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