dropping by the clinic to have my prenatal check-up. But I actually
feel alright. However, the doctor mentioned that my blood pressure was
slightly elevated. She wanted me to go back to the clinic yesterday
for follow-up. She wants to see the results of my urine examination.
But my problem is I have plenty of things to do especially in the morn-
ing. It is, indeed, difficult to find the time for the urine examination
and the regular prenatal consultation at the clinic. One more thing,
the clinic is out of my way when I go to the market. But I don't think
I have to worry because I have had seven pregnancies and they were
all normal. All of them were even home deliveries attended to by the
'hilot' (traditional birth attendant) ...

* ... I have such a lot of things to attend

to as a fish vendor that I could
hardly see to the needs of the children. The children are usually left
at home by themselves everyday, except for Manuel. Pedro and Cita
who go to school. Nieves is the only older child who is left to take
care of the three younger ones when we are not around. But I can't
expect her to do everything. That's the reason why the scabies of
Andres and Lita have not improved. I was able to buy the medicine
prescribed by the doctor. However, it was quite expensive that I was
not a?le to buy another one when it was consumed. This 'gal is aso'
(scabies) must be due to the weather. Quite a lot of children in the
neighborhood have this. See, even Rina got it, too.

* ... Rina is really small in built since she was a baby. She is not fond
of eating too ...

* .. My husband and I would like to give the children a better future.

We would like them to finish even just a vocational education. With
a higher educational attainment they would not have to experience the
kind of life we have now -a meager income d_espite hard work. We
can't really expect to earn much since we ~re JUSt el7mentary school
graduates. We have such a goal for our children. thats why we don't
want additional children anymore. We have decided on this since I
have delivered my fifth child, Andres. Howeve~, we have been hear-
ing a lot of things about the melh od~~f ~:~~ly pl~nning that cause
abortion, cancer or other problems. decide on a method

76
 because of fear of possible side effects. We might have more prob-
lems to worry about due to any of these methods .. ."

The other members of the family include: Mr. A, 40 years old and a
construction worker; Manuel, 14 years old, in first year high school; Pedro, 12
years old, in Grade six; Gita , 10 years old, in Grade four; and Nieves, 8 years
old and not yet in school.

• All the other children help in the household chores after school work.
They fetch water from a public artesian well about half a kilometer
from the house.

• Mrs. A has the major responsibility in so far as the health of the family
is concerned .

• The other data that the nurse observed in so far as the conditions or
resources in the home include:

• dimensions of each room is 3 meters by 3 meters

• small screened cabinet for food storage
• one-burner gas stove for cooking purposes
• earthen jar with cover for drinking water supply
• dining table with two benches
• lighting: electricity
• toilet facility: closed pit privy type situated beside the garbage
pit; foul smelling and with plenty of fl ies all over
• garbage disposal: dumping in open pit situated at the back of
the house two meters away; with plenty of flies.

The results of the nurse's in-depth second-level assessment on the iden-

tified health condition or problems are presented in the following tables. Note
that the problem statements have been defined in specific terms so as to re-
flect the family's inability to perform certain aspects of the health tasks. Thus,
the problems are stated as family nursing problems .

Cues/Data Family Nursing Problems

• 37 year-old mother of seven at 21

weeks AOG, with BP of 140/90
A. Possible Complicated Pregnancy
1. Inability to recognize presence
and slight pedal edema; wt.: 118 of a possible complication of
lbs.
pregnancy due to lack of knowl-

• Mother verbalized , "... I did not

have problems during my previous
edge .
2. Inability to provide adequate
nursing care to a pregnant
pregnancies, and even with my
member due to :
present pregnancy.. .It just hap-
a. lack of knowledge on the na-
pened that I passed by the health
ture and management of the
center on my way to my in-
laws ... so I thought of dropping by health condition

77
 cu es /D at a fa m il y N ur si ng P
ro bl em s
. . B b . la ck of kn ow le
th e cl1n1 c ... ut,
ac tu al ly I fe el
th· k I ha ve to
dg e on th e
. na tu re an d ex te nt
alright. ·· 1 don t hatn of nurs-
wor ry beca use 1 ve had seven in g ca re ne ed ed .
.
pregnancies and they were all nor-
mal. .." 3. F ai lu re to ut ili ze
co m m un ity
re so ur ce s fo r he al
• busy with w or k as th ca re due
fis h ve nd or , to :
hardly has time to go
to th e ce n- a. fa ilu re to pe rc ei
ter for follow- up ; ve be ne fit s
of he al th ca re , an
d
* b. ph ys ic al in ac ce
has major responsibi ss ib ili ty of
lity on health re qu ire d se rv ic e fa
matters; ci lit y fo r
ur in al ys is , i.e . in
te rm s of
• health center is 3 di st an ce fr om ho us
km. fr om th e e.
house;

* laboratory for urinal

ysis is 10 km .
away, not situated w
ithin the co m -
munity .

• Rina , three years ol

d, w ei gh s 10 B . M al nu tr iti on as
kg s. ; lo ok s pa le , a he al th deficit
le th ar gi c an d
apathetic; m ar ke dl y 1. In ab ili ty to re co gn
un de rw ei gh t iz e th e pres-
and undernourished. en ce of m al nu tr iti on
in a de-
pe nd en t m em be r
du e to la ck
• Mother verbalized, of kn ow le dg e.
"Rina is really
sm al l in bu ilt si nc 2 . Inability to de ci de
e sh e w as a ab ou t taking
baby. She is no t fo ap pr op ria te he al th
nd of ea tin g action due
too .. ."; to fa ilu re to co m pr
eh en d th e
na tu re , m ag ni tu de
and scope
• Three preschool m em of th e pr ob le m
be rs us ua lly
are left to th e ca re 3. \n ab i\i ty to pr ov
of ei gh t- ye ar - id e ad eq ua te
old sister w he n pare nu rs in g care to a m
nts ar e w or k- em ber suf-
in g an d ol de r ch fe rin g fr om m al nu
ild re n ar e in tr iti on du e
school ; to :
a. la ck of kn ow le
dg e ab ou t
* Mother is very bu sy
he lp in g ea rn
th e he al th co nd iti on ;
b . la ck of kn ow le
a living th at sh e co dg e on th e
uld ha rd ly see na tu re an d ex te nt
to the needs of th of nu rs -
e children; in g ca re ne ed ed
c. in ad eq ua te re
• Family in co m e is P so ur ce s fo r
50 0.00 a da y• ca re , i.e ., re sp on
si bl e
ily m em be r an d fin fa m -
an ci al
co ns tra in ts .
- Cues/Data
-* Three preschoolers have scabies ;
* Mother verbalized, "... I have such
a lot of things to attend to as a
fish vendor that I could hardly see
to the needs of the children ...
Nieves is the only older child who
is left to take care of the younger
ones when we are not around. But
I can 't expect her to do every-
thing. That's the reason why the
scabies of Andres and Lita have
not improved ... ! was able to buy
medicine ... but it was quite expen-
sive that I was not able to buy
another one when it was con-
sumed . This (scabies) must be
due to the weather. Quite a lot of
children in the neighborhood have
this. See, even Rina got it, too.";
• Family income is P500.00 a day;
• Water supply is taken from a pub-
lic well 1/2 km. from the house;
• Rina contracted the scabies of the
two older siblings ;
* Mother believes that scabies is
due to weather condition
* Family lives in a two-room house,
each room with a dimension of 3
meters by 3 meters, and;
* Water supply comes from a pub-
lic well 1/2 km. from the house
Family Nursing Problems
C. Scabies as a health deficit
1. Inability to provide adequate
nursing care to preschoolers
with scabies due to:
a. lack of knowledge about
the health condition;
b. inadequate knowledge of
the nature and extent of
nursing care needed;
c. inadequate family resources
for care, specifically:
* responsible family mem-
ber
• financial resources
• physical resources, i.e.,
water supply facilities
D. Threat of cross-infection from a
communicable- disease case
1. Inability to recognize the pres-
ence of the health threat due
to lack of knowledge about
the condition
2. Inability to make decisions
with respect to taking appro-
priate health action on th e
threat due to failure to com-
prehend the nature of th e
problem
3. Inability to provide a home
environment conducive to
health maintenance and per-
sonal development due to:
a. Ignora nce of preven tive
measures
 cue s/D ata Fam ily Nur sing Problems --- ,

• Family has nine members with a b. Ina deq uat e fam ily
gross income of P500 .~0 a day sou rces , specifically re-
and three children studying * financial resource and
* Mother is still at childbearing pe-
* phy sica l faci litie s i e
livin g spa ce and ~ate~
riod ; she's very busy earning a liv- sup ply
ing that she can not take care of
the children E. Fam ily size beyond wha t family
reso urce s can ade qua tely pro-
* Mother verbalized, " .. My husband vide
and I would like to give the chil-
dren a bett er futu re. We wou ld
1. Ina bilit y to mak e dec isio ns
like them to finish eve n just vo-
with resp ect to taking appro-
cati ona I edu cati on ... We hav e
pria te hea lth acti ons due to
such a goal for our children that 's
lack of knowledge as to alter-
why we don 't wan t additional chil-
native courses of action open
dre n any mor e ... How eve r, we to the fam ily.
have been hearing a lot of things
about the met hod s of fam ily plan-
ning that cau se abo rtion , can cer
or othe r prob lem s. We can 't de-
cide on a met hod bec aus e of this
fear of possible side effects. We
mig ht hav e mor e pro blem s to
wor ry abo ut due to any of these
methods.

The results of the nurs e's first-level ass ess

men t on the home and env
ronmental conditions are pres ente d belo w.
Sec ond -lev el ass ess men t on thes
health condition or problems will be don e as
soon as she gets the opportunil
to determine how the family is able to perf orm
the health tasks on all of thes«

Cues/Data Hea lth Problems

• Nine members stay in a two-room F. Inad equ ate living space

hou se; eac h room with a dim en-
sion of 3 meters by 3 meters
• Fam ily income is P50 0.00 a day;
• Gar bag e disp osa l is dum ping in G. Imp rope r garbage d'isp osal
an ope n pit situated at the back
of the hou se, two met ers awa y;
with plen ty of flies all ove r;
-
...-
Cues/Data Health Problems

• Type of toilet facility is closed pit

privy, foul-smelling and with plenty
H. Unsanitary waste disposal

of flies; situated at the back of the

house.

CONCLUSION
The nursing assessment described in this chapter is a deliberate, sys-
tematic process of gathering and analyzing data to identify and continuously
validate health and nursing problems of families. Effective nursing of clients
depends on an accurate description of each health and nursing problem. The
assessment process, as operationalized in this chapter, offers the nurse the
opportunity to strengthen her skill at making sound judgment using data based
on evidence. It challenges her mind to evaluate assumptions/premises and
arrive at valid conclusions . By going through the process of data collection
and analysis, she learns that clients have varied views of life, that they hold
different aspirations and that they respond to situations or problems in unique
ways. Nursing assessment is an opportunity for learning about the families'
ways of knowing.

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