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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:
Pinangay, Marni Flores P.
BSN - II
Submitted to:
Mr. Ray Dominic C. Ladera
Instructor
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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I.
Family Demographic Profile
a.
b.
c.
d.
No.
Head of the family – Michael Apre
Address – Barangay Siha Borongan E. Samar
Type of family: Nuclear Family
Profile (summary)
Name
Family Role
Age
Date of
Birth
Civil
Status
1.
Michael Arre
Father
31
Married
2.
Lany Arre
Mother
27
Married
Nina Gail Arre
Daughter
Nursing
Diagnosis
(*from individual
NCP)
Impaired Verbal
Communication
Figure A. Sketch of living space of family Arre
Bedroom
Kitchen
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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II.
Individualized Nursing Care Process (NCP)
ASSESSMENT
NURSING DIAGNOSIS
Subjective:
“Ang sakit ng dibdib ko,
saka dito sa kaliwang
bahagi ng braso ko” as
verbalized by the patient
Acute chest pain r/t
myocardial ischemia
resulting from
coronary artery
occlusion with
loss/restriction of
blood flow to an area
of myocardium and
necrosis of the
myocardium
Objective:
-Restlessness
-Facial grimacing
-Fatigue
-Weak pulse
-Cold and clammy skin
-Shortness of breath
-Elevated temperature
Planning
STG:
Within 1 hr. of nursing intervention the
client will have improved comfort in
chest as evidenced by:
-states a decrease on the rating of the
chest pain.
-is able to rest displays reduced tension
and sleeps comfortably.
LTG:
-the client had an improved feeling of
control as evidenced by verbalizing a
sense of control over present.
-Goal was met
NURSING INTERVENTION
1. Assess the client’s characteristics of
chest pain, the location, duration and
quality. Have client a rate the pain on a
scale of 1-10 & documents findings.
2. Getting history of previous cardiac
pain.
3. Assess the Bp, Heart rate and
respiration every episode of chest pain.
4. Bed rest during pain in comfort
position. Have a relaxed environment to
promote calmness.
5. Administer the medication and
monitor response to drugs. Inform
physician of the result.
RATIONALE
1. The pain is indication of
MI. Assisting the client to
rate the pain, to
differentiate pre existing
and current pain patterns
as well as identify
complications.
2. This information may
help to compare current
pain from previous
problems and
complications.
3. There may be an
increased of respiration as
a result of pain.
4. To reduce oxygen
consumption and reduced
anxiety .
6. Inform patient in activity alteration and 5. The priority is to control
the pain and monitor the
limitations.
progress of the client .
7. Inform patient’s family the effects and
side effects contraindications and
symptoms of the medication.
6. To decrease the oxygen
demand and workload on
the client.
7.To promote knowledge
and to comply with the
correct therapeutic regimen
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
EVALUATION
STG:
Within 1 hour of
nursing intervention,
the client had
improved comfort as
evidenced by:
- a decreased in the
training of the chest
pain.
-Is able to rest and
sleep comfortable.
LTG:
Within 2 days of
nursing intervention,
the client had an
improved feeling of
control. As the client
verbalized a sense of
control over present
situation
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Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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A. Assessment:
1. Demographic profile
Name : Michael Arre
Age: 31 yrs. old
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Occupation: Farmer
Civil status: Married
Educational attainment: Highschool Level
2. NursingHistory
1. History of Present Illness
- According to him, he suffers a chest pain.
2. Past HealthHistory
– He has no injury.
3. Immunization status
- Incomplete
4. Family Health History
- He has no family history
5. Allergies
- He has no allergies on foods as well as on medications.
3. Gordon’s Typology of 11 Functional Health Patterns(*use the assessment tools provided to
you during NCP lecture)
1. Health-perception/health-management pattern.
2. Nutritional/Metabolic pattern: During the interview with him he said that he has no
prohibition on diet. He often eats fish and vegetables fatty foods and drink water only when he
is thirsty. His eating patterns are 3 times daily. He advised to eat low fat, low salt light meals
with vegetables, fish and bread. Change the food preference, avoid fatty food and drink plenty
of water.
3. Elimination pattern:
-
The patient eliminates 3 times a day he is being told that the normal elimination
pattern which is 3-4 times daily.
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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4. Activity/exercise pattern- Mr. Arre expresses that he experiencing a fatigue, because of her
work which is Farmer. He stop going to the farm because of his illness. He has no history of
falls.
Functional Level Classification
Findings/Assessment
1. Perceived ability for bed mobility
0
2. Perceived ability for general mobility
0
3. Perceived ability for dressing
0
4. Perceived ability for bathing.
0
5. Perceived ability for grooming
0
6. Perceived ability for toileting
0
7. Perceived ability for home maintenance
0
8. Perceived ability for shopping
0
9. Perceived ability for cooking
0
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= complete dependent.
Justification: the client is completely dependent.
5. Sleep and rest pattern: The patient religious affiliation is Roman Catholic, he seldom
go to church due to his job but he never forgot to pray. When he goes to church he
brings his wife. He also believes in Quack doctors. The patient never blame GOD for
his condition, the patient’s relationship with God remained unchanged.
6. Cognitive/perceptual pattern: Upon assessment the health and cognitive perception is he is
aware and understand his present medical condition that he is suffering from chest pain which
will lead to myocardial infarction if not treated, the impact on this on his self perception is his
being worried and restless but he has to accept his medical condition needs comfort and
support from his family and relatives also by praying to God Almighty.
7. Self-perception/self concept pattern: Mr. Arre states that the major concern at this time is
about their health of his daughter. And also the food they eat everyday because he has no
work yet. He said also that he cannot able to give whatever they need because of his
condition.
8. Role/relationship pattern- Mr. Arre states that he is married to Mrs. Lany Bejar and they
have a daughter who is Nina Gail Arre. According to him they have a good relationship with
each other and also to their relatives, friends and neighbours.
9. Sexuality/reproductive pattern- He has no history of prostate glands, No experience of any
problems in sexual functioning and satisfied with sexual relationship.
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10. Coping/stress tolerance pattern- He experience stressful events in the past year when Nina
and him experience a the same illness.
11. Value/belief pattern- He believe that through the faith of God they can face their problems at
all time.
4. Physical assessment (Head-to-Toe assessment)(*use the assessment tools provided to you
during NCP lecture)
1.
Areas
GENERAL SURVEY:
Assessment Findings
Conscious
2.
SKIN (general)
General Skin color: with pallor
Skin texture: rough
Skin turgor: poor
Skin moisture: dry
3.
HEAD:
Scalp: Symmetrical
Rounded, smooth and has uniform
Absence of nodules and masses
-Eyebrows are symmetrically aligned and have equal
4.
EYES
movement
-Lids close symmetrically and blinks
-Has [brown] eyes
-Pupils is Black, equal in size, pupils equally
rounded and reactive to light and accommodation,
pupils constrict when looking at near objects, dilates
at far objects, converge when object is moved
toward the nose at four inches distance and by using
penlight.
5.
EARS
-No cerumen
-Firm, mobile and non tender
-Symmetrical in shape
-Pinna recoils after it is being coiled
6.
Nose
-Symmetric and straight no flaring, uniform in color
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-Mucosa is pink
-No lesions
-No tenderness
7.
MOUTH:
-Symmetrical, pale lips, brown gums and able to
purse lips
8.
PHARYNX:
9.
NECK:
Unable to assess
-Position in midline without tenderness
-Trachea: midline
-Thyroids: non palpable
-thyroid enlargement: None
10.
CHEST AND LUNGS:
Breathing Pattern: Regular breathing pattern
(-) use of accessory muscles
Lung/chest expansion symmetric
Tactile Fremitus: Unable to access
Percussion: Unable to access
Breath Sounds: normal
(-) ICS retraction
(-) sputum
11.
HEART:
(-) Heaves
(-) murmur
(-)Thrills and tenderness
PMI: unable to access
12.
BREAST AND
AXILLAE:
(-) Breast enlargement nodules lesions
Areola shape: symmetric and pigmented
(-) Breast tenderness, masses
(-) nipple retraction
(-) lesions
13.
ABDOMEN:
14.
BACK AND
EXTREMITIES:
(+) Skin dryness
Peripheral impulse present, regular
Nail and beds: pallor
(-)Clubbing of fingers
(-) Edema
Muscle tone and strength: strong equality
Symmetrical, spine in midline
(-)spinal deformity
•
•
(-)fractures
(-) nail clubbing & inflammation
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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15.
GENITO-URINARY:
•
Unable to assess
16.
NEUROLOGICAL
EXAMINATION
MENTAL STATUS:
•
Unable to assess
•
•
•
•
Normal Speech
Oriented to time and person, not oriented to place
(-) memory Intact
(+)Alert, conscious, and coherent
•
Unable to assess
19.
GLASGOW COMA
SCALE:
CRANIAL NERVES:
•
Unable to assess
20.
REFLEXES:
17.
18.
Tendon Reflexes
Right
Left
Biceps
Unable to Unable to assess
assess
Triceps
Unable to Unable to assess
assess
Radial
Unable to Unable to assess
assess
Patellar
Unable to Unable to assess
assess
Achilles
Unable to Unable to assess
assess
Pathologic Reflexes:
(-) Babinski
(-) ankle clonus
(-) kernig’s signs
(-) brudzinsky’s sign
(-) decorticotaion
(-) decerebration
21.
MOTOR/CEREBELLAR:
•
unable to assess
22.
SENSORY:
•
unable to assess
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5.
Vital signs / Measurable cues / Anthropometric Data (use graphs; line, bar, pie charts for
multiple reading)
Parameter
Procedure
Height
Have the individual
stand with his/her back
against the height
board. 2. Have the
individual stand with
feel slightly apart and
back as straight as
possible. The heels,
buttocks and shoulder
blades should touch
the wall or surface of
height board. 3. Have
the individual look
straight ahead with
head erect. 4. Place the
headpiece flat against
the wall at a right
angel to the head.
Lower the headpiece
until it firmly touches
the crown of the head.
5. Read the
measurement at eye
level where the lower
edge of the headpiece
intersects the
measuring tape or
where specified on the
equipment. 6. Read the
measurement to the
nearest ¼ inch. 7.
Record the
measurement on the
growth chart.
-
- 165cm
Analysis and
Interpretation
- Normal
Weight
Have the participant
remove shoes and
heavy outer clothing
such as coat, jacket.
Read the result then
document it.
-
-55lbs
- Normal
120/8o
mmHg
60-10 bpm
-20.20
120/80 mmHg
-Normal
Normal
60bpm
Normal
BMI
BP
Pulse Rate
Respiration Rate
Place the two fingers
(index and middle
finger) on the area of
the wrist. Use a watch
w/a second hand and
count the beat in
minute or 60 seconds.
Respiratory rate is
taken without letting
the patient know what
you are doing because
he/she may control
Normal
Value
16-20 cpm or
12-20 cpm
Actual Findings
10bpm
Not normal due to
chest pain
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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Temperature
6.
his/her breathe which
may result to a false
respiratory rate. Every
ups and down of the
clients breathing is
address as one cycle.
Use a wristwatch with
second hand, get the
RR for 60 sec. or 1
minute.
36.5-37.5 oC
Nowadays a digital
thermometer is being
used to take an axillary
temperature. All you
need to do is to
remove plastic cover.
Clean the pointed end
with cotton and
rubbing alcohol in a
circular motion. Put
the tip of the
thermometer securely
in the armpit. Hold the
arm tightly at the side.
Keep the thermometer
in the armpit until the
digital thermometer
beeps and then Record
the result.
36.8 oC
Normal
Drug Study
Drug
and
content
Dosage /
frequenc
y
Generic:
Atorvastatin
20mg.tab
Brand:
Lipitor
Classificatio
n: Statins
OD
Indication
Used for
treatment of
elevated
cholesterol LDL
triglycerides and
to elevate HDL
cholesterol
-prevents angina
Contraindicatio
n
Drug interaction
Hypersensitivity
, active
liverdisease or
unexplained
persistentelevat
ions of
serumtransami
nase,
Decrease
elimination of ator
Vastatin could
increase levels of
atorvastatin in the
body and increase
the risk of muscle
toxicity from
atorvastatin.
-should not be
combined with
drugs that decreases
its elimination
Nurses
responsibilit
y
-Tell patient to
take drug
at thesame
time each day
tomaintain its
effects
-Instruct
patient to take
amissed dose
as soon as
possible. If it’s
almost time
for his next
dose, he
shouldskip the
missed dose
-Advise patient
to
notify prescrib
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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er immediately
if hedevelops
unexplained
muscle pain,
tenderness, or
weakness
Generic:
Aspirin
Brand:
Bayer
Aspirin
Used to treat mild
80mg/ca to moderate pain
p PO.OD and also to reduce
q lunch
fever or
inflammation.
Sometimes used
to treat or
prevent heart
attack, stroke and
angina. Aspirin
should be used for
cardiovascular
condition only
under the
supervision of a
doctor
Contraindicated
with allergy to
salicylates (more
common with
nasal polyps,
asthma,hemophil
ia, bleeding
ulcers,
hemorrhagic
states, blood
coagulation
defects,
hypoprothrombi
nemia, vitamin K
deficiency
(increased risk of
bleeding)
Interacts with other
drug ex. Ammonia
chloride have been
known to enhance
the intoxicity effect
of salicylates and
alcohol also increase
the gastrointestinal
bleeding associated.
With the types of
the drugs, also
known to display a
number of drugs
from protein binding
sites in the blood.
May also inhibit the
absorption of
Vitamin C.
-Take extra
precautions to
keep this drug
out of the
reach of
children; this
drug can be
very dangerous
for children.
-Use the drug
only as
suggested;
avoid
overdose. Avoid the use
of other overthe-counter
drugs while
taking this
drug. Many of
these drugs
contain aspirin,
and serious
overdose can
occur.
-Take the drug
with food or
after meals if
GI upset
occurs.
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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.
Generic:
Diazipan
Brand:
Valium
Generic:
Amlodipine
Brand:
Norvasac
1
mg
BID TIV
for his
bedtime
Treatment
of
anxiety, alcohol
withdrawal,
muscle spasm
and seizure
Contraindicated
with hypersensiti
vity to
benzodiazepines;
psychoses, acute
narrow-angle
glaucoma, shock,
Can potentially
interacts with
certain other
medication:
-alcohol
-anti depressant
antipsychotic
barbiturates
-grape fruit
-narcotics
-seizure medication
-sleep medication
5mg/day
Used to chronic
stable Angina,
dysrhythmias,
hypertension and
unstable angina
Hypersentivity to
drug or its
components
-Active hepatic
disease or
unexplained
persistent serum
transaminase
elevations
Increase:Neurotoxity lithium
-Hypotension
alcohol,anti
hypersensitive
nitrates
-Amlodipine level
-diltiazen
Decrease:
-anti-hypersensitive
effect NSAIDs
Teaching Point:
Take this drug
exactly as
prescribed. Do
not stop taking
this drug (longterm therapy,
antiepileptic
therapy)
without
consulting your
health care
provider
-Advise him to
minimize GI
upset by eating
small, frequent
servings of
food and
drinking plenty
of fluids
-Instruct him
to avoid
grapefruit
7. Pathophysiology and Anatomy
12. Is not diagnosed.
8.
Laboratory/Diagnostic Study
13. No laboratory results.
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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Form A: Gordon’s Functional Health Pattern (Mr. Arre)
Gordon’s
Functional
Health Pattern
Nursing History
Subjective
Health Perception and
Health Management
“I am suffering from chest
pain” as verbalized by Mr.
Arre.
None
`Presence of adverse personal Failure
to
recognize
or
habits:
respond
to
important
-Smoking
symptoms
reflective
of
-Poor diet selection
changing health state.
-Alcohol abuse
-poor hygiene
Nutrition and Metabolism
“I eat meals 3x a day and
drink 7-8 glass of water. I
have no allergies in any
food and medication.
None
Inability t o procure adequate
amounts of food
Lack of financial resources to
obtain nutritious food.
Elimination
‘I eliminate every 2x a day.
My usual
None
Bowel incontinence related to
lack of accessible toileting
facilities
Difficult to eliminate due to
lack of accessible toileting
facilities.
Activity and Exercise
“I have no history of falls. my
former occupation is farmer
but when I felt the pain in
my chest I stop going to
farm”
None
Activity Intolerance related to
pain and sedentary lifestyle
Inability to begin or perform
activity
Cognition and
Perception
PE
Objective
Laboratory
(if available or if
diagnosed)
Nursing Diagnosis
(at least one diagnosis per
typology)
None
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Justification for the Nursing
Diagnosis
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Sleep and Rest
“I usually sleep 7-8 hours,
earliest time in going to sleep
is at 8:00 pm and I woke up
at 4:00 am, sometimes I take
a nap at noon for about 30
minutes” as verbalized by
Mr. Gerardo
None
Roles and Relationship
“I and my wife has a good
relationship with each other,
we have an average
parenting
skills”
as
verbalized by Mr. Arre
None
Sexuality and
Reproductive Function
“ I doesn’t have any history
of
sexual
transmitted
disease” as verbalized by
Mr. Arre
Stress and coping
Response
Values and Beliefs
“I relieved my stress through ”
as verbalized by Mr.Arre
Sleep pattern disturbance
related pain/discomfort
Sleep pattern can be affected
by
noisy
and
bright
environment
None
Sexuality patterns related to
physical changes or limitations
Safe sex practices
None
Coping ineffective individual
related to recent change in
health status
Spiritual Well-Being,
Readiness for Enhanced
Inability to make decisions,
None
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Patient can manage his time.
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Form A: Summary of Gordon’s Functional Health Pattern
Assessment
Nursing Diagnosis
Planning
Intervention
Nursing History
“When I carry out a heavy object I
suddenly felt a pain in my chest” as Definition
verbalized the Mr. Arre
PE
Diagnostic
Examination/Laboratory
None
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
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Worksheet C (Health Teaching Plan - Individual)
Teaching Objectives
derived from nursing care
plan
*
Strategies
Learning Content
Time
Duration
Resources
* with reference
References: (very important, DO NOT FORGET to include this)
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
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Form A: Gordon’s Functional Health Pattern (Mrs.Arre)
Gordon’s Functional
Health Pattern
Nursing History
Subjective
Health Perception and
Health Management
” I am not satisfied with my Conscious
health status because lack
of financial that cannot buy
a sufficient and
appropriate nutritious food
as verbalized by Mrs. Arre.
None
Nutrition and
Metabolism
“I had a weight loss in the
past 6months, my usual
eating pattern is 2 meals a
day” as verbalized by Mrs.
Arre
None
PE
Objective
Laboratory
(if available or if
diagnosed)
General Skin color: with
Nursing Diagnosis
(at least one diagnosis per
typology)
pallor
Skin texture: rough
Skin turgor: poor
Skin moisture: dry
Elimination
‘I have no problem in
usual frequency of bowel
movement” As verbalized
by Mrs. Arre
Scalp: Symmetrical
None
Rounded, smooth and has
uniform
Absence
of
nodules and
masses
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Justification for the
Nursing Diagnosis
Page 19 of 48
Activity and Exercise
“I have no history of falls.
my former occupation is
farmer but when I felt the
pain in my chest I stop
going to farm”
-Eyebrows are symmetrically
None
aligned and have equal
movement
-Lids close symmetrically
and blinks
-Has [brown] eyes
-Pupils is Black, equal in
size, pupils equally rounded
and reactive to light and
accommodation, pupils
constrict when looking at
near objects, dilates at far
objects, converge when
object is moved toward the
nose at four inches distance
and by using penlight.
Cognition and
Perception
“I expresses concern and
worry about my child and
husband because they are
-No cerumen
None
-Firm, mobile and non tender
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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both experiencing an
illness. but my usual view
of myself is positive.” as
verbalized by Mrs. Arre
Sleep and Rest
-Symmetrical in shape
-Pinna recoils after it is being
coiled
“I usually sleep 7-8 hours,
earliest time in going to
sleep is at 8:00 pm and I
woke up at 4:00 am,
sometimes I take a nap at
noon for about 30
minutes” as verbalized by
Mr. Gerardo
None
-Symmetric and straight no
flaring, uniform in color
-Mucosa is pink
-No lesions
-No tenderness
Roles and
Relationship
“I and my wife has a good -Symmetrical, pale lips,
relationship with each
brown gums and able to
other, we have an average
parenting skills” as
purse lips
verbalized by Mr. Arre
None
Sexuality and
Reproductive Function
“ I doesn’t have any
history of sexual
transmitted disease” as
verbalized by Mr. Arre
None
Unable to assess
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Stress and coping
Response
“I experienced stressful
events in the past month
when the time that my
daughter and husband
experience both illness”
as verbalized by Mr.Arre
-Position in midline without
None
tenderness
-Trachea: midline
-Thyroids: non palpable
-thyroid enlargement: None
Values and Beliefs
“I believed that whatever
Breathing Pattern: Regular
problems we encounter
breathing pattern
now, God won’t leave us
because we have faith and
(-) use of accessory
trust him.
muscles
None
Lung/chest expansion
symmetric
Tactile Fremitus: Unable
to access
Percussion: Unable to
access
Breath Sounds: normal
(-) ICS retraction
(-) sputum
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
,
Page 22 of 48
(-) murmur
(-)Thrills and tenderness
PMI: unable to access
(-) Breast enlargement
nodules lesions
Areola shape: symmetric
and pigmented
(-) Breast tenderness,
masses
(-) nipple retraction
(-) lesions
(+) Skin dryness
Peripheral impulse present,
regular
Nail and beds: pallor
(-)Clubbing of fingers
(-) Edema
Muscle tone and strength:
strong equality
Symmetrical, spine in
midline
(-)spinal deformity
•
•
(-)fractures
(-) nail clubbing &
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
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inflammation
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Page 24 of 48
A. Assessment
1. Demographic profile
Name: Lany Bejar
Age: 27 years
Sex: Female
Nationality: Filipino
Religion: Roman Catholic
Occupation: House Wife
Civil status: Married
Educational Attainment: College Under Graduate
2. Nursing History
1. History of present illness: Mrs. Arre states that she has a fever
in the past week.
2. Past Health History: She states that she has a history in chronic
disease
+ injury- No injury experience
+ Hospitalization- Not yet admitted in any hospital
3. Immunization status: Complete
4. Family health History:
5. 1 Father side: None
6. 2. Mother side: None
7. Allergies: No allergy experience
3. Gordon's Typology of 11 functional health patterns.

Health-perception/health management pattern- Her health status is
Good and she is satisfied of what is her health is. She doesn’t use tobacco and even
alcohol, she has no history of chronic disease and no allergies. As she rate her
working conditions it is Good and her living conditions at home is poor due to lack of
supply, materials, manpower and even financial. She also exercised on daily basis
but it only takes 30mins. As she verbalized also she doesn’t know how to do the self
breast self examination.

Nutritional/Metabolic pattern- In last 6 months she had her weight gain but
she like to lose her weight. She describes her appetite as normal. She had food
intolerances, she has no dietary restrictions. She drinks 8-9 glasses of water. She
describes her usual lifestyle as sedentary.
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
Elimination pattern- She has a normal frequency of bowel movements.
Usually no problem, last bowel movement yesterday. Her usual leisure time activities/
hobbies is reading novel, planting and even gardening. She has no difficulties in
maintaining activities of daily living.
 Activity/exercise pattern- She exercised on daily basis but only
takes 30 mins. No history of falls.
Functional Level
Classification
Findings/Assessment
•
Perceived ability for bed 0
mobility
•
Perceived ability for
0
general mobility
•
Perceived ability for
0
dressing
•
Perceived ability for
0
bathing.
•
Perceived ability for
0
grooming
•
Perceived ability for
0
toileting
•
Perceived ability for
0
home maintenance
•
Perceived ability for
0
shopping
•
Perceived ability for
0
cooking
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= complete dependent.

Sleep and Rest pattern- Her usual sleep habits is at 8pm because as early of
that time she can rest for a period of time. Usually she has no problems in sleeping
such as awakening during the night, difficulty of sleeping, early awakening and
insomnia. Then the method she used to promote her sleeping is relaxation technique.
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
Cognitive/Perceptual Pattern- In terms of decision making she states that
sometimes, she doesn't know what to do because of many problems. She cannot
concentrate to make decision because a lot of problems running out of her mind.

Self-perception/self concept pattern- Ms. Arre states that the major
concern at the current time is the health of her husband and daughter. The usual view
of herself is somewhat positive because she believe that all the problem they
encounter they can solved it. She never been a negative thinker.
 Role-relationship pattern- She is married with Mr. Arre and they have a
daughter who is Nina Gail. They have good relationship to each other. She has an
average parenting skill. She states that she verbally expressing sadness.

Sexuality/reproductive pattern- She states that she has no vaginal
discharge, bleeding, and lesions. She is not experiencing any problems in sexual
functioning. She also states that she is satisfied with her sexual functioning. They use
a contraceptive method which is implanon.

Coping/stress tolerance pattern- She experienced a stressful events in
the past 6 months when the time comes that Nina and Mr. Arre experience an illness.

Value/belief pattern- She believed that whatever problems we encounter now,
God won’t leave us because we have faith and trust him.
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4. Physical assessment (head- to-toe assessment)
Areas
Assessment findings
1. GENERAL SURVEY:
Conscious
2. SKIN:
General Skin color: with pallor
Skin texture: rough
Skin turgor: poor
Skin moisture: dry
3. HEAD:
Scalp: Symmetrical
Rounded, smooth and has uniform
Absence of nodules and masses
4. EYES:
-Eyebrows are symmetrically aligned and have equal
movement
-Lids close symmetrically and blinks
-Has [brown] eyes
-Pupils is Black, equal in size, pupils equally rounded
and reactive to light and accommodation, pupils
constrict when looking at near objects, dilates at far
objects, converge when object is moved toward the
nose at four inches distance and by using penlight.
5. EARS:
-No cerumen
-Firm, mobile and non tender
-Symmetrical in shape
-Pinna recoils after it is being coiled
6. NOSE:
-Symmetric and straight no flaring, uniform in color
-Mucosa is pink
-No lesions
-No tenderness
7. MOUTH:
-Symmetrical, pale lips, brown gums and able to
purse lips
8. PHARYNX:
-Not assessed
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9. NECK:
-Position in midline without tenderness
-Trachea: midline
-Thyroids: non palpable
-thyroid enlargement:None
10. CHEST AND LUNGS:
The chest wall is intact with no tenderness and
masses. There’s a full and symmetric expansion and
the thumbs separate 2-3 cm during deep inspiration
when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless
respirations.
The spine is vertically aligned. The right and left
shoulders and hips are of the same height.
11. HEART:
There were no visible pulsations on the aortic and
pulmonic areas. There is no presence of heaves or
lifts.
12. BREAST AND AXILLAE:
(-) Breast enlargement nodules lesions
Areola shape: symmetric and pigmented
(-) Breast tenderness, masses
(-) nipple retraction
(-) lesions
-The abdomen of the client has an unblemished skin
and is uniform in color. The abdomen has a
symmetric contour. There were symmetric
movements caused associated with client’s
respiration.
-The jugular veins are not visible.
13. ABDOMEN:
14. BACK AND EXTREMITIES:
15. GENITO-URINARY:
16. NEUROLOGICAL
EXAMINATION:
17. MENTAL STATUS:
18. GLASGOW COMA SCALE:
19. CRANIAL NERVES:
olfactory:
Optic:
Oculomotor, trochlear, abducens:
Trigeminal:
Facial:
Vestibulo nochlear:
glossopharyngeal:
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
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Vagus:
Accessory:
Hypoglossal:
20: REFLEXES:
Pathologic Reflexes:
21. MOTOR/CEREBELLAR:
22. SENSORY
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
5. Vital signs/ measurable cues/ anthropometric Data.
Parameter
Procedure
Normal
Actual
Analysis and
findings
interpretation
Have
the
Height
5’1
Mrs. Arre
individual stand
height is
with his/her back
normal
against the height
board.Have the
individual stand
with feel slightly
apart and back as
straight as
possible. The
heels, buttocks
and shoulder
blades should
touch the wall or
surface of height
board.Have the
individual look
straight ahead
with head erect.
Place the
headpiece flat
against the wall at
a right angel to the
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Weight
BMI
BP
head. Lower the
headpiece until it
firmly touches the
crown of the head.
Read the
measurement at
eye level where
the lower edge of
the headpiece
intersects the
measuring tape or
where specified on
the equipment.
Read the
measurement to
the nearest ¼
inch. 7. Record
the measurement
Have the
participant remove
shoes and heavy
outer clothing
such as coat,
jacket. Read the
result then
document it.
Unable to assess
Patient should
60lbs
90/60
She had a weight
loss because they
can’t eat
appropriate
amount of food
Hypotension
sit upright with
their upper arm.
Place the BP cuff
on the patient's
arm.Palpate/locate
the brachial artery
and position the
BP cuff so that the
ARTERY marker
points to the
brachial
artery. Wrap the
BP cuff around the
arm. Position the
stethoscope. Then
document the
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result.
Pulse rate
Respiration
rate
Temperature
Place the two
60-10Bpm
fingers (index and
middle finger) on
the area of the
wrist. Use a watch
w/a second hand
and count the beat
in minute or 60
seconds
Respiratory rate is 16-20Bpm
taken without
letting the patient
know what you are
doing because
he/she may
control his/her
breathe which
may result to a
false respiratory
rate. Every ups
and down of the
clients breathing is
address as one
cycle. Use a
wristwatch with
second hand, get
the RR for 60 sec.
or 1 minute.
Nowadays a
36.5-37.5 oC
digital
thermometer is
being used to take
an axillary
temperature. All
you need to do is
to remove plastic
cover. Clean the
pointed end with
cotton and rubbing
alcohol in a
circular motion.
Put the tip of the
thermometer
securely in the
armpit. Hold the
arm tightly at the
side. Keep the
66Bpm
Has a normal
Pulse rate
35cpm
Has a normal
respiration rate
36’oC
Normal
temperature
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thermometer in
the armpit until the
digital
thermometer
beeps and then
Record the result.
A. Assessment
1. Demographic profile
Name: Nina Gail Arre
Age: 2 years old
Sex: Female
Nationality: Filipino
Religion: Roman Catholic
Occupation: None
Civil status: Single
Educational Attainment: No Formal Schooling
2. Nursing History
1. History of present illness: Her mother states that she suffers
pneumonia.
2. Past Health History: According to her mother Nina has a past
illness w/c is asthma.
+ injury- No experience in injury
+ Hospitalization - According to her mother she admitted on
Borongan Doctor's Hospital
3. Immunization status: Immunization was complete
4. Family health History:
5. 1 Father side: Her father has a history of Pneumonia
6. 2. Mother side: Her mother has no health history
7. Allergies: Nina has an allergy of medicine that prescribed by her
physician
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•
Individual Nursing Care Process.
Assessment Diagnosis Planning
Activities
After 1hr. of
Subjective:
in
nursing
Parents said tolerance intervention
her daughter evidence
the patient
can’t breathe by patient will be able
and very
was
to
weak
supported demonstrate
by her
a decreased
Objective:
relatives
in
Temperature: when
physiologic
37’c
performing signs of
Pulse rate:
activities
intolerance
58Bpm
Respiratory
rate: 28bpm
Intervention
Monitor vital
signs
Adjust
activities
that may
cause
undesired
physiologic
changes
Evaluation
After 1hour
the patient
was able to
demonstrate
in
physiologic
of
intolerance
3. Gordon's Typology of 11 functional health patterns.

Health-perception/health management pattern- Baby Nina uderstand
medical diagnosis and she accept medical condition through the help by her parents.
She is allergic of some medicines that prescribed to her by her physician. She
followed the routine prescribed for her and she never bought any health care
assistance in the past year.
 Nutritional/Metabolic pattern- She currently in a soft diet. Her usual eating
pattern 3 meals a day and oral fluid intake in limited less than 1L a day. She had a
weight loss in last 6 months.

Elimination pattern- Her usual frequency of bowel movement is normal. She
defecate 2x a day and urinate regularly.
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
Activity/exercise pattern- Cannot play daily due to weakness but she can
walk and sit. She has no exercise every day.
Functional Level
Findings/Assessment
Classification
•
Perceived ability for 0
bed mobility
•
Perceived ability for 0
general mobility
•
Perceived ability for 0
dressing
•
Perceived ability for 0
bathing.
•
Perceived ability for 0
grooming
•
Perceived ability for 0
toileting
•
Perceived ability for 0
home maintenance
•
Perceived ability for 0
shopping
•
Perceived ability for 0
cooking
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= complete dependent.

Sleep and Rest pattern- Sleeping pattern of her is usually 8-10 hours at night
and 1 hour nap every day. She has a difficulty of going to sleep because of cough.
Her usual method used to promote sleep is medication and relaxation.
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 Cognitive/Perceptual pattern- Her response is not really well. She is not
really alert because of weakness. Has history of incontinence that related to
increased abdominal pressure by coughing. No history of diarrhea and constipation.

Self-perception/self concept pattern- Her major concern at the current
time is her health. She visualize herself as a positive girl that the illness she suffer
now can be cured. Her admission affect his body changes.

Role-relationship pattern- She lives with her both parents that has an
average rate parenting. She also supported and guided by her both parents in any
situation. She verbally expressing sadness because of her illness.

Sexuality/reproductive pattern- Baby Nina is not yet experiencing a
menstruation. She has no vaginal discharge, bleeding, lesions. She has no
experience in sexual functioning.

Coping/stress tolerance pattern- She rate her usual handling stress is
good, because her way to relieved stress is to sleep, relaxed and sometimes bonding
together with her parents.

Value/belief pattern- She believes that God will take care of everything, she
learn to live without worries, she trust and have faith so that God won't never leave
them at any situation.
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•
4. Physical assessment (head- to-toe assessment)
Areas
Assessment findings
•
GENERAL SURVEY:
•
SKIN:
Nina Skin is dry, brown in color and warm to touch
•
HEAD:
The head is rounded in shape, no massess palpated
Scalp is clean and moist, no lies, dandruff and flakes
seen
•
EYES:
Both eyes are equally reactive to light.
The eyes are clear with white sclera. Conjunctiva is
pink, moist and shiny.
Pupils are black in color, equal in size and round.
Both eyes coordinated and move with parallel
alignment
•
EARS:
External ear canal is clean and moist.
Pinna of the ear is symmetrical to the outer canthus
of the eyes.
Auricle color the same as color of the skin.
•
NOSE:
No vein distention carotid pulse is palpable.
•
MOUTH:
Is not dry and chopped
No lession present
Uniform pink in color
Her gums are pink in coor, no bleeding seen.
•
PHARYNX:
Not assess
•
NECK:
Muscle of the neck are equal in size
No palpable lymph nodes
No vien distention
Carotid pulse palpated
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•
CHEST AND LUNGS:
Chest is symmetrical
Chest wall intact
No tenderness and massess
Breathing is difficult, it is irregular
•
HEART:
There were no visible pulsations on the aortic and
pulmonic areas. There is no presence of heaves or
lifts.
•
BREAST AND AXILLAE:
•
ABDOMEN:
Abdomen is flat and normal in size
Umbilicus is not inverted and it is clean
It is soft to touch, no tenderness
•
BACK AND EXTREMITIES:
Complete sets of extremeties
No lesions palpated
•
GENITO-URINARY:
Not aseses
•
NEUROLOGICAL
EXAMINATION:
Not assess
•
MENTAL STATUS:
Not assess
•
GLASGOW COMA SCALE:
Not assess
•
CRANIAL NERVES:
Not assess
olfactory:
Optic:
Oculomotor, trochlear, abducens:
Trigeminal:
Facial:
Vestibulo nochlear:
glossopharyngeal:
Vagus:
Accessory:
Hypoglossal:
20: REFLEXES:
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Not assess
Pathologic Reflexes:
Not assess
•
MOTOR/CEREBELLAR:
Not assess
•
SENSORY
Not assess
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3. Vital signs / Measurable cues / Anthropometric Data (use graphs; line, bar, pie
charts for multiple reading)
Parameter
Procedure
Height
Have the individual
stand with his/her
back against the
height board. 2.
Have the individual
stand with feel
slightly apart and
back as straight as
possible. The heels,
buttocks and
shoulder blades
should touch the
wall or surface of
height board. 3.
Have the individual
look straight ahead
with head erect. 4.
Place the headpiece
flat against the wall
at a right angel to the
head. Lower the
headpiece until it
firmly touches the
crown of the head. 5.
Read the
measurement at eye
level where the
lower edge of the
headpiece intersects
the measuring tape
or where specified
on the equipment. 6.
Read the
Normal
Value
-
Actual
Findings
-
Analysis and
Interpretation
-
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measurement to the
nearest ¼ inch. 7.
Record the
measurement on the
growth chart.
Weight
Have the
participant remove
shoes and heavy
outer clothing such
as coat, jacket.
Read the result
then document it.
BMI
BP
Pulse Rate
Respiration Rate
Temperature
Place the two
fingers (index and
middle finger) on
the area of the
wrist. Use a watch
w/a second hand
and count the beat
in minute or 60
seconds.
Respiratory rate is
taken without
letting the patient
know what you are
doing because
he/she may control
his/her breathe
which may result to
a false respiratory
rate. Every ups and
down of the clients
breathing is address
as one cycle. Use a
wristwatch with
second hand, get
the RR for 60 sec. or
1 minute.
Nowadays a digital
thermometer is
being used to take
an axillary
temperature. All you
need to do is to
remove plastic
-
-
- Normal
120/8o
mmHg
60-10 bpm
120/80 mmHg
Normal
60bpm
Normal
16-20 cpm
or 12-20
cpm
36.5-37.5
oC
10bpm
36.5oC
Not normal due
to chest pain
Normal
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cover. Clean the
pointed end with
cotton and rubbing
alcohol in a circular
motion. Put the tip
of the thermometer
securely in the
armpit. Hold the
arm tightly at the
side. Keep the
thermometer in the
armpit until the
digital thermometer
beeps and then
Record the result.
3. Drug Study
Drug
and
content
Salbutamol
Drug
content- also
a albuterol it
is a
bronchodilat
or that
relaxes
muscles in
the airways
and
increases air
flow to the
lungs
Dosage /
frequenc
y
Indication
Contraindicatio
n
Drug interaction
Nurses
responsibilit
y
SyrupInitially
0.1 mg/kg
P.O.T.I.D,
Not to
exceed 2
mg. 1(tsp)
t.i.d.
maximum
dosage is
4mg
(2tsp)t.i.d
To prevent and
relieve
bronchospasm in
patients with
reversible
obstructive airway
disease
Hypersensitivity
to drug
Beta adrenergic
blockers;inhibited
albuterol action
possibly causing
brochospasm in
asthmatic patient.
-Digoxin; decreased
digoxin blood level
-Mao inhibitors:
increased
cardiovascular
adverse effect
-Oxytoxics- severe
hypotension
Potassium: wasting
diuretics : ECG
Monitor the
patient
-Stay alert for
hypersensitivit
y reactions and
paradoxical
branchospasm.
Stop drug
immediately if
these occur
-Monitor
serum
electrolyte
levels
Teaching the
patient
-Tell patient or
significant
others swallow
extended
release tablets
whole and not
to mix them
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Hypersensitivity Alkopurinol:
to drug or any increased risk of
penicillin
rash
Chlorampenicolmcrolides,
sulfonamides,
tetracycline
decreased
amoxicillin efficacy
Amoxicillin
Generic name
paracetamol
Brandname
Calpol
2.5 ml
Relief of mild to
moderate pain
treatment of fever
Hypersensitivity
with food.
-Teach signs
and symptoms
of
hypersensitivit
y reaction and
paradoxical
bronchospasm.
Monitor for
signs and
symptoms of
hypersensitivi
ty reaction
-Evaluate for
seizures
when giving
high doses
-Monitor
patient’s
temperature
and watch for
other signs
and
symptoms of
super
infection
-Tell parents
they may give
liquid form of
drug directly
to child or
may mix it
with food or
beverages.
Assess
patient’s fever
or pain: type of
location,
intensity
duration,
temperature
and diaphoresis
-Asses allergic
reactions: rash
if these occur
drug may have
to be
discontinued.
-Teach patient
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to recognize
signs of
chronic
overdose:
bleeding,
bruising,
malaise, fever,
sore throat.
III. Family Nursing Care Plan
A. Initial Data Base for Family Nursing Practice
a. Family structure, characteristics, and dynamics- They are 3 members in
the family. The member is Michael Arre, which is head of the family 31 years
of age. He is married to Lany Bejar which is 27 years old and they have a
daughter which is Nina Gail Arre a 2 yrs old. All of them are native in the Brgy
Siha Borongan E. Samar. The type of there family is Nuclear.
b. Socio – cultural and Cultural Characteristics- Mr. Michael is a farmer but
unfortunately he cannot work right now because of his illness he felt right now.
His income is Ᵽ500 per month. His wife is only in their house and has no
income. Their income is not enough to meet their basic necessities, like food
clothing and shelter because luck of money. The wife is the one who was
making decision of the money how it is going to spent. Mr Michael is a high
school graduate and his wife is a college degree and his daughter has no
formal schooling yet.
c. Home and Environment- In terms of housing their adequacy of living space
is not enough because they could not provide materials that can help to bigger
the space of their house due to financial problem. They sleep in the cement
they have no bed. Because their ventilation is window only the presence of
resting sites of vectors of diseases like mosquitoes, roaches and flies their
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room. The source of their water supply is only in the faucet that comes from
the mountain. They have no toilet supply, they go to the their neighbour if they
use it.
d. Health status of each Family Member- Mr. Arre has past illness which is
asthma and his current illness now is chest pain. His child Nina suffer now a
pneumonia.
e. Values, habits, practices on health promotion, maintenance and disease
prevention- Immunization status of 2 family member is complete but Mr. Arre
was not. They do not use of protective measures like bed nets. No adequate
footwear in parasite infected areas. there relaxation is sleeping and if the
family have time they could bonding.
B. Family Nursing Problems - Summary of First – Second Level Assessment
Cues/Data
Family Nursing Problems
First level – second level
assessment
C. Problem – Priority Setting
Criteria
Computation
Actual Score
Justification
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1. Nature of the problem
2. Modifiability
problem
of
the
3. Preventive potential
4. Salience of the problem
TOTAL Score
Criteria
Computation
Actual Score
Justification
1. Nature of the problem
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2. Modifiability
problem
of
the
3. Preventive potential
4. Salience of the problem
Total Score
D. List of Prioritized Family Nursing Problems
Family Nursing Problem
Score
1. Poor home/environmental
condition/sanitation
2.
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E. Family Nursing Care Plan
Health Problem
Family Nursing
Problems
Teaching
Objectives
Strategies
derived from nursing
care plan
*
Goals and
Objectives
Interventions
Learning Content
Time
Duration
Resources
Resources
* with reference
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015
Evaluation
Evaluation
Page 47 of 48
F. Family Health Teaching Plan
Documentation:
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Page 48 of 48
Family Nursing Care Process (FNCP) format for CHN practice – ESSU College of Nursing 2015