A Case Study Illustrating Nursing Assessment

Situation:

On an afternoon of a prenatal clinic data the community health nurse was going over
the record file of the patients seen in the morning. She crossed checked this file with the
prenatal appointment book and realized that Mrs. Santos., a 37 years old patient, on her second
trimester of pregnancy, missed her appointment for that day. The nurse went over her record
of previous follow – up. She obtained the following data taken during the patient’s first prenatal
check – up done a week ago.
 Gravida VIII Para VII
 Age of Gestation (AOG) – 21 weeks
 Blood Pressure – 140/90; Weight: 118 lbs
 Abdominal Palpation
 breech presentation
 fundic height – 14 cm
 fetal heart tone – 135 beats/minute; right upper quadrant; regular but faint
 other findings:
 slight pedal edema
 Impression: Pregnancy Uterine, 21 weeks
 management:
 low salt diet
 urinalysis
 to come back next prenatal clinic day
Since the nurse decided to do a home follow – up on the patient, she read the clinical records
of the other members of the family who have gone to the clinic for consultation. She noted
down the following data:
Rina, three years old, got sick of bronchopneumonia, three months ago; weight – 10 kgs
Lita, four and a half years old and Andrea, six years old, were brought to the clinic a
month ago for scabies management included personal hygiene and Benzyl Benzoate in
two applications 12 hours apart and followed by a shower after 12 or 24 hours.

Assessment Process – The available data gathered during this first level assessment reflected
the existence of the following health problems:
1. health deficit
a. Possible Preeclampsia
Supporting cues: 37 years old mother of seven at 21 weeks age of gestation, with
BP of 140/90 and slight pedal edema; weight – 118 lbs
b. Scabies:
Supporting Cues: two pre – schoolers brought to the center for scabies one month
ago
c. Malnutrition
Supporting Cues: 3 year old daughter weight 10 kgs.
 2. health threat
a. threat of cross infection from a communicable disease case
Supporting cues: Two preschoolers with scabies
b. Family size beyond what family resources can adequately provide
Supporting cues: A family of seven, two with scabies, one with malnutrition; mother
at child – bearing period

The nurse decided to do a home follow – up on this family. As part of her preparation for the
home visit, she itemized the important points that are needed to be able to do an in-depth
second level assessment on the list of health problems gathered from the individual clinical
records of the family members. By going through the following question, she aims to determine
the family’s ability to perform the health tasks on the health problems identified earlier:

1. Why did Mrs. Santos fail to go to the clinic check – up? what does the family think about
Mrs. Santos’ condition?
2. How Rina now?

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

 The family lives in a two – room house of light materials situated in a congested urban
community about 3 km from the health center.
 Lita and Andree have varying degree of infected and healed skin eruptions and scabs on
their hands and feet
 Rina looks pala, lethargic and apathetic with scabies too.
 Mrs. Santos is a fish vendor in the community’s market and earns a profit of 250/day.
Mrs. Santos verbalized; “With a meager daily income of P250.00 my husband earns I
need to help increase the family’s income through selling fish, I am so busy that I can
not find the time to have my urine examined. But I do not have problems during my
previous pregnancies and even with my present pregnancy. That’s why I seldom go for
check up at the clinic. It just happened that I guessed by the health center on my way
to my in – law last week, so I thought of dropping by the clinic to have my prenatal
check - up. But actually I feel alright. The doctor mentioned that my blood pressure is
slightly elevate. 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 mornings. It is indeed, difficult to insert in my schedule the
appointment 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” (indigenous midwife)
 … I have such a lot of things to attend to as a fish vendor that I should see 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 elder 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 able to buy another one when it was consumed. This “galis 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 king of life we have now – a meager income despite
the hardwork. We can’t really expert to earn much since we are just elementary school
graduates. We have such a goal for our children that’s why we don’t want additional
children anymore. We have decided on this since I delivered my fifth child, Andrea. We
have been hearing a lot of things about the methods of family planning that cause
tuberculosis, cancer or other diseases. We can’t decided on a method because of this
fear of possible side effects. It might prove to be more expensive on our part, if anyone
of us will get sick as a consequences of any of these methods.

The other members of the family include, Mr. Santos, 40 years old and a construction worker.
Manuel, 14 years old, first year high school. Pedro, 12 years old, grade six; Cita 10 years old,
grade four, Nieves, 8 years old.

 All the older children help in the household chores after schoolwork. They fetch water
from a public artesian well about half a kilometer from the house.
 Mrs. Santos 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 purpose
 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 flies all over.
 garbage disposal; dumping in open pit situated at the back of the house two
meters away with plenty of flies.

The result of the nurse’s in – depth second level assessment on the identified health problems
are presented.

Establishing Priorities – The scoring for such health problem is presented below:

A. Possible Preeclampsia

Criteria Computation Actual Score Justification

1. Nature of the 3/3 x 1 1 The problem is a health deficit
problem and requires more immediate
intervention
 2. Modifiability of 2/2 x 2 2 The resources and
the Problem interventions to solve the
problem are available to the
family
3. Preventive 3/3 x 1 1 The possibility of complications
Potential during labor and delivery and
occurrence of abnormalities in
the infant are prevented if pre
eclampsia is eliminated early
as possible
4. Salience of 0/2 x 1 0 The family does not recognize
the Problem the existence of the problem
Total score 4

B. Malnutrition

Criteria Computatio Actual Score Justification

n
1. Nature of the 3/3 x 1 1 It is a health deficit that
Problem require immediate
management to eliminate
untoward consequences
2. Modifiability 2/2 x 2 2 The problem is easily
modifiable since the nurse’s
resources are available; she
can help the family on
effective budgeting of money
and scheduling of time; she
can develop the skills of other
members to achieve good
nutrition – proper food
selection and preparation and
feeding practices
3. Preventive 3/3 x 1 1 Susceptibility to other diseases
Potential and infections can be
prevented if malnutrition is
eliminated; normal growth and
development can thus be
achieved.
4. Salience 0/2 x 1 0 It is not a felt problem.
Total Score 4

C. Scabies as a health deficit to three preschool members and a health threat to the others.

Criteria Computation Actual Score Justification

1. Nature of the 3/3 x 1 1 It is a health deficit that
Problem requires immediate attention
and adequate management to
 reduce likelihood of transfer of
the disease to the rest of the
family members
2. Modifiability ½x2 1 The family does not have
adequate resources to solve
the problem. Inadequacy of
living space and water supply
are barriers to achievement of
good personal hygiene which
is important in the
management and prevention
of scabies
3. Preventive 3/3 x 1 1 Transferability of scabies to
Potential other family members is
reduced or eliminated if the
problem is managed
adequately as soon as possible

Total Score 4

D. Family Size Beyond What Family resources can adequately provide

Criteria Computation Actual Score Justification

1. Nature of 2/3 x 1 2/3 It is a health threat.
Problem 2/2 x 2 2 Current knowledge,
2. Modifiability interventions and resources
are available to solve the
problem.
3/3 x 1 1 The possibility of increasing
3. Preventive family size is reduced; the
Potential available family resources can
be utilized to encourage
growth – promoting
experiences for members.
2/2 x 1 1 The family recognize the
4. Salience problem as serious and
needing immediate attention.
Total Score 4 – 2/3

E. Inadequate Living Space

Criteria Computation Actual Score Justification

1. Nature of Problem 2/3 x 1 2/3 It is a health threat that does
not demand immediate
action.
2. Modifiability ½x2 1 Increasing the living space
will require quite a financial
expenditure. The family’s
 resources are presently not
adequate considering the
other problems, however,
furniture can be arranged to
allow for more space.
3. Preventive 3/3 x 1 1 Increasing the living space
Potential will:
a. reduce transferability
of communicable
diseases e.g. scabies
b. provide for privacy to
members
c. provide for bigger
space to allow
adequate movements
when performing
housework and joint
recreational leisure or
play activities
4. Salience No data
available
Total score 2 – 2/3

F. Unsanitary Waste Disposal

Criteria Computation Actual Justification

Score
1. Nature of Problem 2/3 x 1 2/3 It is a health threat.
2. Modifiability 2/2 x 2 2 Resources are available and
interventions feasible.
3. Preventive 3/3 x 1 1 Occurrence of parasitism and
Potential other communicable diseases
can be reduced or minimized.
4. Salience No data available
Total Score 3 – 2/3

The list of health problems ranked according to priorities is presented:

1. Family size beyond family resources 4 – 2/3

2. a. Possible Pre eclampsia 4

b.Malnutrition 4

c. Scabies as threat and deficit 4

3. Unsanitary ‘waste disposal 3 2/3

4. Inadequate living space 2 2/3

 Family Nursing Care Plan
Health Family Nursing Goal of Care Objectives of Intervention Measures Methods of
Problem Problem Care Nurse – Resources
Family Required
Contact
Family Size Inability to After After nursing 1.Discuss with the Home Material
beyond make decisions nursing intervention, couple the basic Visit Resources:
what with respect to intervention the family needs of each Visual Aids
family taking the family specifically member including
resources appropriate will decide the couple will those of the marital Human
can health action on be able to partners Resources:
adequately due to: appropriate understand 2.Provide adequate Time and
provide actions to the purpose knowledge on the efforts of
Misconceptions make this and methods various ways of both the
or erroneous pregnancy of and maintaining the size nurse and the
information the last one resources for of the family family
about proposed for Mrs. family 3.Discuss with the
courses of Santos planning: couple the Financial
action advantages and Resources:
a. Can explain disadvantages of Money for
Lack of what planning each method to transportation
knowledge as the family is encourage better
to alternative all about decision – making
courses of b. can on the one most
action open to enumerate appropriate for
the family the various them.
ways of 4.Provide
maintaining information on
the size of the available services
family. 5. Explore with the
c.will select a family especially
method most with the couple,
appropriate ways of
for them encouraging growth
d.can tell promoting leisure
when service and relaxation
for family activities
planning are
offered
including
clinic hours
e.will decide
to practice
ways of
maintaining
family size
after Mrs.
Santos
delivery

Health Family Nursing Goal of Care Objective of Intervention Method of Resources

Problem Problem care Measures Nurse – Required
Family
Contact
Possible 1.Inability to After nursing After nursing 1.Broaden the Home Material
Pre - recognize the intervention, intervention, knowledge of the Visit Resources:
eclampsia presence of a the pregnant the family family on Visual aids
possible member will will: complications of
complication deliver a. pregnancy Time and
in pregnancy spontaneousl encourage a.Discuss the effort of the
due to y to a normal Mrs. Santos implications of the nurse and the
ignorance of baby to leave signs and family
facts. regular symptoms
2.Inability to prenatal presented by Mrs. Transportation
provide checkups at Santos Expenses
adequate the clinic b.Discuss the
nursing care b.Implement consequences of
to a pregnant agreed – failure to take
member due upon health appropriate action
to: actions, on the problem
a. Ignorance especially on 2.Discuss with the
of facts on the the areas of family the courses
nature and nutrition, of action open to
management physical them and the
of the health activity and consequences of
condition general the actions on
b.Ignorance of personal family health
the nature and hygiene functioning
accent of c.decide on 3.Explore the ways
nursing care a hospital to which urinalysis
needed; delivery for can be done,
3.Inability to Mrs. Santos either, by having:
utilize a. a member bring
resources for the specimen to
health care the laboratory and
due to: have the results
a. Failure to available
perceive the b.the agency set
benefits of up its own
health care laboratory for
b. simple tests,
Inaccessiblity especially if
of required accessibility of a
service for laboratory service
urinalysis is a major problem
of most of the
clients in the
community.
 Health Family Goal of Care Objective of Intervention Method of Resources
Problem Nursing Care Measures Nurse – Required
Problems Family
Contact