qA guide or framework

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
1. NATURE OF THE PROBLEM
* Health Threat
2. MODIFIABILITY OF THE
PROBLEM
* Easy Modifiable
3. PREVENTIVE POTENTIAL
* Highly Preventable
4. SALIENCE
* Not a problem needing
immediate attention
Score Justification
Poor sleep related to changes sleeping pattern
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)
This is easily modifiable if proper health
teaching is given to the client. There are
2 2 2 actions that can promote easy sleeping for
women
This is highly preventable with the use of
proper actions and position for a good sleep.
3 1 1
Monitoring the time of sleep is also important.
It is not perceived as a problem as evidenced
by, “Nakakatulog naman ako hanggang hapon
0 1 0
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