University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

N105: NURSING INTERVENTIONS I

Family Health Nursing Focus

FAMILY SERVICE PROGRESS RECORD

Head of the Family (Initials): CDN Family Number: 2

Address (Barangay/City or Municipality): 1901-K, Interior 53, Zamora St. Brgy. 843, Pandacan, Manila

Assessment, Nursing Interventions, Signature over

Family Nursing Problems Evaluation
Action Taken, Responses/ Progress Notes Printed Name
10/10/2022 N/A Actions Taken:
7:30 - 11:30 AM ● Visited the San Miguel Health Center for a courtesy
call N/A
● Visited the Rosario Reyes Health Center for a
courtesy call.
● Took a short quiz about FHN, TB-DOTS Program, ANDREA KHAYE
IMCI, etc. L. GUTIERREZ
10/11/2022 N/A Assessment: N/A
7:30 - 10:00 AM ● Nabor family is an extended family composed of
eight members.
● Index cases: CDN (45) and RRN (59). CDN currently
has heart failure and liver cirrhosis. RRN currently
has hypertension and cerebral aneurysm.
● Address: 1901-K Interior 53, Zamora St., Brgy. 843,
Pandacan, Manila.
● CDN’s mother, younger siblings, nephew, and niece
live on the second and third floors of the house ANDREA KHAYE
together with their respective families. L. GUTIERREZ
● Maternal power dynamics.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 1

 ● CDN decides on matters of healthcare and
care-tending to both of them.
● Harmonious relationship between and among all
members living in the household.
● Genogram:
○ CDN is the eldest out of the four siblings.
○ 2nd eldest: deceased due to the rupturing of
her appendix simultaneously upon the
delivery of her child.
○ 3rd sibling (37): alive, no acute and chronic
diseases
○ Youngest (31): with hypertension.
○ CDN’s mother: had stroke, w/vertigo and
hypertension
○ CDN’s father: deceased due to an
occupational accident of falling in
association with his preexisting, undiagnosed
heart condition/ problem.
○ RRN’s siblings all have hypertension except
for the fourth who died due to leptospirosis.
○ 2nd and 3rd eldest sibling of RRN, who both
had hypertension, are already deceased
because of cerebral aneurysm and blood clot ANDREA KHAYE
formation in the brain. L. GUTIERREZ
○ 5th eldest (62): w/ hypertension and angina
○ As for RRN’s parents, it was mentioned by
RRN’s older sister that their mother died on
April 5, 1991 due to a cardiac condition and
pneumonia, while their father died in March
2003, due to heart attack.
● Both RRN and CDN are unemployed.
● Both are hugely dependent on the Social Security
System (SSS) disability pension of RRN amounting
to ₱ 2, 100. 00 per month.
● CDN’s family supports them both.
● CDN handles the finances of their family and its
allocation for their different essential needs.
● Budget breakdown:
Monthly Expenses Amount

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 2

 Electricity ₱ 200.00

Water ₱ 350.00

Medications ₱ 2, 500. 00

Food ₱ 5,000. 00

Others No specific amount

mentioned.

Total Estimate ₱ 8, 100. 00

● Education:
○ RRN: 2nd Year High School
○ CDN: 3rd Year Undergraduate; BS Education
● Both are Filipino.
● Family does not believe in traditional medicine (e.g.
usog, bati, albularyo, kulam, anting-anting).
● Family relates well with the people in the community.
● Both CDN and RRN only participate in community
activities if the event itself is usually just about
provision of free medications.
● CDN and RRN live in a 3-storey house. They only
occupy the first floor of the house while the second
floor is occupied by her sister, and the third floor by ANDREA KHAYE
her brother. L. GUTIERREZ
● The house is predominantly made of concrete and its
living area is also the family’s bed and dining space.
● One standard LED fluorescent in the living space, and
one Compact Fluorescent Lamp (CFL) in the comfort
room. The house is well-ventilated with one big
window and three electric fans.
● Sleeping arrangement: CDN and RRN sleep in one
queen-sized bed placed in the living room. CDN’s
nephew and niece also occasionally sleep with them
on the same bed while CDN’s mother sleeps on the
floor of the living room using a foam mattress.
● Crowding Index: 5
● As for the presence of vectors of diseases, rats,
cockroaches, and mosquitoes are the most apparent
but they are usually just outside and not inside their
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 3
 house.
● No fire and accident hazards inside the house since
the gas stove used for cooking are placed outside of
the house. Despite having stairs, this is not used by
both CDN and RRN since they mainly occupy the
first floor of the house.
● Water:
○ Maynilad
○ Household service connection system
(individual water faucet in each household).
○ Drinking water: 1 gallon for ₱ 40.00
● Kitchen
○ Own gas stove.
○ Beneath the stove are where pots and pans are
put and air dried.
○ Kitchen area is cluttered.
○ Kitchen tools like spatula, tongs, strainer, and
ladles are hung in a stainless hookbar right
above the faucet. Kitchen utensils like spoon,
fork, and plates are dried in a plastic dish
drainer.
● Wastes and garbage
○ Placed outside their house near the gate in
one bucket with a cover, unsegregated.
● Toilet facility
○ The family owns one individual toilet facility ANDREA KHAYE
where they urinate, defecate, and shower. It is L. GUTIERREZ
generally clean and has adequate space for
toileting and showering.
○ Flush type toilet system in which a pail is
used to flush the urine and excreta.
● No pets.
● Main social and recreational facility accessible to the
family is the basketball court.
● As for the main health center facility, the most
accessible for the family is the Bagong Barangay
Health Center, which is just a walking distance from
their house.
● CDN does not regularly visit or have her check-ups
there since her health condition requires interventions
that can only be fully provided by a hospital. CDN’s
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 4
 main healthcare facility is the Sta. Ana Hospital.
● RRN often visits José R. Reyes Memorial Medical
Center in Sta. Cruz, Metro Manila because it is where
he is accustomed to. Nevertheless, when there are free
medications offered by the Bagong Barangay Health
Center, he is able to receive some.
● Family utilizes the public transportation system
● The family does not own any type of car, motorcycle,
and other vehicle.
● CDN mainly uses her mobile phone and utilizes
social media platforms like Facebook to connect with
other people, friends, and relatives.
● Both CDN and RRN received their primary doses
and booster shots of COVID-19 vaccines

Nursing Interventions:
● Therapeutic Communication
● Establishment of rapport
● Contract setting
● Gathering of information for Assessment Data Base.

Actions Taken: ANDREA KHAYE

● Conducted an initial interview about the family L. GUTIERREZ
structure and dynamics, any comorbidities or serious
illnesses in each family member, presence of
vulnerable groups, etc.
● Determined the family size.
● Informed the client about the duration of the student
nurse- family patient interaction
● Briefed the family about contract setting.
● Asked questions for Assessment Data Base.
● Observed the family’s home and environment.

Responses:
● AMM verbalized agreement to the activity.
● Contact numbers were provided to facilitate
communication.
● Mode of communication was established.
● Client provided comprehensive answers on questions
for Assessment Data Base.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 5

10/12/2022 N/A Assessment: N/A
10:30 - 11:45 ● Client has been diagnosed with Hypertension several
AM years ago.
● Client regularly visits the Jose R. Reyes Memorial
Medical Center to have his consistent check-ups for
blood pressure as this is needed for his SSS Disability
pension.
● Client revealed that his BP usually increases when he
is tired or when the weather is too hot.
● Current medications of RRN prescribed by his doctor
dated on September 12, 2022.
Medications Dosage Instruction

Acetylsalicylic 100 mg One tab / day

Acid (ASA)

Telmisartan + 40 + 12.5 mg One tab / day

Hydrochlorothia
zide (HCT2)

Atorvastatin 40 mg One tab / day

Amlodipine 10 mg One tab / day

ANDREA KHAYE
● Client currently has a cerebral aneurysm. L. GUTIERREZ
● Client had chickenpox and diarrhea before but cannot
recall when. Mumps, measles, polio, diphtheria,
pneumonia, dengue, and hepatitis were all
unremarkable.
● Most recent vaccine: AstraZeneca vaccine
● No known food and medication allergies and does not
take any form of herbals and vitamins.
● Client was also hospitalized several years ago for his
appendectomy.
● “Okay naman. Malusog naman. Pakiramdam ko
naman malayo ako sa pagkakaroon ng sakit.”

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 6

 ● Client has tried smoking before when he was 18 years
old and smokes about 3 sticks a day, then stopped at
the age of 20.
● 0.5 pack years - Light smoker
● RRN verbalized that he only drinks alcohol when
there are special occasions like birthdays. He usually
prefers hard drinks like beer, and takes an average of
5 shots.
● Client has high salience towards his health. He does
not encounter problems when complying to medical
orders. He ensures that he buys all the prescribed
medications and takes them as ordered to be able to
maintain his health and promote wellness.
● See ADB for client’s 24-hour food recall.
● RRN has good appetite when eating and does not
experience eating discomforts nor have dietary
restrictions.
● “Madalas pag nasubo ako, madaming natatapon na
mga kanin ganon.” RRN’s sister further added that
“kapag kumakain, para siyang bata na maraming
mumo.”
● Fluid intake: 2-3 L of water a day. Client does not like
drinking artificial juices but he drinks soft drinks
about 2-3 times a week.
● RRN does not monitor his weight even though they ANDREA KHAYE
have a weighing scale at home. Nevertheless, he does L. GUTIERREZ
not experience any sudden increase or decrease in his
weight.
● Defecation patterns:
○ Regular, once a day, and usually every after
dinner.
○ Client’s stool was classified as Grade 3
(Normal) in the Bristol Stool Chart which is
characterized as sausage shape with cracks in
the surface.
● Micturition patterns:
○ 4x or more in the morning.
○ Urine was described to be yellowish to white
in color without any foul odor.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 7

 ● RRN still has sufficient energy to accomplish daily
activities and display full self-care when performing
ADLs.
● Client seldom performs basic dynamic stretching.
● In terms of gait, the client walks slightly unsteady and
slow. Because of his brain aneurysm, RRN’s left
peripheral visual field was compromised.
● Instead of walking straight, he has the tendency to
walk to the right side to avoid bumping into anything
he cannot peripherally see on his left side.
● RRN usually sleeps at around 10:00 PM then wakes
up at around 4 or 5:00 AM. No sleep medications are
being taken. RRN usually prefers taking both naps in
the morning at around 10:00 AM and in the afternoon
a few minutes after eating lunch.
● For modes of relaxation, RRN likes just spending
time watching the news on the television, sleeping,
and taking frequent rests. RRN added that he also
likes listening to music to relax his mind.
● Upon observation, the client's cognition is not that
sharp anymore. It was assessed that the client's
answers are not that reliable anymore as well. This is
the reason why when interviewing RRN, another
person needs to be present to verify his answer, ANDREA KHAYE
usually his wife or his sister. L. GUTIERREZ
● Client does not easily get mad, nervous, irritated, or
sad. Whenever he feels stressed about something, he
just takes a break and stretches his body.
● Client is not part of any form of organizations or
groups in his community.
● Testicular or prostate problems were unremarkable.
● Client puts God at the center of his life.

Nursing Interventions:
● Nursing Health History of RRN

Actions Taken:
● Conducted an in-depth Nursing Health History for
RRN

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 8

 Responses:
● RRN provided comprehensive answers on his
Nursing Health History.
10/13/2022 N/A Assessment: N/A
10:30 - 11:45 ● CDN is currently diagnosed with Heart Failure and
AM experiences severe dyspnea upon exertion and even at
rest.
● Client’s condition started about two years ago back in
January 2020 while she was still abroad, particularly
in Kuwait.
● Before, the client revealed that she has been
diagnosed with uncontrolled hypertension.
● One morning two years ago, the client experienced
severe dyspnea. Client was in severe cardiorespiratory
distress for about one hour and so was brought to
Mubarak Al-Kabeer Hospital immediately.
● Client was confined in the hospital for 7 days and was
diagnosed with heart failure.
● CDN’s previous medications:
ANDREA KHAYE
Drug Name Dose L. GUTIERREZ
Acetylsalicylic acid (ASA) 81 mg
(Aspirin)

Bisoprolol fumarate 5 mg

Simvastatin 20 mg

Lisinopril 20 mg

Pantoprazole 40 mg
● Months later, the client revealed that her condition has
started to worsen. She consistently experienced
exacerbations. Client mentioned that she had
shortness of breath and angina with just simple
performance of activities of daily living (ADLs) such
as walking, climbing the stairs, and moving.
● Because of the worsening of her heart condition, the
client decided to move back here in the Philippines
last September 2021.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 9

 ● Client didn’t consult a healthcare professional
immediately after arriving in the Philippines. It was
only until she could no longer tolerate the symptoms
of her heart failure that she decided to visit a doctor
which was only this August 2022 in Sta. Ana
Hospital.
● Client’s current medications:
Medication Dosage Instruction

Spironolactone 50 mg Once/ day

Furosemide 40 mg 2x/ day

Lactulose 2 spoons (at

night)
● Back in Kuwait, the client regularly visits the doctor
weekly to have her routine check-ups.
● Childhood diseases: measles, chickenpox, and
ANDREA KHAYE
diarrhea.
L. GUTIERREZ
● Most recent immunization: First booster against
COVID-19.
● No known food and medication allergies and does not
take any form of herbals and vitamins because she
revealed that they are actually contraindicated for her.
● Client, however, takes Xanthone Plus Gold
(Mangosteen 350 mg + Ampalaya 50 mg +
Malunggay 50 mg + Garlic 50 mg + Spirulina 50 mg)
once daily every morning after breakfast.
● Client described her overall health as “medyo-medyo
okay” and “alanganin” since her heart failure is only
getting worse day by day.
● Client does not smoke any tobacco products, drink
any alcoholic beverage, nor have taken any form of
illicit drugs even before when she was young. CDN
has no vices.
● Client does not regularly perform self-breast
examination to check for masses, lumps, tenderness,
and abnormalities of the breast.
● Client has high salience towards her health.
● See ADB for client’s 24-hour food recall.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 10

 ● CDN no longer has a good appetite and can no longer
tolerate eating large amounts of food because of her
cardiac condition and massive ascites.
● Client is easily nauseated by oily and fatty foods.
● No eating discomforts and dietary restrictions other
than the limited salt intake.
● Client only drinks < 1 L of water. No artificial juices
and soft drinks are taken.
● Client no longer monitors her weight even though
they have a weighing scale at home. Client’s weight is
also only quite increasing despite her massive ascites
since client’s food intake is extremely insufficient.
● Defecation patterns:
○ Three times a day, one in the morning, after
lunch, and after dinner.
○ Grade 7 in the Bristol Stool Chart which is
characterized as soft, liquidy, and watery
stools with no solid pieces.
○ Yellowish in color similar to a breastfed
infant’s poop due to her medications.
ANDREA KHAYE
● Micturition patterns: L. GUTIERREZ
○ CDN urinates around 6 times or more in the
morning.
○ Urine is yellowish in color, with an odor that
is quite similar to the food or medication she
just took.
○ Severe nocturia, with urination for about
every 15 minutes at night especially when her
legs are severely edematous.
● Client no longer displays full self-care when
performing ADLs.
● Sleeping schedule: 9:00 PM - 7:00 AM.
● Client has disturbed sleeping patterns due to
experience of nocturia.
● Siesta time: 1-2 hours from 2:00 PM - 4:00 PM.
● CDN no longer tolerates sleeping in supine.
● “Para akong nalulunod masyado kapag nakahiga.”
She usually sleeps in a sitting position near the edge
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 11
 of the bed with 4 pillows under her back to reduce
venous return to and congestion in the heart, and
relieve her dyspnea.
● CDN likes just spending time watching the news on
the television, sleeping, and taking frequent rests.
● Far-sighted.
● CDN often feels sad when she thinks too much about
her health.
● Client is not part of any form of organizations or
groups.
● CDN’s menstrual cycle,
○ Menarche: 11.
○ LMP: 09/08/2022.
○ Regular menstruation
○ No discomfort.
○ Lasts for 5 days and CDN consumes about 1
pack of napkin pads a day.
○ Menstrual bleeding is increased during the ANDREA KHAYE
first three days and decreases in the L. GUTIERREZ
succeeding days.
● Roman Catholic. Regards religion as important in
their life.
● Pertinent PE results of CDN:
○ Slightly unkempt, looks slightly dyspneic,
slightly restless, looks older than normal age
○ Ectomorph
○ PR: 62 bpm (Brachial); irregular
○ RR: 27 breaths/min; dyspnea upon exertion
and at rest
○ BP:
■ 10/11/2022: 140/90 mmHg
■ 10/13/2022: 110/70 mmHg
■ 10/25/2022: 130/ 90 mmHg
○ Pain rating of pulmonic area during 10/12/22
using Numerical Rating Scale: 9/10
○ Pain rating of pulmonic area during 10/13/22
using Numerical Rating Scale (NRS) : 7/10
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 12
 ○ Slightly yellowish integument
○ (+) Use of accessory muscles when breathing
○ (+) Crackles at lower lung fields
○ Apparent Jugular (neck vein) distention
○ HR: 96 beats / min
○ Massive ascites
○ (+) Bipedal pitting edema on lower
extremities, Grade 4 (Bates’ Guide To
Physical Examination and History-Taking,
2012)
○ Gait: coordinated, steady, slow, walks with
assistance from objects

○ With dentures
○ No mandible teeth in the R and L buccal
cavity
○ (+) Tooth cavities
○ Increased hair fall
○ Pale sclera
○ Reported far-sightedness; wears glasses ANDREA KHAYE
○ (+) Colds that does not resolve, transparent in L. GUTIERREZ
color, minimal in amount
● Pertinent PE results of RRN:
○ Gait and Posture: Uncoordinated, unsteady,
○ BP:
■ 10/11/2022: 140/120 mmHg
■ 10/13/2022: 160/100 mmHg
■ 10/25/2022: 140/100 mmHg
○ WHR: 0.87 - Moderate risk (WHO, n.d.)
○ Absent left peripheral visual field
○ Do not wear eyeglasses; “malabo na kapag
medyo malayo”
○ (+) Colds
○ (+) Ethmoid sinus tenderness
○ Absent front incisors, R and L upper and
lower molars, and L upper first premolar
○ (+) Tooth cavities

Nursing Interventions:
● Nursing Health History of CDN

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 13


10/25/2022 ● Heart Failure of CDN as a
7:30 - 9:30 AM Health Deficit
● Liver cirrhosis of CDN as a
Health Deficit
● Disturbed Sleeping Patterns
of CDN as a Health Threat
● Inadequate Nutritional
Intake of CDN as a Health
Threat
Inability to make decisions
with respect to taking
appropriate health action due
to:
- Feeling of
helplessness brought
about by perceived
magnitude / severity
of the problem
- Lack of/ inadequate
knowledge/ insights
to alternative courses
of action open to
them
Inability to provide adequate
nursing care to the sick,
disabled, dependent, or
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022
● Physical Examination of CDN and RRN
Actions Taken:
● Conducted an in-depth Nursing Health History for
CDN.
● Conducted the physical examination of both RRN and
CDN, excluding the genito-urinary and breast and
axilla assessment.
Responses:
● CDN provided comprehensive answers on her
Nursing Health History.
● Physical Examination of both clients were finished.
Assessment/Responses: 1. Verbalize her personal
● Client described her overall health as “medyo-medyo perception of current health
okay” and “alanganin”. status
● “Mahirap na masolusyunan…maghintay na lang ng ● Objective fully met
oras.” ● CDN verbalized her
● CDN often feels sad when she thinks too much about personal perception of
her health because it is already progressing current health status and
negatively. overall psychosocial
● Client does not know any options she can utilize to well-being.
address her health problems. ● “Okay naman ako.
● Results of Echocardiography: Medyo mas mabuti-buti
○ Eccentric left ventricular hypertrophy with kumpara last week.”
multi-segmental wall motion abnormality 2. Report decreased dyspnea
with severely depressed global systolic with a rating of 2 or less
function. using the 5-point Likert ANDREA KHAYE L.
○ Doppler evidence of relaxation abnormality Scale for Dyspnea GUTIERREZ
○ Dilated left atrium and right atrium ● Objective fully met
○ Atherosclerotic aortic root ● Client reported a score of
○ Aortic sclerosis with aortic insufficiency +2 2 (Mild shortness of
○ Mitral sclerosis with severe mitral breath) using the Likert
regurgitation Scale for Dyspnea.
○ Severe tricuspid regurgitation ● O2 saturation: 98%
○ Moderate to severe pulmonary hypertension ● Client verbalized use of
● Results of Color Flow Doppler 2:1 Deep Breathing
○ Abnormal color flow display across the mitral technique.
valve, aortic valve, and tricuspid valve ● Upon observation, the
○ Pseudonormal mitral E/A ratio client is less dyspneic
○ Moderate pulmonary hypertension compared to last week.
14
 vulnerable / at risk family ● Physical Examination CDN is also able to better
member due to : ○ Slightly unkempt, looks slightly dyspneic, tolerate performance of
- Disability progression slightly restless, looks older than normal age house activities like
which exhausts ○ Ectomorph cooking and going to the
supportive capacity ○ PR: 62 bpm (Brachial); irregular bathroom.
of family members ○ RR: 27 breaths/min; dyspnea upon exertion 3. Report decreased grade of
- Inadequate family and at rest her bilateral pitting edema
resources for care, ○ BP to Grade 3 or less
specifically financial ■ 10/11/2022: 140/90 mmHg ● Objective fully met
constraints ■ 10/13/2022: 110/70 mmHg ● Upon assessment, client's
■ 10/25/2022: 130/ 90 mmHg pitting edema was
○ Pain rating of pulmonic area during 10/12/22 downgraded to Grade 3
using Numerical Rating Scale: 9/10 (Pitting Edema Grading
○ Pain rating of pulmonic area during 10/13/22 Scale).
using Numerical Rating Scale (NRS) : 7/10 ● Client verbalized use of
○ Slightly yellowish integument compression stockings
○ (+) Use of accessory muscles when breathing the night after the health
○ (+) Crackles at lower lung fields teaching.
○ Apparent Jugular (neck vein) distention ● Client still continues to
○ Heart rate: 96 beats / min take Furosemide and
○ Massive ascites Spironolactone.
○ (+) Bipedal pitting edema on lower ● Client continues to limit
extremities, Grade 4 (Bates’ Guide To her water intake.
Physical Examination and History-Taking, 4. Discuss at least 3 important ANDREA KHAYE
2012) dietary guidelines for L. GUTIERREZ
○ Gait: coordinated, steady, slow, walks with patients with heart failure.
assistance from objects ● Objective fully met
● Prescribed medications for CDN when she was still in ● Client verbalized 4
Mubarak Al-Kabeer Hospital in Kuwait important dietary
guidelines for heart
Drug Name Dose
failure.
Acetylsalicylic acid (ASA) 81 mg 1.Dapat bawasan ang asin.
(Aspirin) <2 g lang.
2.Kapag kakain ng carbs, 4
Bisoprolol fumarate 5 mg servings.
3.I-maintain ang
Simvastatin 20 mg potassium. Kumain ng
saging.
Lisinopril 20 mg
4.Iwasan ang mga de-lata,
Pantoprazole 40 mg processed foods tulad ng
maling at hotdog.
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 15
 ● Current medications of CDN 5. Express adherence to
Medication Dose Instruction
regular monitoring of
weight
Spironolactone 50 mg Once/ day ● Objective fully met
● The family actually has a
Furosemide 40 mg 2x/ day weighing scale. CDN
verbalized that she will
Lactulose 2 spoons (at put their weighing scale
night) near their CR so that the
moment she wakes up,
● *Most cues are as mentioned above (in CDN’s NHH). she can immediately
● Cues for liver cirrhosis check her weight and
○ Ultrasound report of whole abdomen record it.
considers liver cirrhosis with the following 6. Utilize a weight monitoring
findings suggestive of portal hypertension: record/ sheet
■ Mildly dilated portal vein ● Objective partially met
■ Mild Splenomegaly ● Client mentioned that she
■ Massive ascites weighed the next morning
■ Bilateral renal parenchymal disease but didn't use a weight
■ Non-dilated biliary tree monitoring sheet.
● Client verbalized that she ANDREA KHAYE
■ Slightly yellowish integument L. GUTIERREZ
■ Muscle wasting will track her weight in
○ Massive ascites the next few days and
○ (+) Bipedal pitting edema on lower write it on a notebook.
extremities, Grade 4 7. Express increased quality
○ Slightly yellowish integument and duration of sleep
○ Pale sclera ● Objective not met.
○ *Client’s liver cirrhosis is a complication of ● CDN still has disturbed
her heart failure. Heart failure happened first sleeping patterns despite
before she was diagnosed with liver cirrhosis. morning intake of her
Most cues for heart failure are applicable for medications.
the cues of liver cirrhosis. 8. Report increased comfort as
evidenced by a score of 1-3
in the Likert scale for
Failure to utilize community ● CDN and the whole family does not know any Comfort level
resources for healthcare due community resources they can utilize to help manage ● Objective fully met
to: the symptoms of her heart failure. ● CDN graded her comfort
- Lack / inadequate ● The family does not have the money to actually with a score of 3 (More or
knowledge of utilize any healthcare resource. less comfortable) using
community resources the Likert scale for
● Client verbalized that she wants to get a second
for healthcare comfort.
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 16
 - Inaccessibility of opinion from a different physician at a different 9. Express adherence to the
required care/ service hospital but does not know where. planned nursing
due to cost interventions to improve
constraints Nursing Interventions: quality of life
- Lack or inadequate ● Health Teaching ● Objective fully met
family resources, ● Vital signs checking ● “Tingin ko kaya ko
specifically, financial namang i-apply ang mga
resources Actions Taken: naituro.”
● Obtained vital signs. 10. Determine at least 1
● Assessed the client’s overall psychosocial well-being. community resource for
● Alleviated the client’s anxiety and restlessness by healthcare that can be
therapeutic communication. utilized
● Identified the patient’s methods of handling stress. ● Objective fully met
● Promoted effective techniques for reducing stress. ● VPT verbalized that she
● Reiterated to the patient that current therapies for still utilizes the services
heart failure are targeted on reducing the progression of Sta. Ana Hospital.
of disease, promoting comfort, and enhancing quality ● Client mentioned that her
of life. next hospital visit is in
the first week of ANDREA KHAYE
● Educated client about methods to decrease dyspnea.
November at Sta. Ana L. GUTIERREZ
○ Home Oxygen Therapy
○ Breathing training Hospital.
○ Proper positioning ● VPT mentioned that she
● Discussed other tips to reduce dyspnea. was thankful for knowing
● Explained the mechanism of edema formation in heart Philippine Heart Center
failure. and she will contact them
● Explained the different grades of Pitting Edema. if she can.
● Discussed ways to manage increased fluid volume.
● Educated the client about the paracentesis procedure.
● Encouraged the client to consult a healthcare
professional to determine the right course of action in
terms of alleviating the current symptoms of her heart
failure.
● Explained significant findings from the nutrient
analysis
● Educated the client about the recommended diet for
patients with heart failure.
● Emphasized the need to significantly reduce salt
intake.
● Explained the dietary guidelines for patients with
heart failure, including the recommended servings per
each food category.
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 17
 ● Encouraged the client to eat small but frequent meals.
● Explained to the client the importance of reading food
labels.
● Reiterated the need to reduce fluid intake to minimize
fluid retention.
● Discussed the importance of regular monitoring of
weight.
● Reminded the client about the most important key
points when monitoring weight.
● Provided a weight monitoring sheet with a record of
date and time, and weight per day.
● Assessed when the client takes her medications.
● Facilitated the change of the timing of medications to
minimize nocturia. ANDREA KHAYE
● Reiterated proper positioning and frequent turning to L. GUTIERREZ
promote comfort.
● Determined client’s thoughts and feelings about the
palliative approach to her condition.
● Determined current comfort level after the
implementation of interventions.
● Determined client’s thoughts and feelings about
adherence to the planned nursing interventions to
improve quality of life.
● Educated the client about community resources
accessible to her.

Responses:
● (See Evaluation column).
10/25/2022 Hypertension of RRN as a Assessment: 1. Discuss hypertension in his
9:30 - 10:00 AM Health Deficit ● (10/11/2022) BP: 140/120 mmHg own words
● (10/13/2022) BP: 160/100 mmHg ● Objective fully met
Inability to provide adequate ● (10/25/2022) BP: 140/100 mmHg ● RRN verbalized that
nursing care to the sick, ● Prescribed medications for RRN: hypertension is when
disabled, dependent, or ○ Telmisartan + Hydrochlorothiazide (HCT2) your blood pressure is
vulnerable / at risk family (40 + 12.5 mg) elevated or above 120/80
member due to: ○ Amlodipine (10 mg) mmHg.
- Lack of / inadequate ● Nutrient analysis: 2. Verbalize the normal blood ANDREA KHAYE
knowledge about the pressure reading L. GUTIERREZ
disease/ health ● Objective fully met
condition ● RRN mentioned that the
- Inadequate family normal blood pressure
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 18
 resources for care, Excessive Inadequate reading is <120/80
specifically financial Fat (g) Energy (kcal) mmHg.
constraints CHO (g) CHON (g) 3. Explain at least 3 important
dietary modifications in
Na (mg) Ash (g)
Fiber (g)
patients with hypertension
Ca (mg) consistent with the DASH
P (mg) Diet
Fe (mg) ● Objective fully met
Retinol (µg) 1.Kailangan bawasan ang
B-carotene (µg)
Thiamin (mg) asin. <2g.
Riboflavin (mg) 2.Kailangang iwasan din
Niacin (mg) ang mga pagkain na hindi
Vit. C (mg) maalat pero mataas ang
asin.
● Hypertension and heart problems are the most 3.Magbasa ng nutritional
predominant chronic condition running in the family. facts ng mga pagkain.
4.Kumain ng mga prutas at
● Almost all of RRN’s siblings have hypertension.
gulay.
● The fifth eldest sibling of RRN, aged 62, is revealed 4. Explain what a balanced
to be suffering from hypertension and angina . diet is and its importance to
● All the remaining siblings of RRN are also one’s health, using their
hypertensive. own words
● Both of RRN’s parents died due to a cardiac ● Objective fully met
condition. ● Client discussed ANDREA KHAYE
Pinggang Pinoy in his L. GUTIERREZ
● Client reported that he has been diagnosed with
hypertension a few years back. own words. It is
● Client’s BP usually increases when he is tired or when important because it
the weather is too hot. serves as a visual guide
about the right proportion
● Client does not seem to understand the nature,
of food recommended for
severity, complication, and management of his
one's age.
hypertensive condition.
5. Classify at least 4 food
● Despite RRN’s verbalization of liking a healthy diet, ingredients as Go, Glow,
it is evident in the nutrient analysis of RRN’s 24-hour and Grow foods accurately.
food recall that his food intake is high in fats, ● Objective fully met
carbohydrates, and sodium. ● Client accurately
● Client’s 24-hour food recall is composed of processed classified 6 food
and canned foods. ingredients as Go, Glow,
● Client does not like drinking artificial juices but he and Grow foods
drinks soft drinks about 2-3 times a week. 1.Kanin - Go;
● Client does not regularly monitor his blood pressure 2.Repolyo - Glow;
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 19
 because they don’t have the automated 3.Saging - Glow
sphygmomanometer. 4.Karne - Grow;
● RRN likes spending his time watching the news on 5.Tinapay - Go;
the television, sleeping, and taking frequent rests. He 6.Itlog - Grow
further added that he also likes listening to music to 6. Verbalize understanding of
relax his mind. the sufficient amount per
● RRN no longer performs any type of structured food category
exercise. recommended for their age
● Objective partially met
● Client only remembered
Failure to utilize community ● Client mentioned that sometimes he can’t take the food proportion for
resources for healthcare due medications because there are no medications to take grow and glow foods.
to: in the first place. 7. Express adherence to
- Lack / inadequate ● Client does not visit the most accessible healthcare consistent application of the
knowledge of facility (Bagong Barangay Health Center) for BP planned activities in
community resources monitoring. nutrition to maintain normal
for healthcare ● Client does not visit the Bagong Barangay Health blood pressure
- Lack or inadequate Center for provision of medications since he is ● Objective fully met
family resources, accustomed to going to Jose R. Reyes Memorial ● “Ita-try ko sundan ‘yung
specifically, financial Medical Center for health check-ups for his Pinggang Pinoy para
resources hypertensive condition. ma-maintain ang BP.” ANDREA KHAYE
L. GUTIERREZ
● Client is not well-off to consistently buy maintenance 8. Verbalize adherence in
medications for hypertension. utilizing community
resources to address
Nursing Interventions: hypertension
● Objective partially met
● Health teaching ● Client verbalized that he
● Vital signs checking will try to visit Bagong
Barangay Health Center
Actions Taken: to monitor his BP.
● Reiterated to the client the BP reading during the ● Client expressed
previous house visits. adherence to BP
● Conducted a health teaching about hypertension. monitoring by logging his
● Reiterated the results of the nutrient analysis of BP on a small notebook.
RRN’s 24-hour food recall. ● The next day, the client
● Conducted a health teaching about Dietary visited Jose R. Reyes
Approaches to Stop Hypertension (DASH Diet). Memorial Medical Center
● Emphasized the importance of Pinggang Pinoy and of for his monthly check-up.
conforming with the national guidelines related to Her BP was checked but
nutrition. he wasn't able to recall
● Differentiated Go, Glow, and Grow Foods and the values. He also didn't
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 20
 provided examples of food ingredients under each record and log his BP on
category. a notebook.
● Discussed the food proportion sufficient for RRN’s
nutritional needs according to his age, as per
Pinggang Pinoy.
● Explored client’s thoughts and feelings about
continuous application of the planned interventions to
maintain normal blood pressure.
● Discussed the health programs and services offered at
the Bagong Barangay Health Center.
● Encouraged CDN to continue to go on follow
check-ups based on the doctor’s order. ANDREA KHAYE
● Encouraged the client to visit the healthcare center for L. GUTIERREZ
BP monitoring.
● Encouraged the client to log his BP readings on a
small notebook for easier tracking of his hypertensive
condition.

Responses:
● (See Evaluation column).
10/25/2022 Risk for falls for RRN as a Assessment: 1. Identify at least 2
10:00 - 10:15 Health Threat ● Uncoordinated and unsteady gait precautionary measures to
AM ● Absent left peripheral visual field due to brain reduce risk for falls
Inability to provide adequate aneurysm ● Objective fully met
nursing care to the sick, ● Client verbalized 3
disabled, dependent, or ● Upon observation of the client’s gait, RRN walks precautionary measures to
vulnerable / at risk family slightly unsteady and slow. reduce risk for falls.
member due to: ● “Itong sa kaliwa, hindi ko na masyado nakikita yung 1.Tumayo nang mabagal.
- Lack of/ Inadequate 2.Gumamit ng mga
sa gilid ko ganon.”
knowledge of the handrails at bars kung
nature and extent of ● RRN’s sister revealed that instead of walking straight, kinakailangan.
nursing care needed he has the tendency to walk to the right side to avoid 3.Panatilihing malinis ang ANDREA KHAYE
bumping to anything he cannot peripherally see on his bahay upang maiwasang L. GUTIERREZ
left side. madapa.
● Client needs to be accompanied by another person 2. Express adherence to the
when walking to far places, like when he needs to use of precautionary
measures to reduce risk for
have his check-up in the hospital.
falls
● “Naiinis nga ako minsan sa mga batang takbo nang ● Objective fully met
takbo. Kasi hindi na nga maayos ‘yung kaliwang

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 21

 mata ko kaya minsan nakakabunggo ko ‘yung mga ● Client expressed that he
bata sa labas ganon.” will utilize the use of
● Client does not know how to deal with his current precautionary measures to
reduce risk for falls.
condition.
● Client also mentioned
● Client does not do anything to ensure his safety. that he will delegate his
tasks to the other
Nursing Interventions: members of the family
● Health teaching and that he will avoid
bringing gallons of water
Actions Taken: to their second floors. ANDREA KHAYE
● Educated the client about various precautionary L. GUTIERREZ
measures he can utilize to reduce risk for falls.
● Reiterated to the client the importance of delegating
tasks at home (especially heavy tasks utilizing the
stairs.
● Explored client’s thoughts and feelings about
adherence to the use of precautionary measures to
reduce risk for falls.

Responses:
● (See Evaluation column).
10/26/2022 N/A Nursing Interventions: 1. CDN verbalized use of
9:00 - 9:30 AM ● Continuation of evaluation compression stockings the
night after the health
Actions Taken: teaching.
● Asked CDN on use of compression stockings during 2. CDN mentioned that she
the night. weighed the next morning
● Asked CDN if she weighed herself the next morning but didn't use a weight
after the health teaching. monitoring sheet.
● Assessed CDN’s level of comfort. 3. CDN graded her comfort
● Asked CDN if breathing techniques were utilized. with a score of 3 (More or
● Asked RRN if his BP was logged on a notebook. less comfortable) using the ANDREA KHAYE
Likert scale for comfort. L. GUTIERREZ
4. Client verbalized use of 2:1
Responses: Deep Breathing technique.
● (See Evaluation column). 5. The next day (10/26/2022),
the client visited Jose R.
Reyes Memorial Medical
Center for his monthly
check-up. Her BP was
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 22
 checked but he wasn't able
to recall the values. He also
didn't record and log his BP
on a notebook.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 23