FAMILY SERVICE AND PROGRESS RECORD Name of Family: Lucas Brgy.

Matungao, Bulakan, Bulacan

SUMMARY ON SIGNIFICANT FINDINGS

A. DEMOGRAPHIC/ SOCIO ECONOMIC AND ENVIRONMENTAL CHARACTERISTICS

FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/ RELATIONAL PATTERN MEMBERS OF HOUSEHOLD LIVING MEMBERS NOT CURRENTLY WITH FAMILY LIVING WITH FAMILY
Melissa Lucas John Paulo Lucas Jean Michelle Lucas Ages 35 2 1 Birthdate Month Day October 30 May 19 July 02 Civil Status Married Type of Family: Nuclear Matriarchal Cecilio Lucas Year 1978 2009 2010

SOCIO-CULTURAL CHARACTERISTIC
All of the member of the family our Roman Catholic Adequate income to support the basic needs o the family Cecilio and Melissa is both a college school graduate. Cecilio work as a factory worker in Taipei, Taiwan Their monthrly income is more than P5000 They are both living in Bulakan, Bulacan since birth Their priorities in expenses are as follows: Food, Health, Clothing, Utilities, Recreation and Savings. In terms of decision making, Melissa is the one who decides for her family.

HOME AND ENVIRONMENT

Age: 38 Birthdate: Dec 11, 1973

Dominant Family Members in

Their house has 2 rooms; 1 for their parents; 1 for them Their water supply came from a public water pump that was used for cooking, washing and bathing They have their owned comfort room, closed pit privy, less than 20 ft and good sanitary condition They dont have any garbage can instead they practice open burning in their background. They have friendly neighborhood Their mode of transportation was tricycle and PUV They usually clean their backyard to prevent the presence of any insecticides in their house They used cell phone as their means of communication.

decision making on matters of health and care tending: Mother Family dynamics, communication patterns, interactional processes and interpersonal relationship: None Discuss about it and father decides on the issue/concern

They are catholic but dont go to church regularly.

They were aware of the Brgy.Health Center Program

B. HEALTH STATUS

HISTORY OF PRESENT/CURRENT OR SIGNIFICANCE PAST ILLNESS

History of Community Acquired Pneumonia

NUTRITIONAL ASSESSMENT
The family always buy fish and vegetables in the market; they seldom buy meats. Occasionally they bought food in the carinderia near their houses for convenience. They usually eat 3 times a day. They seldom eats canned goods and noodles. Sometimes, they drink carbonated beverages

DEVELOPMENTAL ASSESSMENT

RISK FACTOR ASSESSMENT

PHYSICAL ASSESSMENT
Normal Vital Signs

RESULT LABORATARY /DIAGNOSTIC AND OTHER SCREENING PROCEDURE

No laboratory and diagnostic examination / screening procedure done to our client

C. VALUES, HABITS, PRACTICES on HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

BELIEF/PRACTICES

IMMUNIZATION STATUS
The whole family member received complete immunization since birth.

ANTENATAL REGISTRATION/ FAMILY PLANNING

Mr. Bunag does not yet practices family planning because they dont have child/children yet.

LIFESTYLE PRACTICES

AWARENESS of COMMUNITY/ DOH HEALTH PROGRAMS

They used the availability and effectiveness of their Health Center to promote good heath by simply visiting it at least twice a month or more if needed.

They considered their private physician as a first resort in times of sickness They self medicate when experiencing sickness They used the belief in not taking a bath when a girl experience menstruation They believe that there are kulams

Smoking is one of his vices. Occasionally they drink alcoholic beverages

II. HEALTH CONDITION AND PROBLEM SHEET

HEALTH CONDITIONS AND PROBLEMS

Improper waste disposal

FAMILY NURSING PROBLEMS

Inability to recognize the presence the condition or the problem due to: Lack or inadequate knowledge about the conditions

SUPPORTING DATA/CUES
Garbage in the backyard Open drainage system and kanal beside their house

DATE IDENTIFIED RESOLVED

July 12, 2011 July 18, 2011

ACTION/S TAKEN, RESPONSES AND EVALUATION OUTCOMES

Health Teaching -Proper cleaning of backyard -Proper Garbage Disposal -Waste Segregation

Presence of vectors and rodents

Unsegregated Garbage

Unsegregated garbage Open dumping at the backyard

III.

FAMILY NURSING CARE PLAN FAMILY NURSING PROBLEMS OBJECTIVES OF NURSING CARE
Within 4 hours of Inability to provide a home environment which is conducive to health maintenance and personality development due to Inadequate family resources and knowledge nursing interventions, the family will be able to: their practices on handling and preparing 1. Recognize the risk factors that will contribute to the identified problems; 2. Identify the different measures to prevent the arousal of the risk factors of the problem 3. Determine the importance of preparing food.

HEALTH CONDITION

PLAN OF INTERVENTION

EVALUATION PLAN

1. Establish rapport. 2. Assess the family concerning

Improper Food Handling as Health Threat

EVALUATION CRITERIA/INDICATORS, STANDARDS

Goal met. After 4 hours of nursing interventions, the family was able to practice the proper ways about handling food as evidenced by the demonstration of the familys washing of plates, proper arrangement of their kitchen utensils and cleaning of their kitchen as observed by the student nurses after the discussion of proper ways on handling food.

METHODS

TOOLS

Home visit

-Discussion

-Time & Effort

of the student family members

nurses and the

3. Discuss with the family the

health problems that will occur if improper food handling will persist and lead to undesirable illnesses such as diarrhea 4. Teach the family to do proper handwashing and encourage

and handling the food properly; 4. Practice and apply the techniques of food handling and preparation; 5. Keep their kitchen clean and free from insects an rodents.

them to perform it before and after handling foods 5. Encourage the family to keepthe house clean specially thekitchen area

NURSING HEALTH HISTORY

A. Biographical Data Name: JPL Sex: Male Address: Brgy. Matungao, Bulakan, Bulacan Religion: Roman Catholic Birthdate: Dec. 11, 2009 Birthplace: Malolos City, Bulacan Position to the Family: Youngest son (2nd child) Health Care Financing: n/a Occupation: n/a

B. Chief Complaint Yung anak ko ay may madalas makaranas ng sakit sa tiyan at pagtatae. As verbalized by the mother. This is one of the major concern of the mother for her sons health condition. The condition that he is experiencing recently show symptoms such as diarrhea, stomach cramps, evidences of frequent watery stool with greenish color, foul odor, and presence of mucus. The child began to felt those sign and symptoms last 2 weeks until now ( Aug 17, 2011). Her mother noticed that her child feels uncomfortable especially when the child feels pain in his abdominal part. C. History of Present Illness The mother stated that her son experiencing recently, is he showing some evidences of frequent watery stool with greenish color, foul odor, and presence of mucus giving rise to a certain health condition commonly called as amoebiasis or dysentery. It can be acquired by ingesting food-borne microorganisms orally from contaminated food or water which gives result to an infection in the intestinal tract of the human.

D.

History of Past Illness

According to the mother, last year, after the full term delivery of the child, the physician gave an order that her child should be confined in the hospital. The main reason for this is the child showed symptoms of difficulty in breathing, cyanosis, and chest pain.The physician diagnosed the child having an infant pneumonia due to accumulation of infectious pathogenic strain in the respiratory tract of the child. The disease had been inhibited and cured by following the doctors prescription properly and by taking antibiotic drugs to interfere the action of pathogens that causes infectious disease. E. Family History of Illness the clients relatives have a stable health conditionthere are no deceased person indicated in the familial health status. There are no incidence of genetic diseases such as Diabetes Mellitus and even mental illnesses. The childs grandmother is experiencing an enlargement of the hearts tissue or cardiomegaly. The mother of the client suffered in amoebiasis when she is in the age of 20.

GORDONS FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Management Pattern Sa tingin ko, ok naman ang health niya.. yun nga lang, madalas naman siyang magkasakit. As verbalized by the mother. She perceived that her son is vulnerable in certain diseases. Even though her son had taken complete vaccination, she is still not comfortable because she thinks that her sons resistance against illnesses is not stable enough to prevent acquiring diseases again. As for that assertion, she needed to have an immediate action for it by having her child medical check-up for at least 6 times a month as needed. She also did not skip days without her son taking his vitamins and supplement. Her son is experiencing amoebiasis recently and she believes that it was acquired by his trough licking and sucking things that are being contaminated such as toys. She had her childs medical check-up last 2 weeks. She never ignored nor refuted the doctors prescription because she believes that it serves as an important key to cure an illness.

B. Nutritional and Metabolic Pattern

Aug 16 Breakfast 200 ml of bottled milk 3 pcs. of Marie biscuit 250 ml bottled milk cup rice piece of lakatan banana 180 ml of water French fries 250 ml bottled milk

Aug 17 250 ml bottled milk

Lunch Merienda / Snack Dinner

Usuall, the child takes about 3-4 times of bottled milk per day. Her mother felt that her son is gaining weight by lifting his son as an indication. She doesnt know the exact measurement of the weight of her child. Charlie has no problem in his appetite. It is just that he chooses food that he wants to eat. Hindi siya kumakain ng gulay lalo na pag hindi masarap ang lasa gaya ng okra at ampalaya. Uttered by the mother. It is because he doesnt like its taste.

C. Elimination Pattern

Frequency

Amount

Characteristic Clear appearance Light yellow color Aromatic odor Greenish in color Foul odor Soft and watery stool

Urine

6x a day

Approx. 1500 ml per day

Stool

3-4x a day

Base on the mothers observation, her second child sweats excessively especially when the weather is hot during noon time and summer season.

D. Activity and Exercise Pattern Playing outside the house, playing with toys and friends, walking, and running outdoors are the activities that her child typically do everyday. The mother considered those activities can be a form of her sons exercise and it can give contribution to growth and development of her son. Watching TV, playing, and even going to malls are activities that they spend their quality time together when the family has a time for leisure

E. Sleeping and Rest

The client normally get enough of sleep everyday. As a child, he doesnt experience any form of sleep deprivation that usually occurs in adult. He usually fall asleep during 8 o clock in the evening and awakes in about 5-6 oclock in the morning. He takes a one hour nap after meal.

F. Cognitive- Perceptual pattern The mother said that her child has no impairment in his sensory functions. He doesnt have difficulties in visualizing his surrounding. He easily learn, discover, and remember things that captured and caught his interest and attention. During the interview process, the child reacted and responded well. G. Self- Perception and Self Concept Pattern As being asked, the mother described his son as one of the important persons in her life. Her child made her life worth living. She felt that she reached the state of fulfillment as a mother and a woman after she gave birth to her children. She consider her son as a blessing given by God. She is hoping that her son may someday become a loving person to the family. H. Role Relationship Our client belongs to a extended family. He with his immediate family lives in his grandmothers house. His mother is a plain housewife while her father works as an technician abroad in Taipei, Taiwan. Hindi talaga maiiwasan ang pagkakaroon ng problema. stated by the mother. One of the major family problems regarding family regulation and finances is meeting the familys basic needs. She herself manages the expenditures properly by budgeting their monthly finances. She owned a sari-sari store in front of their house which gives an additional budget to their finances.

I.

Coping Stress Tolerance

Mother said that her son is sensitive in noise especially when the noise is loud and distorted that can make him feel irritated and cry. Her mother make him comfortable by giving her child bottled milk and singing him a lullaby. Her son also gets irritated when his things such as toys are using by other without any permission. Her mother make ways to prevent it by placing her childs toys in a proper place. J. Value belief Pattern

Religion and family are things that the mother considered important to her life and her family as well. The family faithfully believe in a thought that with god beside them, nothing is impossible to happen. Her family is a wonderful bless given by God and she shows her gratitude to Him by devoting her time and effort in giving love and care to the family.

Nursing Health History

A. Biographic Data
Name: JME Address: Brgy. Matungao, Bulakan, Bulacan Age: 23 y/o Civil Status: Single Sex: Female Birthday: June 12., 1988 Race: Asian Nationality: Filipino Religion: Roman Catholic Educational Attainment: Underground Final Diagnosis: Fever; 38.7 C

B. Chief Complaint The client has chief complaint of having fever.

C. History of Past Illness According to my patient, she did not experience any serious disease or illness in the past. But she said that there are days that she experienced colds and headache because of stress in her work. She doesnt have any allergies. She completed his immunization when she was a child. She also stated that she experienced having a fever two to three times in a year. D. History of Present Illness According to my patient, Aside from having fever, she experienced colds and headache these past few days. She did not go to the hospital for check-up; she is just having selfmedication and takes a rest until it disappears.
Genogram

GORDONS FUNCTIONAL HEALTH PATTERN

Health Perception and Health Management Pattern

According to my patient, if she will rate her health with a scale of 1-10, 10 being the highest and 1 being the lowest, she told me that she can rate it as 8 because she does not encounter any major illness or disease. She also verbalized that fever, headache and cold is her common problems.

Nutritional and Metabolic Pattern

According to my patient, she eats fruits and vegetables. She likes to eat fish than meat. She seldom eats canned goods and noodles. Even though they dont have enough money to buy and to cook expensive foods, she makes sure that they eat three times a day and eats nutritious foods. 72 HOUR DIET RECALL July 9 Breakfast 1 glass of coffee 3 pcs pandesal Breakfast 1 bowl of lugaw 1 glass of water July 10 Breakfast 4 pcs of sky flakes glass of water July 11

Lunch 1 saucer of sinigang na bangus 1 cup of rice

Lunch 1 piece of galungong 1 cup of rice

Lunch piece of tilapia 1 cup of rice

1 glass of water

1 glass of water

1 glass of water

Dinner 1 saucer of sinigang na bangus 1 cup of rice 1 glass of water

Dinner 1 saucer of pinakbet 1 cup of rice 1 glass of water

Dinner 1 cup of rice saucer of miswa 1 glass of water

Elimination Pattern
The client verbalized that she urinates regularly, at least 3-4 times a day. The usual color of her urine is light yellow. She also said that she does not experience any difficulty in urinating. With regards to her stool, it is well-formed and has a pungent odor. She bowels regularly at least 2 times a day.

Activity and Exercise Pattern My client stated that she can do activities of daily living without difficulty. She also said that she has enough energy to accomplish the ADL. 0 Feeding 0 Dressing 0 Bathing 0 Grooming 0 Toileting 0 General Mobility 0 Bed mobility

Level 0- Full self-care Level I- Requires use of equipment or device Level II- Requires assistance or supervision from another person Level III- Requires assistance or supervision from another person or device

Level IV- IS dependent and does not participate Sleep Rest Pattern
As verbalized by my patient, she sleeps anytime she feels sleepy. Sometimes, she sleeps 9 in the evening and wake in 6 in the morning. She also said that she has no difficulty in sleeping and can complete 6-8 hours of sleep in a day.

Cognitive Perceptual Pattern As stated by her, she does not have any difficulty in seeing, hearing, feeling, tasting, and smelling nor in learning things. The client does not wear any corrective lenses.

Self-Perception and Self-Concept Pattern For the client, her family is her source of strength.

Role Relationship Pattern According to my patient, she has three siblings and she is the eldest. She is already married and a mother of one son. They live together with his parents.

Sexuality Reproductive Pattern

The patients menarche stated when she was 14 years old and regularly menstruate. She is sexually active and has intercourse with her husband 2-3 times a week. She had her first pregnancy at the age of 22.

Coping Stress Tolerance

As stated by my client, she considers her work as the reason for her stress. And whenever stresses, she just goes and spent time with her family especially to her son to relieve her stress.

 Value Belief Pattern

The whole family of my client is Roman Catholic. They dont go to church regularly. The client believes that whenever there is a problem that arise, she knows that God has a plan for it just wait for the good to come. They are regularly going to the church every Sunday to attend the mass.

Nursing Health History E. Biographic Data

Name: HEB Address: Brgy Matungao, Bulacan, Bulacan Age: 54 y/o Civil Status: Married Sex: Male Birthday: June 5, 1967 Race: Asian Nationality: Filipino Religion: Roman Catholic Educational Attainment: Elementary graduate Final Diagnosis: Hypertension

F. Chief Complaint The client has chief complaint of having headache because of stress and hypertension

G. History of Past Illness According to my patient, He did not experienced any serious disease or illness in the past. But she said that there are days that she experienced pain in the back of her lneck and. She doesnt have any allergies.. She also stated that she experienced having a fever two to three times in a year. H. History of Present Illness According to my patient, Aside from having neck pain, headache and dizziness, she experienced colds and headache these past few days. She did not went to the hospital for check-up, she is just having self-medication and take a rest until it disappears

Genogram

GORDONS FUNCTIONAL HEALTH PATTERN

Health Perception and Health Management Pattern

According to my patient, if he will rate her health with a scale of 1-10, 10 being the highest and 1 being the lowest, he told me that he can rate it as 7 because even though he does not encounter any major illness or disease, he feels weak because he is getting older. He also verbalized that having headache and increased blood pressure due to stress is his common problems. Nutritional and Metabolic Pattern According to my patient, He eats fruits and vegetables. He likes to eat fish than meat. She seldom eats canned goods and noodles. Even though they dont have enough money to buy and to cook expensive foods, he makes sure that they eat three times a day and eat nutritious foods. 72 HOUR DIET RECALL July 15 Breakfast 1 glass of coffee Breakfast 1 bowl of noodles 1 glass of water Lunch 1 saucer of tinolang manok Lunch Lunch July 16 Breakfast 3pcs of pandesal 1 glass of water July 17

1 cup of rice 1 glass of water

1 piece of pritong bangus 1 cup of rice 1 glass of water

1 piece of sinigang na baboy 1 cup of rice 1 glass of water

Dinner 2 pcs of halabos na isda 1 cup of rice 1 glass of water Dinner 1 saucer of pinakbet 1 cup of rice 1 glass of water Dinner 1 cup of rice saucer of chopseuy 1 glass of water

Elimination Pattern

The client verbalized that he urinates regularly, at least 3-4 times a day. The usual color of her urine is light yellow. He also said that he does not experience any difficulty in urinating. With regards to his stool, it is well-formed and has a pungent odor. He bowels regularly at least 2 times a day.

Activity and Exercise Pattern My client stated that she can do activities of daily living without difficulty. She also said that she has enough energy to accomplish the ADL. 0 Feeding 0 Dressing 0 Bathing 0 Grooming 0 Toileting General Mobility 0 Bed mobility

Level 0- Full self-care Level I- Requires use of equipment or device Level II- Requires assistance or supervision from another person Level III- Requires assistance or supervision from another person or device Level IV- IS dependent and does not participate Sleep Rest Pattern As verbalized by my patient, he usually sleeps as early as 8 oclock in the evening and wake in 5 oclock in the morning. She also said that she has no difficulty in sleeping and can complete 6-8 hours of sleep in a day.

Cognitive Perceptual Pattern According to my patient, he does not have any difficulty in seeing, hearing, feeling, tasting, smelling nor in learning things. The client does not wear any corrective lenses.

Self-Perception and Self-Concept Pattern For the client, his family is her source of strength. He believes that whenever problems come into their lives, he accepts it and think its part of life and Gods plan.

Role Relationship Pattern According to my patient, He has five siblings and he is the third in the youngest . He is already married and a father of 3 daughter and 3 sons. They live together even some of his daughters/sons were married.

Sexuality Reproductive Pattern The patient is circumcised when he was 13 years old. They used natural method in family planning. He is sexually active and have intercourse with her wife at least twice a week.

Coping Stress Tolerance As stated by my client, he considers his work as the reason for his stress. And whenever stresses, he just goes and spent time with her family or sometimes drink a little.

Value Belief Pattern The whole family of my client is Roman Catholic. They are regularly going to the church every Sunday to attend the mass. The client believes that whenever there is a problem that arise, she knows that God has a plan for it just wait for the good to come. She also know that God is with them all the time and is there no matter what happen.