of nursing care designed to provide ways in solving health related problems of the family as a whole.
qThis is the blueprint of
care that nurse design to minimize or eliminate the identified health or family problem. qThe prioritized condition/s or problems. qThe goals and objectives of nursing care. qThe plan of interventions. qThe plan of evaluating care. q Assessment phase qIdentification of the problem/s qFormulation of goals and objectives qPlot nursing interventions qEvaluate the outcomes CRITERIA WEIGHT 1. Nature of the problem Scale: Wellness State 3 Health Deficit 3 1 Health Threat 2 Foreseeable Crisis 1 2. Modifiability of the problem Scale: Easily Modifiable 2 2 Partially Modifiable 1 Not Modifiable 0 3. Preventive potential Scale: High 3 1 Moderate 2 Low 1 4. Salience Scale: A serious problem, immediate attention needed 2 1 A problem but not needing immediate attention 1 1. Decide on score for each criteria 2. Drive the score by the highest possible score and multiply by weight Score X Weight Highest Score 3. Sum up the scores for all criteria. The highest score is 5, equivalent to the total weight Problem 1: No Birth Plan as Health Threat Criteria Weight Score Justification 1.NATURE OF THE This is considered as health threat because women PROBLEM with no or incomplete birth plan tends to feel * Health Threat 2 1 0.67 less safe and more stressed at childbirth which results to panic attacks during labor and delivery (Aeserth et al, 2004) 2. MODIFIABILITY Health teaching about the importance of having a OF THE PROBLEM birth plan and be able to encourage the mother’s * Easy Modifiable 2 2 2 book will be an indication of effective health teaching. 3. PREVENTIVE This is highly preventable because with the use POTENTIAL of IEC, health teaching and encouragement about * Highly 3 1 1 the birth plan are big factor that will affect Preventable their readiness in the upcoming birth 4. SALIENCE “Birth Plan? Ano yun? Wala.” and Kailangan pa * Not a problem ba yun?” as verbalized by the client. We can say needing immediate attention 0 1 0 that this is not a problem perceived by the client due to lack of knowledge over the said matter Problem 2: Low Gestational Weight as Health Threat Criteria Weight Score Justification
1. NATURE OF THE According to Pilliteri (2018), normal weight gain
PROBLEM for the whole pregnancy should be 25-35lbs, * Health Threat specifically 1lb per week during the 2nd and 3rd 2 1 0.67 trimester. Slow weight gain in pregnancy may indicate poor nutrition and eating habits by the mother, affecting the growth and development of the baby 2. MODIFIABILITY OF With the right health teaching about proper food THE PROBLEM 2 2 2 intake in accordance with gaining weight, this * Easy Modifiable problem will be easily modifiable for the client
3. PREVENTIVE The PHN’s health teaching, IEC and free vitamins
POTENTIAL at the health center will make sure that the 3 1 1 * Highly Preventable client understands of gaining proper weight during pregnancy 4. SALIENCE The family recognizes it as a problem needing * A problem needing immediate attention evidenced by “Ayun basta 2 1 1 immediate attention kumakain ako ganun kasi sabi sa akin kulang daw ako sa timbang,” as stated by the mother. Problem 3: Disturbed Sleeping Pattern as Health Threat
Criteria Weight Score Justification
1. NATURE OF THE PROBLEM Poor sleep related to changes sleeping pattern
* Health Threat can adversely affect health, and it also has a critical impact on pregnant women, potentially 2 1 0.67 leading to maternal complications such as hypertension and gestational diabetes (Peters, 2019) 2. MODIFIABILITY OF THE This is easily modifiable if proper health PROBLEM teaching is given to the client. There are 2 2 2 actions that can promote easy sleeping for * Easy Modifiable women 3. PREVENTIVE POTENTIAL This is highly preventable with the use of proper actions and position for a good sleep. * Highly Preventable 3 1 1 Monitoring the time of sleep is also important.
4. SALIENCE It is not perceived as a problem as evidenced
by, “Nakakatulog naman ako hanggang hapon * Not a problem needing 0 1 0 immediate attention kaya okay lang.” HEALTH PROBLEM INTERVENTION PLAN IDENTIFIED FAMILY NURSING GOAL OF CARE OBJECTIVES NURSING METHODS OF NURSE RESOURCES REQUIRED/ EVALUATION PROBLEM ASSESSMENT INTERVENTION FAMILY CONTACT USED Low gestational weight Inadequate Within 3 weeks of Within 3 weeks of The PHN will: a. Clinical Visit -August a. Materials After 3 weeks of nursing as health threat weight for a nursing nursing intervention, 22,2019 intervention the client 1. Establish rapport. 1. PHN Bag pregnant woman intervention, the the family will: was able to: in the 2nd client will be able a. Learn the 2. Explain to the client 2. Initial Database a. Learned the Subjective Data: trimester. to gain at least 1- about Gestational b. Home Visit importance of importance of 3. Ballpen 2 kg weight gain both “Ay yung timbang, hindi weight gain in 1. First Home Visit – weight gain in normal and abnormal 4. IEC (see annex E) ko chinicheck yun, Lack of pregnancy. and its possible August 22,2019 pregnancy ngayon lang din nung b. Enumerated knowledge about b. Enumerate foods outcomes. nagpacheck up ako foods that are proper food that are essential b. Manpower ngayon.” 3. Discuss to the family 2. Second Home Visit – intake. in gaining weight. essential in the importance of August 23,2019 1. Francisco Health c. Comply in the foods that should be Center, Caloocan City gaining weight Sabi sa akin ng midwife necessary tasks taken and to avoid. c. Complied in the 2. BSN 2Y1 – 1 Group 1A kulang daw ako sa that is essential in 3. Third Home Visit – necessary tasks 4. Instruct the family timbang kaya kumain gaining weight . August 29,2019 3. Clinical Instructor: Ms. that is essential about proper daw ako nng mabuti para Jocelyn C. Tebrero in gaining weight preparation of food to mahabol ko daw.” decrease risk of 4. Relox Family d. The client gained 4. Fourth Home Visit – contamination 1kg August 30,2019 Objective Data: 5. Encourage the e. Goal met Temp: 36C pregnant woman to PR: 95bpm always check and 5. Fifth Home Visit RR:19cpm monitor weight gain if not per week, per – September 5,2019 BP: 100/70mmHg Age: 20 month Pre-Pregnant Weight: 52 kg 6.Farewell Home Visit – September 6,2019