Republic of the Philippines EASTERN SAMAR STATE UNIVERSITY COLLEGE OF NURSING Community Organizing Participatory Action Research(COPAR) Related Learning Experience (RLE) Family Nursing Care Process (FNCP) With Individualized Nursing Care Process (NCP) Submitted by: Porteza, Anthony Andy M. Submitted to: Mr. Ray Dominic Ladera, RN Instructor October 2015 FAMILY DEMOGRAPHIC PROFILE Head of the Family: Mr. Carlito Balagbis Barangay Siha, Borongan Eastern Samar Type of Family: Nuclear Name Family Role Age Date of Birth Carlito Balagbis Monica Capito Lisa Balagbis Father Mother Daughter 47 64 14 Feb. 10, 1968 Jul 23, 1951 Dec. 3, 2001 Floor Plan Figure A. Sketch of living space of the Family Civil Status Married Married Single Nursing Diagnosis INDIVIDUALIZED NURSING CARE PROCESS Demographic Profile (Father) Name: Balagbis, Carlito Age: 47 Sex: Male Nationality: Filipino Religion: Roman Catholic Occupation: Farmer Civil status: Married Educational Attainment: Elementary level Nursing history History of present illness Mr. Carlito is suffering from fever for almost 3 days, as evidenced by his body weakness, elevated body temperature, and associated with cough and cold. He stated that he can’t do his work on the farm yet due to his condition. He said that his illness was due to over fatigue, plus the unfavorable changing weather. Past Health History Mr. Carlito said that in the past 1982 he had measles which lasted for more than 1 month. He said he almost died because of that illness. He didn’t seek any medical assistance rather he prefer herbal medication. He has no history of falls and hospitalization. Immunization Status Mr. Carlito stated that he’s not yet immunized, because in his childhood, immunization/vaccination was rare. Family Health History According to the mother of Mr. Carlito, she has goiter. In the past years she experienced lowering/depressing of her tongue causing numbness of her face. She didn’t seek any medical assistance nor went for hospitalization, instead she just looked for herbal medications which she called it “panhangin” Mr. Carlito’s father suffered from fever in the past 3 months, and in the same it was treated through herbal medication. Allergies Mr. Carlito doesn’t have any allergies so far. GORDONS TYPOLOGY OF FUNCTIONAL HEALTH PATTERN 1. HEALTH PERCEPTION AND HEALTH MANAGEMENT Mr. Carlito is a farmer and describes his usual status as fair and satisfied. He uses tobacco consuming 2 packs a day for almost 30 years. Mr. Carlito is also a drunkard. He drinks red horse when there is occasion and when he is stressed. He suffered from measles which lasted for more than one month in year 1982. He doesn’t have any allergy on foods. He is not used to seek health/medical assistance whenever he is sick. He rate his living condition at home as fair. He also mentioned that he has difficulty in seeking services such as grocery shopping, pharmacy, health care facility, transportation especially those that require financial resources. Mr. L’s regular exercise is attributed to his work as farmer, he is exercised whenever he does farm works such as feeding and caring his carabao, planting, and walking in the farm. 2. NUTRITION AND METABOLIC PATTERN Mr. Carlito said that he lost 4 kg of his weight in the past 6 months. He’s not fond of eating regularly; he just eats whenever he is hungry. His typical food intake include bread,root crops, 1-2 cup of rice per meal, his viand is usually vegetable and fish as he is a farmer but sometimes he eats meat. He’s able to drink approximately 1 gallon of water per day. He does not take any food or vitamin supplements. He said he had neither food intolerances nor dietary restrictions. He described his usual lifestyle as active. His average day’s food intake is summarized by the table below. Food Items Approximation Edible portion Calories Measurement (weight Total Calories in grams) Bread (pan de 3 pieces (5x5 cm 40 sal) each) 2servings/slices 1 Fish cm) slice (7x3x2 30 100 300 26 130 Malunggay 2 1 cup cooked 90 16 16 servings/cup ½ cup packed 80 100 800 cm 65 40 40 cm 80 100 200 Rice, cooked 2 pcs. banana 1 (3 diameter) sweet potato 2 (6 diameter) Total calories ------------------------------------------------------------------------------ 1, 486 Total calories needed ------------------------------------------------------------------ 1, 976 Difference --------------------------------------------------------------------------------- -490 Justification The total caloric intake of Mr. Carlito each day is not yet sufficient for his metabolic need. 3. ELIMINATION PATTERN Mr. Carlito don’t have a problem in defecation. He defecates once a day. He described his feces as yellowish to brown in color, formed and with normal consistency. He never used any bowel movements. Mr. Carlito described his voiding pattern as normal. He says he urinates more than 5x a day. He does not experience retention, pain, burning neither sensations nor bladder spasms. 4. ACTIVITY AND EXERCISE PATTERN Mr. Carlito is independent in doing some of his daily activities. He perceives himself as strong and has sufficient energy to perform required activities at home. Mr. Carlitobelieves that he doesn’t need assistance in doing daily activities. Mr. Carlito said that he can climb 100 stairs and walk 3 km without experiencing fatigue and weakness. He spends his leisure time in doing household chores. Here is the ADL functional level of Mr. Carlito. FUNCTIONAL LEVEL CLASSIFICATION FINDINGS/ASSESSMENT Perceived ability for bed mobility 0 Perceived ability for general mobility 0 Perceived ability for dressing 0 Perceived ability for bathing 0 Perceived ability for grooming 0 Perceived ability for toileting 0 Perceived ability for home maintenance 0 Perceived ability for shopping 0 Perceived ability for cooking 0 JUSTIFICATION: Mr. Carlito is completely independent and strong enough to perform activities of daily living. Legend: 0= complete independent 1= requires use of equipment or device 2=requires help from another person for assistance, supervision, or teaching. 3= Requires help from another person and equipment or device 4=requires help from another person and equipment or device. 5. SLEEP REST PATTERN Mr. Carlito gets an average sleep of 8 hours daily. He goes to sleep at 8:00pm and wake up at 4:00am. He sometimes experience difficulty in going to sleep so he drinks warm fluid to be able to sleep. Since Mr. Carlito is a farmer, he wakes up early in the morning. 6. COGNITIVE PERCEPTUAL Mr. Carlito was in pain as he was suffering from fever. He said that his whole body was weak, but he doesn’t want to be hospitalized, so he just stayed at home and took herbal medication. He doesn’t have has difficulty in decision making. He can define what his current problem is but can’t seek for medical assistance due to financial problem. 7. SELF PERCEPTION AND SELF CONCEPT PATTERN Mr. Carlito stated that his major concern at the current time is his health wellness so he can already work in his farm. He has a positive view of himself and believes that he can attain his health wellness. He ranked his perception of his level of control and assertiveness in current situation as 5. 8. ROLE RELATIONSHIP PATTERN Mr. L is living with his wife. They have 1 child. He rates his social activities as active and comfortable. He likes to work in the farm, and do activities/chores at home. 9. COPING-STRESS TOLERANCE PATTERN Mr. Carlito had traumatic event in the past year when he suffered from measles because he almost died from it. He rated his usual handling of stress as average and he believes that the primary way to deal with stress or problems is to be optimistic. Physical Assessment (Head-to-toe assessment) AREAS General Survey Skin Head Eyes Ears Nose ASSESSMENT FINDINGS weak, in pain, clear speech, calm, conscious and coherent, 38.4c body temp. Brown, warm, good turgor, no exudates, no lesion and burns. Symmetrical scalp, flat black and coarse hair normally distributed Pupils were reactive to light (-)lesion, (-) impacted cerumen NA Mouth Moist mucus membrane, dental carries noted, tongue in midline, dry lips. NA NA NA NA NA NA NA Pharynx Neck Chest and Lungs Heart Breast and Axillae Abdomen Back and Extremities Vital Signs/ Measurable Cues Parameter Normal Value Actual Findings Analysis and Interpretation Temperature Respiratory rate 36.6 21 38.4 18 Hyperthermia Normal Blood pressure Pulse rate 120/80 75 120/80 68 Normal Normal INDIVIDUALIZED NURSING CARE PROCESS Demographic Profile (Mother) Name: Capito, Monica Age: 64 Sex: Female Nationality: Filipino Religion: Roman Catholic Occupation: None(housewife) Civil status: Married Educational Attainment: None (grade 1 only) Nursing history History of present illness Mrs. Monica is suffering from cough for almost 3 days, as evidenced by her respiratory difficulty. She stated that her illness was due to cold weather when they stayed at their farm overnight. For now she’s unable to go with her husband in their farm. Past Health History Mrs. Monica said that in the year 2010 she was diagnosed with UTI. She said. She didn’t seek any medical assistance rather she prefer herbal medication. He has no history of falls and hospitalization. Immunization Status Mrs. Monica stated that he’s not yet immunized, because in his childhood, immunization/vaccination was rare. Family Health History According to Mrs. Monica her mother has a history of goiter and hyper menorrhea. She can’t remember any history of her father because he left them when they were still children. Allergies Mrs. Monica doesn’t have any allergies so far. GORDONS TYPOLOGY OF FUNCTIONAL HEALTH PATTERN HEALTH PERCEPTION AND HEALTH MANAGEMENT Mrs. Monica is a housewife, sometimes goes with her husband to help working in the farm. She describes his usual status as fair and satisfied. She suffered from last 2010. She doesn’t have any allergy on foods. She’s not fond of seeking health/medical assistance whenever he is sick. He rate his living condition at home as fair. He also mentioned that he has difficulty in seeking services such as grocery shopping, pharmacy, health care facility, transportation especially those that require financial resources. Mrs. Monica’sregular exercise is also attributed to his work in the farm. NUTRITION AND METABOLIC PATTERN Mrs. Monica said that he lost 2 kg of his weight in the past 6 months. She’s not fond of eating regularly; she just eats whenever he is hungry. Her typical food intake include bread, root crops, 1-2 cup of rice per meal, his viand is usually vegetable and fish as her husband is a farmer but sometimes she eats meat. He’s able to drink approximately 10 glasses of water a day. She does not take any food or vitamin supplements. She said she had neither food intolerances nor dietary restrictions. She described her usual lifestyle as active. Her average day’s food intake is summarized by the table below. Food Items Approximation Edible portion Calories Measurement (weight Total Calories in grams) Bread (pan de 3 pieces (5x5 cm 40 sal) each) 100 300 2 servings/slices 1 slice (7x3x2 30 26 130 Fish cm) Malunggay 1 cup cooked 90 16 16 servings/cup ½ cup packed 80 100 800 cm 65 40 40 cm 80 100 200 2 Rice, cooked 2 pcs. banana 1 (3 diameter) sweet potato 2 (6 diameter) Total calories ------------------------------------------------------------------------------ 1, 486 Total calories needed ------------------------------------------------------------------ 1, 976 Difference --------------------------------------------------------------------------------- -490 Justification The total caloric intake ofMrs. Monica each day is not yet sufficient for her metabolic need. ELIMINATION PATTERN Mrs. Monica doesn’t have a problem in defecation. He defecates once a day. She described her feces as yellowish to brown in color, formed and with normal consistency. She never used any bowel movements. Mrs. Monica described her voiding pattern as normal. She urinates more than 4x a day. He does not experience retention, pain, burning neither sensations nor bladder spasms. ACTIVITY AND EXERCISE PATTERN Mrs. Monica is independent in doing her daily activities. She perceives herself as strong and has sufficient energy to perform required activities at home. Mrs. Monica believes that she doesn’t need assistance in doing daily activities. Mrs. Monica said that she can climb 15 stairs and walk 50 m without experiencing fatigue and weakness. She spends hirs leisure time in doing household chores. Here is the ADL functional level ofMrs. Monica. FUNCTIONAL LEVEL CLASSIFICATION FINDINGS/ASSESSMENT Perceived ability for bed mobility 0 Perceived ability for general mobility 0 Perceived ability for dressing 0 Perceived ability for bathing 0 Perceived ability for grooming 0 Perceived ability for toileting 0 Perceived ability for home maintenance 2 Perceived ability for shopping 0 Perceived ability for cooking 0 JUSTIFICATION: Mrs. Monica almost completely independent and strong enough to perform activities of daily living. Legend: 0= complete independent 1= requires use of equipment or device 2=requires help from another person for assistance, supervision, or teaching. 3= Requires help from another person and equipment or device 4=requires help from another person and equipment or device. SLEEP REST PATTERN Mrs. Monica gets an average sleep of 8 hours daily. She goes to sleep at 8:00pm and wake up at 4:00am. She doesn’t experience difficulty in going to sleep. COGNITIVE PERCEPTUAL Mrs. Monica was in pain as she was suffering from cough. She doesn’t want to be hospitalized, so she just stayed at home and took herbal medication. She doesn’t have any difficulty in decision making. She can define what her current problem is, but can’t seek for medical assistance due to financial problem. SELF PERCEPTION AND SELF CONCEPT PATTERN Mrs. Monica stated that her major concern at the current time is his health wellness so he can already perform household chores well and go with her husband to help working in the farm. She has a positive view of herself and believes that she can attain her health wellness. She ranked his perception of his level of control and assertiveness in current situation as 5. ROLE RELATIONSHIP PATTERN Mrs. Monica is living with her husband. They have 1 child. She rates his social activities as active and comfortable. He likes to work in the farm, and do activities/chores at home. COPING-STRESS TOLERANCE PATTERN Mrs. Monica had traumatic event in the year 2010 when she suffered from UTI. She rated her usual handling of stress as average and he believes that the primary way to deal with stress or problems is to be optimistic. Physical Assessment (Head-to-toe assessment) AREAS ASSESSMENT FINDINGS Good hygiene, in respiratory ditress, clear speech, calm, conscious and coherent, 36.4c body temp. Brown, warm, good turgor, no exudates, no lesion and burns. Symmetrical scalp, flat black and coarse hair normally distributed Pupils were reactive to light (-)lesion, (-) impacted cerumen NA Moist mucus membrane, (-) dental carries noted, tongue in midline, dry lips. NA NA NA NA NA NA NA General Survey Skin Head Eyes Ears Nose Mouth Pharynx Neck Chest and Lungs Heart Breast and Axillae Abdomen Back and Extremities Vital Signs/ Measurable Cues Parameter Normal Value Actual Findings Analysis and Interpretation Temperature Respiratory rate 36.6 21 36.4 20 normal Normal Blood pressure Pulse rate 120/80 75 130/90 73 Hypertension Normal FAMILY NURSING CARE PLAN Initial Data Base for Family Nursing Practice A. Family structure, characteristics and dynamics NUCLEAR FAMILY FAMILY MEMBER Carlito Balagbis Family Role Father Age Monica Capito Mother 64 Lisa Balagbis Daughter 14 47 Date of Birth Feb. 10, 1968 Jul 23, 1951 Dec. 3, 2001 Residence Civil Status Brgy. Siha Married Brgy. Siha Married Brgy. Siha Single Nursing Diagnosis B. Socio-economic and cultural characteristics Family member Educational attainment Occupation Carlito Balagbis Monica Capito Lisa Balagbis Elementary Farmer None Housewife Elementary None(student) C. Home and Environment Source of income Farming Monthly Income P 3,000.00 none Total monthly Expenses P 2,500.003,000.00 Religion Roman Catholic