Republic of the Philippines
EASTERN SAMAR STATE UNIVERSITY
Borongan, Eastern Samar (ZC 6800)
Tel. # (055) 261-2500; Telefax # (055) 262-2725
COLLEGE OF NURSING
Community Organizing – Participatory Action
Research (COPAR)
Family Nursing Care Process
(FNCP)
With Individualized Nursing Care Process
(NCP)
Submitted by:
GEROY, GISELLE C.
08 – 22704
Submitted to:
RAY DOMINIC R. LADERA
Instructor
Date
March 07, 2012
Page 2 of 89
ASESSMENT
FAMILY MEMBER 1:
I. Demographic Profile
Name: Alvarez, Tarcelo
Date of Birth: May 24, 1937
Age: 74
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Address: Barangay Pagbabangnan, San Julian Eastern Samar
Occupation: Farmer
Civil Status: Married
Father’s Name: Alvarez, Manuel (+)
Occupation: Farmer
Mother’s Name: Alvarez, Vicent (+)
Occupation: Housewife
Educational Attainment: Grade 5
II. Nursing Clinical Abstract
Mr. Alvarez, 74 y.o. a resident of Brgy. Pagbabangnan, San Julian Eastern Samar is suffering
from muscle weakness and joint pain.
Vital signs were taken and recorded as follows. T=36.2C PR=72bpm, RR= 25cpm BP= 110/80
mmHg.
Frequent movement and adequate rest was emphasized.
III. Nursing History
1. History of Present Illness
The patient is suffering from muscle weakness. He also experiences joint and muscle pain after
working in the farm.
2. Past Health History
Injury

Client doesn’t remember any major or minor injury.
Hospitalization

Has never been hospitalized.
3. Immunizationa

Client states the he has never been immunized.
4. Family health history
Father’s side
Mother’s side
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Family Nursing Care Process with Individualized Nursing Care Process
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(-) DM
(-) DM
(-) Stroke
(-) Stroke
(-) HPN
(-) HPN
(-) Asthma
(-) Asthma
(-) Arthritis
(+) Arthritis
(-) Cancer
(-) Cancer
(-) TB
(-) TB
Others: None
Others: None
5. Allergies

No known allergies.
IV. Biophysical Assessment
General Appearance
Parameter
Normal Value
Observation
1. Posture/Gestures/Body Movement
Relaxed,
erect
posture,
coordinated movement.
Body frame appropriate
for her age, can stand,
sit, and walk by himself.
Has
coordinated
movement.
Speaks in a moderate
2. Language/Diction
Understandable,
moderate
pace,
tone of voice with clarity.
exhibit
thought association.
3. Facial Expression
Appropriate to the situation
Smiles and respond to
questions appropriately
4. Grooming and Hygiene
Clean and neat
Takes a bath regularly in
the morning, uses soap
and water. No presence
of
skin
itchiness,
No
dryness,
and
presence
unpleasant odor.
Community Organizing- Participatory Action Research (COPAR) – Eastern Samar State University – College of Nursing
Family Nursing Care Process with Individualized Nursing Care Process
rashes.
of
Page 4 of 89
5. Signs of Distress
There
should
be
no
distress noted.
Experiences
joint
and
muscle pain.
Wearing a ”sando”
6. Type of clothing
Appropriate
to
weather
and shorts.
condition.
7. Thought
process,
content,
perception
and
Logical sequence, makes
sense, has a sense of
reality.
Has
no
difficulty
in
hearing and does not
use eye glasses.
V. Gordon’s Typology of 11 Functional Health Pattern
1. Health-perception/ Health-management pattern
Actual Findings:
The client is willing to undergo health management practices to improve his condition.
Normal Findings:
Perception depends on the acuteness of senses. It is the awareness and interpretation of stimuli
that serves as a basis for understanding. Health is a state of physical, mental, and social well-being, and
not merely the absence of disease or infirmity. Health is being free from symptoms of disease and pain as
much as possible (Kozier 2008).
Person has a capacity for a reflective self awareness including assessment of their own
competencies (Kozier 2008).
Analysis and Interpretation:
The client has a good health belief and is willing for consultation at the nearest hospital and to
follow the doctor’s order for the maintenance of his health
2. Nutritional/Metabolic pattern
Actual Findings:
The client eats three meals a day. Consumes 2 cups of rice every meal with fish and vegetables
as their main dish.
Normal Findings:
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Family Nursing Care Process with Individualized Nursing Care Process
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People require essential nutrients in food for growth and maintenance of all body tissues and the
normal functioning of all body process.
Fluid: average adult needs 2500mL/day
Analysis and Interpretation:
He should continue to eat a healthy diet, following the recommended portions of the four food
groups, with special attention to protein, calcium, and limiting cholesterol and caloric intake. Adequate
nutrition leads to good health.
3. Elimination Pattern
Actual Findings:
The client defecates everyday. He urinates 4times a day and sometimes arise during night time,
reports no pain when voiding and defecating.
Normal Findings:
Elimination of waste products of digestion from the body is very essential to health.
Normal characteristics of Feces
Color: brown
Consistency: formed soft, semi-solid, moist
Frequency: 1-2 bowel movement/day
Normal characteristics of Urine
Amt.: 1200-1500/ 24 hours
Color: transparent
Glucose, ketones, blood: not present
Analysis and Interpretation:
The excretory function diminishes with age, but usually not significantly below normal levels
unless a disease process intervenes. The capacity of the bladder and it’s ability to completely empty
diminish with age. This explains the need for elderly adult to arise during the night to void.
4. Activity/exercise pattern
Actual Findings: He sometimes takes a walk in their yard early in the morning. He experiences muscle
weakness. He is also suffering from muscle and joint pain.
Normal Findings: Regular exercise promotes both physical and emotional health. In general, health
guidelines recommended exercise at least 3x a week for 30-45 minutes.
Analysis and Interpretation: Brisk walking is an exercise which strengthens the cardiac muscle, good for
brain and bones, helps alleviate symptoms of depression, and improves fitness and physical function.
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Page 6 of 89
5. Sleep and Rest Pattern
Actual Findings:
Goes to bed at 10 pm and awaken at 4a.m. States he often has trouble falling asleep because of
muscle and joint pain . Sometimes he does not feel rested when she awakens and has difficulty lying flat.
States that he is irritable during night time.
Normal Findings:
Rest and sleep restores the body’s energy levels and are an essential aspect of stress
management.
Adult: 6-8 hours/day
Analysis and Interpretation:
There is disruption of the sleep-wake cycle because of the patient’s disease. He cannot sleep well due to
his condition. Ilness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep
than normal and the normal rhythm and wakefulness is often disturbed.
6. Cognitive/Perceptual Pattern
Actual Findings:
Speech clear without stutter. Word choice appropriate to education and culture.
Follows verbal cues.
Normal Findings:
No deficit in sensory perception.
Analysis and Interpretation:
He examines ideas clearly and concisely. Recalls past events without
difficulty, orientated to time, place, and person.
7. Self-perception/Self-concept pattern
Actual Findings:
He don't considered himself as a holistic person. She thinks that he can't function well than before.
Normal Findings:
Specific component of self-concept includes; personal identity, body image, self-esteem, and role
performance.
Analysis and Interpretation:
Due to his present condition, there is a change to the level of patient self-perception and
self-concept due to her illness on her age of life. She now thinks that she can’t function well as
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Family Nursing Care Process with Individualized Nursing Care Process
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before. Events or situations maychange the level of self-concept overtime illness and trauma can also
affect the self-concept.
8. Role/relationship pattern
Actual Findings:
Patient is married and a farmer. He works in the farm for to satisfy their basic needs. He is also
active and socializes with her friends and neighbors.
Normal Findings:
Individual’s perception may or may not match the evaluation of others who relate to the person.
Roles that individuals follow in given situations involve socialization, to expectations, and standards of
behavior.
Analysis and Interpretation:
He achieves his emotional and moral support from her families and friends, which will help her to
cope with her present condition.
9. Sexuality/reproductive pattern
Actual Findings:
He does not engage in sexuality activity nowadays..
Normal Findings:
Sexual desire varies among individual.
Analysis and Interpretation:
Patient does not engage in sexual activity due to his age and condition.
10. Coping/stress tolerance pattern
Actual Findings:
When he is anxious
he
wants
to
be
alone and
have
some
rest. When he has
problems she used to communicate and share his problems to his family and friends. He makes himself
busy listening to radio.
Normal Findings:
Can manage stress effectively.
Analysis and Interpretation:
The patient has outlet to let her feelings of stress out by interacting with the family and
friends during visitation hours and the ability of the patient to adapt on his condition to lessen stress.
11. Value/belief pattern
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Family Nursing Care Process with Individualized Nursing Care Process
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Actual Findings:
He
believes
that
God
will
always
help
them. According to her family they still attend
mass even without him, praying for patient’s faster recovery.
Normal Findings:
Values are enduring beliefs or attitudes about worth of a person, objet, idea, or action. Beliefs are
interpretations or conclusions that people accept as true. They are based more on faith than fact and may
or may not be true.
Analysis and Interpretation:
He believes that everything has a purpose or reason, the patient take his present situation as a
challenge, and with the
supports
of his
families, he
accepted
his
condition
and
she
will seek medical assistance for check-ups for prevention of her illness in the future.
Without a strong opposition with his values and beliefs, treatment would be easier to improve the
client’s condition.
VI. Vital signs/ Measurable Cues
Area
Procedure
Normal Findings
Actual Findings
Height
Use of measuring
device
---
---
Weight
Weighing scale
---
---
Temperature
Use of thermometer
36°C-37.5°C
36.2C
Normal
65 bpm
Pulse Rate
Palpation
60-100bpm
Normal
18 cpm
Respiratory Rate
Inspection
14-20bpm
Normal
110/80 mmHg
Blood Pressure
Use of BP apparatus
120/80 mmHg
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Family Nursing Care Process with Individualized Nursing Care Process
Page 9 of 89
Normal
Glasgow Coma Scale
Score
Eye Opening Response
Verbal Response
Motor Response
Spontaneous
4
To voice
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sound
2
None
1
Obeys command
6
Localizes pain
5
Withdraws
4
Flexion
3
Extension
2
None
1
Total
15
Temperature
40
30
temperature
20
10
0
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Family Nursing Care Process with Individualized Nursing Care Process
4
5
6
15/15
Page 10 of 89
Pulse Rate
70
60
50
40
30
20
10
0
30
Respiratory Rate
25
20
15
RR
10
5
0
Blood Pressure
200
180
160
140
120
100
80
60
40
20
0
systolic
diastolic
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Page 11 of 89
VII. Physical Assessment
Assessment
Areas
Analysis
Normal Findings
Actual Findings
Inspection and
Normocephalic, no
Normocephalic, no
Palpation
edema, no lesions
edema. No lesion
Technique
&
Interpretation
1. Head
-Skull
NORMAL
should be noted.
-Hair
Inspection
Evenly distributed.
Evenly distributed
NORMAL
-Scalp
Inspection
No dandruff, oily,
No dandruff and
NORMAL
Palpation
even in color.
even in color
Inspection
Symmetrical
-Face
-Eyebrows
Inspection
in
Symmetrical
in
NORMAL
present
NORMAL
facial movement.
facial movement
Normally
the
Are
eyebrows
are
bilaterally,
present bilaterally,
move
symmetrically.
move
symmetrically
the
as
facial
expression
changes,
and
have no scaling or
lesions.
-Eyelashes
Inspection
Evenly distributed
Evenly distributed
along
and
the
lid
margins and curve
NORMAL
curved
outward
outward.
-Eyelids
Inspection
The
upper
normally
lids
overlap
the superior part
Skin
without
is
intact
NORMAL
redness,
swelling, or lesion.
of the iris, and
approximate
completely
with
the
lids
lower
when closed. The
skin
is
without
intact
redness,
swelling,
discharge,
or
lesion.
-Lower
palpebral
Inspection
Pinkish in color
Pinkish in color.
NORMAL
conjunctiva
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-Cornea
Inspection
-Pupils
Inspection
Appears
regular
round,
and
of
equal size in both
Round,
regular
NORMAL
and of equal size
in both eyes.
eyes
-Lacrimal gland
Inspection
No
edema
or
tenderness
over
No
edema
and
tenderness
NORMAL
over
lacrimal gland.
lacrimal gland.
Inspection and
Are
Are
palpation
bilaterally with no
bilaterally with no
swelling
or
swelling
or
thickening,
no
thickening,
no
discharges,
no
discharges,
no
-Eye movement
-Visual acuity
-Ears
-External ear canal
Inspection
equal
sizes
equal
sizes
lesions.
lesions.
No redness and
No
swellingno lesions,
swelling
no foreign bodies,
lesions, no foreign
or discharge.
bodies,
redness
and
NORMAL
NORMAL
no
or
discharge.
-Gross
Not assessed
hearing acuity
-Nose external
Inspection and
Symmetric, in the
Symmetric, in the
Palpation
midline,
midline,
and
in
and
NORMAL
in
proportion to other
proportion to other
facial features.
facial features.
-Internal nares
-Septum
-Lips
Inspection
Lips
should
be
uniform in color,
smooth,
Black
Uniform in color,
NORMAL
smooth, moist.
moist.
persons
normally
may
have bluish lips.
-Gums
Inspection
Gums should look
Gums
pink or coral with a
and
stippled
margins
(dotted)
look
the
surface. The gum
teeth
margins
defined.
at
the
pink
NORMAL
gum
at
are
the
well
teeth are tight and
well defined.
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-Teeth
Inspection
32 teeth for adults,
Has 32 teeth, and
Indicates
white, shiny tooth
has cavities noted.
much
enamel.
-Tongue
Inspection
too
fluoride,
tooth decay
The color is pink
Is pink and even.
NORMAL
It should look pink,
Is
smooth
NORMAL
smooth and moist.
and moist.
NORMAL
and
even.
The
dorsal surface is
normally
roughened
from
the papillae. A thin
white coating may
be present.
-Buccal mucosa
Inspection
pink,
-Palate, soft and hard
Not assessed
-Uvula
Not assessed
-Tonsils
Not assessed
-Neck
Inspection and
No palpable mass,
No palpable mass,
Palpation
not
not tender, uniform
2.
Thorax & Lungs
-Breathing pattern
tender,
uniform in color
in color
Quiet
Dull sound at the
Not
&effortless
right affected lung
indicative of fluid
respiration
noted, presence of
accumulation,
crackles noted
Air
Not assessed
Auscultation
rhythmic,
normal;
passing
through fluid or
mucus in any air
passage
3. Heart
Not assessed
4. Breast
Not assessed
-Areola
Not assessed
-Nipple
Not assessed
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5. Abdomen
Inspection
Unblemished skin;
Unblemished skin
Uniform in color.
and
uniform
NORMAL
in
color.
Auscultation
Audible
bowel
sounds,
absence
Audible
bowel
of arterial bruits,
sounds,
absence
absence of friction
of arterial bruits,
rub.
absence of friction
NORMAL
rub.
No
evidence
enlargement
Percussion
of
of
No
evidence
liver or spleen
enlargement
Symmetric
liver or spleen
contour.
Symmetric
of
of
NORMAL
contour.
Flat, rounded, or
scaphoid.
Flat
Palpation
NORMAL
6. Upper extremities
Inspection
No tenderness, no
No tenderness, no
-Hands, fingers, nails,
Palpation
lesion, uniform in
lesion, uniform in
color,
color, capillary refill
wrist,
elbows,
shoulder
7.
Lower extremities
Thighs, knees, ankle,
capillary
refill 1-2 seconds,
is
nails are short and
and nails are short
clean
and clean
Inspection
No tenderness, no
No tenderness, no
Palpation
lesions, uniform in
lesions, uniform in
color,
color,
foot and distal
deformities
8. Genitatia
no
1-2
NORMAL
seconds,
NORMAL
no
deformities
Not Assessed
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Page 15 of 89
IX. Pathophysiology of Arthritis
Presentation of antigen to T – cells
T – cell and B – cell proliferation.
Swelling of small joints,
Angiogenesis in synovial lining.
Associated with pain, stiffness, and
fatigue
Neutrophil accumulation in synovial fluid.
Warm, swollen, effusions, pain, Cell
proliferation.
and decreased motion, with cartilage
Possible rheumatoid nodules
invasion
Synovitis.
Increase in severity of physical
Early pannus invasion.
signs and symptoms .
Chondrocyte activation.
Degration of cartilage by proteinase.
Subchondral bone erosion.
Joint instability, contractures,
Pannus invasion of cartilage.
Decreased ROM, systemic
Chondrocyte proliferation.
complications
Laxity of ligaments.
Figure 1. Pathophysiology and associated signs of rheumatoid arthritis
In the Rheumatoid arthritis, the autoimmune reaction primarily occurs in the synovial tissue.
Phagocytosis produces enzymes within the joint the enzymes break down collagen causing edema,
proliferation of the synovial membrane, nd ultimately pannus formation. Pannus destroys cartilage and
erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle fibers undergo
degenerative changes. Tendon and ligament elasticity and contractile power are lost.
Deformities of the hands and feet are common in RA. The deformity may be caused by
misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation)
that occurs when bone slips over another and eliminates the joint space.
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Page 16 of 89
X. Prioritization of identified problem
Health problem
Cues
Justification
“Masu-ol it ak kaluluthan ug
Joint pain, swelling and stiffness
and increased disease
nahubag it ak mga siki” as
especially in the morning lasting
activity secondary to
verbalized by the patient
for than 30 minutes. Limitation in
rheumatoid arthritis
(+) pain 6 pain scale
in function can occur when there
(+) swelling
is active inflammation in the
1. Acute pain r/t inflammation
joints.
Smeltzer, Suzanne et, al. Medical
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 1621
2. Fatigue r/t increased
disease activity
(+) stiffness
Stiffness, depression, and
(+) depression
medications may also
compromise the quality of sleep
and increase daytime fatigue.
Smeltzer, Suzanne et, al. Medical
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 1615
3. Impaired physical mobility
decrease ADL
Joints that are hot, swollen, and
r/t decreased range of
painful are not easily moved.
motion
Immobilization for extended
periods can lead to contractures,
creating soft tissue deformity.
Smeltzer, Suzanne et, al. Medical
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 1621
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Health Problem
Scientific Rationale
Goal and Objectives
Acute pain r/t
The autoimmune reaction
Goal: Improvement in
inflammation and
primarily occurs in the
comfort level; incorporation
increased disease activity
synovial tissue.
of pain management
secondary to rheumatoid
Phagocytosis produces
techniques into daily life.
arthritis
enzymes within the joint
the enzymes break down
Rationale
collagen causing edema,
“Masu-ol it ak kaluluthan
proliferation of the
that exacerbate or
ug nahubag it ak mga siki”
synovial membrane, nd
influence pain
as verbalized by the
ultimately pannus
response.
patient
formation. Pannus
The patient was able to:
1. Identifies factors

Provide variety of

comfort measures
a. Application of heat
or cold
Pain may respond
pharmacologic
influence pain
interventions such
erodes the bone. The
changes, rest
exercise,
Foam mattress,
relaxation, and
articular surfaces and joint
supportive pillow,
thermal modalities
motion. Muscle fibers
splints
undergo degenerative
d. Relaxation
changes. Tendon and
techniques,
ligament elasticity and
diversional
contractile power are lost.
activities
Identifies factors
that exacerbate or
b. Massage; position
c.

to non –
destroys cartilage and
consequence is loss of
Evaluation
Objectives:
Subjective:
Objective:
Nursing Intervention
as joint protection,


Limitation in function can
2. Administer anti –
occur when there is active
inflammatory,
disease responds
pain management
inflammation of the joints.
analgesic, and slow –
to individual or
strategies
Smeltzer, Suzanne et, al.
acting antirrheumatic
combination
Pain of rheumatic
Identifies and uses
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Medical Surgical Nursing,
medications as
C: 2004 Lippincot
prescribed.
Williams & Wilkins 10th
3. Individualize
edition. Vol 2 page 1621

Previous pain
medication schedule to
experiences and
meet patient’s need for
management
pain management.
strategies may be
different from
those needed for
persistent pain.
4. Encourage

verbalization of
Verbalization

Verbalizes
decrease in pain
promotes coping.
feelings about pain
and chonicity of
disease.
5.
Teach

Knowledge of

Reports signs and
pathophysiology of
rheumatic pain and
symptoms of side
pain and rheumatic
appropriate
effects in timely
disease, and assist
treatment may help
manner to prevent
patient to recognize
patient patient
additional
that pain often leads to
avoid unsafe,
problems
unproved treatment
ineffective
methods.
therapies.
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6. Assist in identification

The impact of pain

Verbalizes that
of pain that leads to
on an individual ‘s
pain often leads to
use of unproven
life often leads to
the use of non-
methods of treatment.
misconceptions
traditional and
about pain and
unproved self
management
treatment methods
techniques.
7. Assess for subjective
changes of pain.

The individual’s

Identifies changes
description of pain
in quality or
sensation is a
intensity of pain
more reliable
indicator than the
objective
measurements
such as change in
vital signs, body
movement, and
facial expression.
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Page 20 of 89
FAMILY MEMBER 2:
ASESSMENT
I. Demographic Profile
Name: Alvarez, Estrella
Date of Birth: June 30, 1941
Age: 71
Sex: Female
Nationality: Filipino
Religion: Roman Catholic
Address: Barangay Pagbabangnan, San Julian Eastern Samar
Occupation: Housewife
Civil Status: Married
Father’s Name: Nibal, Marcos (+)
Occupation: Farmer
Mother’s Name: Abucay, Candida (+)
Occupation: Housewife
Educational Attainment: Grade 6
II. Nursing Clinical Abstract
Mr. Alvarez, 74 y.o. a resident of Brgy. Pagbabangnan, San Julian Eastern Samar is suffering
from muscle weakness and joint pain.
Vital signs were taken and recorded as follows. T=36.2C PR=72bpm, RR= 25cpm BP= 110/80
mmHg.
Frequent movement and adequate rest was emphasized.
III. Nursing History
1. History of Present Illness
The patient is suffering from muscle weakness. He also experiences joint and muscle pain after
working in the farm.
2. Past Health History
Injury

Client doesn’t remember any major or minor injury.
Hospitalization
Has never been hospitalized.
3. Immunization

Client states the he has never been immunized.
4. Family health history
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Father’s side
Mother’s side
(-) DM
(-) DM
(-) Stroke
(-) Stroke
(-) HPN
(-) HPN
(-) Asthma
(-) Asthma
(-) Arthritis
(+) Arthritis
(-) Cancer
(-) Cancer
(-) TB
(-) TB
Others: None
Others: None
5. Allergies

No known allergies.
IV. Biophysical Assessment
General Appearance
Parameter
1. Posture/Gestures/Body Movement
Normal Value
Relaxed,
erect
posture,
coordinated movement.
Observation
Body frame appropriate
for her age, can stand,
sit, and walk by himself.
Has
coordinated
movement.
Speaks in a moderate
2. Language/Diction
Understandable,
moderate
pace,
tone of voice with clarity.
exhibit
thought association.
3. Facial Expression
Appropriate to the situation
Smiles and respond to
questions appropriately
4. Grooming and Hygiene
Clean and neat
Takes a bath regularly in
the morning, uses soap
and water. No presence
of
skin
itchiness,
No
dryness,
and
presence
rashes.
of
unpleasant odor.
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5. Signs of Distress
There
should
be
no
distress noted.
Experiences chest pain,
and
with
productive
blood
cough
streaked
sputum.
6. Type of clothing
Appropriate
to
weather
condition.
Wearing
a
dress
(daster).
7. Thought
process,
perception
content,
and
Logical sequence, makes
sense, has a sense of
reality.
Has
no
difficulty
in
hearing and does not
use eye glasses.
V. Gordon’s Typology of 11 Functional Health Pattern
9. Health-perception/ Health-management pattern
Actual Findings:
The client is willing to undergo health management practices to improve his condition.
Normal Findings:
Perception depends on the acuteness of senses. It is the awareness and interpretation of stimuli
that serves as a basis for understanding. Health is a state of physical, mental, and social well-being, and
not merely the absence of disease or infirmity. Health is being free from symptoms of disease and pain as
much as possible (Kozier 2008).
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Person has a capacity for a reflective self awareness including assessment of their own
competencies (Kozier 2008).
Analysis and Interpretation:
The client has a good health belief and is willing for consultation at the nearest hospital and to
follow the doctor’s order for the maintenance of his health
10. Nutritional/Metabolic pattern
Actual Findings:
The client eats three meals a day. Consumes 2 cups of rice every meal with fish and vegetables
as their main dish.
Normal Findings:
People require essential nutrients in food for growth and maintenance of all body tissues and the
normal functioning of all body process.
Fluid: average adult needs 2500mL/day
Analysis and Interpretation:
He should continue to eat a healthy diet, following the recommended portions of the four food
groups, with special attention to protein, calcium, and limiting cholesterol and caloric intake. Adequate
nutrition leads to good health.
11. Elimination Pattern
Actual Findings:
The client defecates everyday. He urinates 4times a day and sometimes arise during night time,
reports no pain when voiding and defecating.
Normal Findings:
Elimination of waste products of digestion from the body is very essential to health.
Normal characteristics of Feces
Color: brown
Consistency: formed soft, semi-solid, moist
Frequency: 1-2 bowel movement/day
Normal characteristics of Urine
Amt.: 1200-1500/ 24 hours
Color: transparent
Glucose, ketones, blood: not present
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Analysis and Interpretation:
The excretory function diminishes with age, but usually not significantly below normal levels
unless a disease process intervenes. The capacity of the bladder and it’s ability to completely empty
diminish with age. This explains the need for elderly adult to arise during the night to void.
12. Activity/exercise pattern
Actual Findings: She feels restless and fatigue.
Normal Findings: Regular exercise promotes both physical and emotional health. In general, health
guidelines recommended exercise at least 3x a week for 30-45 minutes.
Analysis and Interpretation: Brisk walking is an exercise which strengthens the cardiac muscle, good for
brain and bones, helps alleviate symptoms of depression, and improves fitness and physical function.
13. Sleep and Rest Pattern
Actual Findings:
Goes to bed at 10 pm and awaken at 4a.m. States he often has trouble falling asleep because of
muscle and joint pain . Sometimes he does not feel rested when she awakens and has difficulty lying flat.
States that he is irritable during night time.
Normal Findings:
Rest and sleep restores the body’s energy levels and are an essential aspect of stress
management.
Adult: 6-8 hours/day
Analysis and Interpretation:
There is disruption of the sleep-wake cycle because of the patient’s disease. He cannot sleep well due to
his condition. Ilness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep
than normal and the normal rhythm and wakefulness is often disturbed.
14. Cognitive/Perceptual Pattern
Actual Findings:
Speech clear without stutter. Word choice appropriate to education and culture.
Follows verbal cues.
Normal Findings:
No deficit in sensory perception.
Analysis and Interpretation:
He examines ideas clearly and concisely. Recalls past events without
difficulty, orientated to time, place, and person.
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7. Self-perception/Self-concept pattern
Actual Findings:
He don't considered himself as a holistic person. She thinks that he can't function well than before.
Normal Findings:
Specific component of self-concept includes; personal identity, body image, self-esteem, and role
performance.
Analysis and Interpretation:
Due to his present condition, there is a change to the level of patient self-perception and
self-concept due to her illness on her age of life. She now thinks that she can’t function well as
before. Events or situations maychange the level of self-concept overtime illness and trauma can also
affect the self-concept.
8. Role/relationship pattern
Actual Findings:
Patient is married and a housewife.
Normal Findings:
Individual’s perception may or may not match the evaluation of others who relate to the person.
Roles that individuals follow in given situations involve socialization, to expectations, and standards of
behavior.
Analysis and Interpretation:
He achieves his emotional and moral support from her families and friends, which will help her to
cope with her present condition.
9. Sexuality/reproductive pattern
Actual Findings:
He does not engage in sexuality activity nowadays..
Normal Findings:
Sexual desire varies among individual.
Analysis and Interpretation:
Patient does not engage in sexual activity due to his age and condition.
10. Coping/stress tolerance pattern
Actual Findings:
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When he is anxious
he
wants
to
be
alone and
have
some
rest. When he has
problems she used to communicate and share his problems to his family and friends. He makes himself
busy listening to radio.
Normal Findings:
Can manage stress effectively.
Analysis and Interpretation:
The patient has outlet to let her feelings of stress out by interacting with the family and
friends during visitation hours and the ability of the patient to adapt on his condition to lessen stress.
11. Value/belief pattern
Actual Findings:
He
believes
that
God
will
always
help
them. According to her family they still attend
mass even without him, praying for patient’s faster recovery.
Normal Findings:
Values are enduring beliefs or attitudes about worth of a person, objet, idea, or action. Beliefs are
interpretations or conclusions that people accept as true. They are based more on faith than fact and may
or may not be true.
Analysis and Interpretation:
He believes that everything has a purpose or reason, the patient take his present situation as a
challenge, and with the
supports
of his
families, he
accepted
his
condition
and
she
will seek medical assistance for check-ups for prevention of her illness in the future.
Without a strong opposition with his values and beliefs, treatment would be easier to improve the
client’s condition.
VI. Vital signs/ Measurable Cues
Area
Procedure
Normal Findings
Actual Findings
10/15/20118:08:00 am
Height
Use of measuring
---
device
---
Weight
Weighing scale
---
---
Temperature
Use of thermometer
36°C-37.5°C
36.7C
Normal
Pulse Rate
Palpation
60-100bpm
67 bpm
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Normal
14-20bpm
Respiratory Rate
15 cpm
Inspection
Normal
110/80 mmHg
120/80 mmHg
Blood Pressure
Use of BP apparatus
Normal
Glasgow Coma Scale
Score
Eye Opening Response
Verbal Response
Motor Response
Spontaneous
4
To voice
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sound
2
None
1
Obeys command
6
Localizes pain
5
Withdraws
4
Flexion
3
Extension
2
None
1
Total
15
4
5
6
15/15
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Temperature
40
30
temperature
20
10
0
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Pulse Rate
80
60
40
20
0
30
Respiratory Rate
25
20
15
RR
10
5
0
Blood Pressure
200
180
160
140
120
100
80
60
40
20
0
systolic
diastolic
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VII. Physical Assessment
Assessment
Areas
Analysis
Normal Findings
Actual Findings
Inspection and
Normocephalic, no
Normocephalic, no
Palpation
edema, no lesions
edema. No lesion
Technique
&
Interpretation
1. Head
-Skull
NORMAL
should be noted.
-Hair
Inspection
Evenly distributed.
Evenly distributed
NORMAL
-Scalp
Inspection
No dandruff, oily,
No dandruff and
NORMAL
Palpation
even in color.
even in color
Inspection
Symmetrical
-Face
-Eyebrows
Inspection
in
Symmetrical
in
NORMAL
present
NORMAL
facial movement.
facial movement
Normally
the
Are
eyebrows
are
bilaterally,
present bilaterally,
move
symmetrically.
move
symmetrically
the
as
facial
expression
changes,
and
have no scaling or
lesions.
-Eyelashes
Inspection
Evenly distributed
Evenly distributed
along
and
the
lid
margins and curve
NORMAL
curved
outward
outward.
-Eyelids
Inspection
The
upper
normally
lids
overlap
the superior part
Skin
without
is
intact
NORMAL
redness,
swelling, or lesion.
of the iris, and
approximate
completely
with
the
lids
lower
when closed. The
skin
is
without
intact
redness,
swelling,
discharge,
or
lesion.
-Lower
palpebral
Inspection
Pinkish in color
Pinkish in color.
NORMAL
conjunctiva
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-Cornea
Inspection
-Pupils
Inspection
Appears
regular
round,
and
of
equal size in both
Round,
regular
NORMAL
and of equal size
in both eyes.
eyes
-Lacrimal gland
Inspection
No
edema
or
tenderness
over
No
edema
and
tenderness
over
lacrimal gland.
lacrimal gland.
Are
-Eye movement
Not assessed
-Visual acuity
Not assessed
-Ears
Inspection and
Are
palpation
bilaterally with no
bilaterally with no
swelling
or
swelling
or
thickening,
no
thickening,
no
discharges,
no
discharges,
no
-External ear canal
Inspection
equal
sizes
NORMAL
equal
sizes
lesions.
lesions.
No redness and
No
swellingno lesions,
swelling
no foreign bodies,
lesions, no foreign
or discharge.
bodies,
redness
and
NORMAL
NORMAL
no
or
discharge.
-Gross
hearing acuity
-Nose external
Inspection and
Symmetric, in the
Symmetric, in the
Palpation
midline,
midline,
-Internal nares
Not assessed
-Septum
Not assessed
-Lips
Inspection
and
in
and
in
proportion to other
proportion to other
facial features.
facial features.
Lips
should
be
uniform in color,
smooth,
Black
NORMAL
Uniform in color,
NORMAL
smooth, moist.
moist.
persons
normally
may
have bluish lips.
-Gums
Inspection
Gums should look
Gums
pink or coral with a
and
stippled
margins
(dotted)
look
the
surface. The gum
teeth
margins
defined.
at
the
pink
NORMAL
gum
at
are
the
well
teeth are tight and
well defined.
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-Teeth
Inspection
32 teeth for adults,
Has 32 teeth, and
Indicates
white, shiny tooth
has cavities noted.
much
enamel.
-Tongue
Inspection
too
fluoride,
tooth decay
The color is pink
Is pink and even.
NORMAL
It should look pink,
Is
smooth
NORMAL
smooth and moist.
and moist.
NORMAL
and
even.
The
dorsal surface is
normally
roughened
from
the papillae. A thin
white coating may
be present.
-Buccal mucosa
Inspection
pink,
-Palate, soft and hard
Not assessed
-Uvula
Not assessed
-Tonsils
Not assessed
-Neck
Inspection and
No palpable mass,
No palpable mass,
Palpation
not
not tender, uniform
7.
tender,
uniform in color
in color
Quiet
Dull sound at the
Not
&effortless
right affected lung
indicative of fluid
respiration
noted, presence of
accumulation,
crackles noted
Air
Thorax & Lungs
-Breathing pattern
Auscultation
rhythmic,
normal;
passing
through fluid or
mucus in any air
passage
8. Heart
Not assessed
9. Breast
Not assessed
-Areola
Not assessed
-Nipples
Not assessed
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10. Abdomen
Inspection
Unblemished skin;
Unblemished skin
Uniform in color.
and
uniform
NORMAL
in
color.
Auscultation
Audible
bowel
sounds,
absence
Audible
bowel
of arterial bruits,
sounds,
absence
absence of friction
of arterial bruits,
rub.
absence of friction
NORMAL
rub.
No
evidence
enlargement
Percussion
of
of
No
evidence
liver or spleen
enlargement
Symmetric
liver or spleen
contour.
Symmetric
of
of
NORMAL
contour.
Flat, rounded, or
scaphoid.
Flat
Palpation
NORMAL
11. Upper extremities
Inspection
No tenderness, no
No tenderness, no
-Hands, fingers, nails,
Palpation
lesion, uniform in
lesion, uniform in
color,
color, capillary refill
wrist,
elbows,
shoulder
2.
capillary
refill 1-2 seconds,
is
1-2
nails are short and
and nails are short
clean
and clean
seconds,
Lower
Inspection
No tenderness, no
No tenderness, no
extremities
Palpation
lesions, uniform in
lesions, uniform in
Thighs, knees, ankle,
color,
color,
foot and distal
deformities
3. Genitatia
no
NORMAL
NORMAL
no
deformities
Not Assessed
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IX. Pathophysiology of Tuberculosis
Inhalation of air – borne nuclei from an infected person is proportional to the amount of time
spent in the same air space
Bacteria are transmitted through the airways to the alveoli
Bacilli are transported via the lymph system and bloodstream
Phagocytes engulf many of the bacteria and TB – specific lymphocytes destroy the bacilli and its
normal tissue
Accumulation of exudate in the alveoli causing bronchopneumonia
(low grade fever, cough)
Macrophages surrounds the Granulomas (new masses of live and dead bacilli) which form a
protective wall
Granulomas are transformed to a fibrous tissue mass called Ghon tubercle
The bacteria and macrophages becomes necrotic forming a cheesy mass
Mass become calcified and form a collagenous scar
(fatigue, weight loss, night sweats, weakness
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Health Problem
Ineffective airway
clearance r/t copious
tracheobronchial
secretions secondary to
pulmonary tuberculosis
Subjective Cues:
“Kinukukuri-an hiya
paghinga. Binabatok it
hiya. “ as verbalized by the
SO
Scientific Rationale
Goals and Objectives
Copious secretions obstruct the
airways in many patients with TB and
interfere with adequate gas exchange.
The tissue reaction results in the
accumulation of exudate in the alveoli,
causing bronchopneumonia. (Medical
Surgical Nursing, Volume I 10th ed.
Smeltzer et. Al, page 537)
Goal: After nursing
intervention, the patient
will be able to maintain
a patent airway.
Objectives:
1. The patient will be
able to
demonstrate
behaviors to
improve airway
clearance.
Nursing Intervention
Rationale

Place the patient in
semi – or high Fowler’s
position. Assist patient
in coughing and deep –
breathing exercises.

Positioning helps
maximize lung expansion
and decreases
respiratory effort.
Maximal ventilation may
open atelectatic areas
and promote movement
of secretions in to larger
airways for expectoration.

Maintain fluid intake of
at least 2500 ml/ day
unless contraindicated.


Administer oxygen if
needed.

High fluid intake helps
thin secretions, making
them easier to
expectorate.
Prevents drying of
mucous membranes;
helps thin secretions.

Administer medications
as prescribed

Reduces thickness and
stickiness of pulmonary
secretions to facilitate
clearance.

Be prepared for / assist
with emergency
intubation.

Intubation may be
necessary in rare cases
of bronchogenic TB
accompanied by
laryngeal or acute
pulmonary bleeding.
Evaluation
The patient was
able to
demonstrate
behaviors to
improve airway
clearance.
Objective Cues:




Difficulty of breathing
Shortness of breath
Non – productive
cough
Presence of crackles
upon auscultation
Measurement Cue:
RR – 25 cpm
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XI. Prioritization tion of identified problem
Health problem
1. Ineffective airway
clearance r/t copious
Cues
Justification
(+) productive cough
Copious secretion obstruct the
(+) blood streaked sputum
airways in many patients with
tracheobronchial
TB and interfere with adequate
secretions secondary
gas exchange.
to pulmonary
Smeltzer, Suzanne et, al. Medical
tuberculosis
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 537
2. Activity intolerance r/t
fatigue
(+) fatigue
Fatigue from excessive coughing,
(+) chest pain
sputum production, chest pain,
generalized state, or cost may
alters patient willingness to eat.
Anorexia, weight loss, and
malnutrition are common in
patients with TB.
Smeltzer, Suzanne et, al. Medical
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 537
3. Deficient knowledge
“Nagtumar a khan una han ak
The patient must understand that
about treatment
knan TB pero yna waray na”.
TB is communicable disease and
regiment and
as verbalized by the patient
that taking medications is the
preventive health
most effective means of
measures and r/t
preventing transmission.
ineffective individual
Smeltzer, Suzanne et, al. Medical
management of the
Surgical Nursing, C: 2004
therapeutic regimen
Lippincot Williams & Wilkins 10th
(noncompliance)
edition. Vol 2 page 537
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ASESSMENT
FAMILY MEMBER 3:
I. Demographic Profile
Name: Alvarez, Benito
Date of Birth: March 02, 1958
Age: 54
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Address: Barangay Pagbabangnan, San Julian Eastern Samar
Occupation: Farmer
Civil Status: Married
Father’s Name: Alvarez, Manuel (+)
Occupation: Farmer
Mother’s Name: Alvarez, Vicent (+)
Occupation: Housewife
Educational Attainment: Grade 2
II. Nursing Clinical Abstract
Mr. Alvarez, 74 y.o. a resident of Brgy. Pagbabangnan, San Julian Eastern Samar is suffering
from muscle weakness and joint pain.
Vital signs were taken and recorded as follows. T=36.2C PR=72bpm, RR= 25cpm BP= 110/80
mmHg.
Frequent movement and adequate rest was emphasized.
III. Nursing History
1. History of Present Illness
The patient is suffering from muscle weakness. He also experiences joint and muscle pain after
working in the farm.
2. Past Health History
Injury

Client doesn’t remember any major or minor injury.
Hospitalization

Has never been hospitalized.
3. Immunization

Client states the he has never been immunized.
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4. Family health history
Father’s side
Mother’s side
(-) DM
(-) DM
(-) Stroke
(-) Stroke
(-) HPN
(-) HPN
(-) Asthma
(-) Asthma
(-) Arthritis
(+) Arthritis
(-) Cancer
(-) Cancer
(-) TB
(-) TB
Others: None
Others: None
5. Allergies

No known allergies.
IV. Biophysical Assessment
General Appearance
Parameter
Normal Value
Observation
1. Posture/Gestures/Body Movement
Relaxed,
erect
posture,
coordinated movement.
Body frame appropriate
for her age, can stand,
sit, and walk by himself.
Has
coordinated
movement.
Speaks in a moderate
2. Language/Diction
Understandable,
moderate
pace,
tone of voice with clarity.
exhibit
thought association.
3. Facial Expression
Appropriate to the situation
Smiles and respond to
questions appropriately
4. Grooming and Hygiene
Clean and neat
Takes a bath regularly in
the morning, uses soap
and water. No presence
of
skin
itchiness,
No
dryness,
and
presence
rashes.
of
unpleasant odor.
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Has productive cough ,
5. Signs of Distress
There
should
be
no
distress noted.
chest
pain
and
experiences fatigue.
Wearing a ”sando”
6. Type of clothing
Appropriate
to
weather
and shorts.
condition.
7. Thought
process,
perception
content,
and
Logical sequence, makes
sense, has a sense of
reality.
Has
no
difficulty
in
hearing and does not
use eye glasses.
V. Gordon’s Typology of 11 Functional Health Pattern
1. Health-perception/ Health-management pattern
Actual Findings:
The client is willing to undergo health management practices to improve his condition.
Normal Findings:
Perception depends on the acuteness of senses. It is the awareness and interpretation of stimuli
that serves as a basis for understanding. Health is a state of physical, mental, and social well-being, and
not merely the absence of disease or infirmity. Health is being free from symptoms of disease and pain as
much as possible (Kozier 2008).
Person has a capacity for a reflective self awareness including assessment of their own
competencies (Kozier 2008).
Analysis and Interpretation:
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The client has a good health belief and is willing for consultation at the nearest hospital and to
follow the doctor’s order for the maintenance of his health
2. Nutritional/Metabolic pattern
Actual Findings:
The client eats three meals a day. Consumes 2 cups of rice every meal with fish and vegetables
as their main dish.
Normal Findings:
People require essential nutrients in food for growth and maintenance of all body tissues and the
normal functioning of all body process.
Fluid: average adult needs 2500mL/day
Analysis and Interpretation:
He should continue to eat a healthy diet, following the recommended portions of the four food
groups, with special attention to protein, calcium, and limiting cholesterol and caloric intake. Adequate
nutrition leads to good health.
3. Elimination Pattern
Actual Findings:
The client defecates everyday. He urinates 4times a day and sometimes arise during night time,
reports no pain when voiding and defecating.
Normal Findings:
Elimination of waste products of digestion from the body is very essential to health.
Normal characteristics of Feces
Color: brown
Consistency: formed soft, semi-solid, moist
Frequency: 1-2 bowel movement/day
Normal characteristics of Urine
Amt.: 1200-1500/ 24 hours
Color: transparent
Glucose, ketones, blood: not present
Analysis and Interpretation:
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The excretory function diminishes with age, but usually not significantly below normal levels
unless a disease process intervenes. The capacity of the bladder and it’s ability to completely empty
diminish with age. This explains the need for elderly adult to arise during the night to void.
4. Activity/exercise pattern
Actual Findings: He sometimes takes a walk in their yard early in the morning. He experiences muscle
weakness. He is also suffering from muscle and joint pain.
Normal Findings: Regular exercise promotes both physical and emotional health. In general, health
guidelines recommended exercise at least 3x a week for 30-45 minutes.
Analysis and Interpretation: Brisk walking is an exercise which strengthens the cardiac muscle, good for
brain and bones, helps alleviate symptoms of depression, and improves fitness and physical function.
5. Sleep and Rest Pattern
Actual Findings:
Goes to bed at 10 pm and awaken at 4a.m. States he often has trouble falling asleep because of
muscle and joint pain . Sometimes he does not feel rested when she awakens and has difficulty lying flat.
States that he is irritable during night time.
Normal Findings:
Rest and sleep restores the body’s energy levels and are an essential aspect of stress
management.
Adult: 6-8 hours/day
Analysis and Interpretation:
There is disruption of the sleep-wake cycle because of the patient’s disease. He cannot sleep well due to
his condition. Ilness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep
than normal and the normal rhythm and wakefulness is often disturbed.
6. Cognitive/Perceptual Pattern
Actual Findings:
Speech clear without stutter. Word choice appropriate to education and culture.
Follows verbal cues.
Normal Findings:
No deficit in sensory perception.
Analysis and Interpretation:
He examines ideas clearly and concisely. Recalls past events without
difficulty, orientated to time, place, and person.
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7. Self-perception/Self-concept pattern
Actual Findings:
He don't considered himself as a holistic person. She thinks that he can't function well than before.
Normal Findings:
Specific component of self-concept includes; personal identity, body image, self-esteem, and role
performance.
Analysis and Interpretation:
Due to his present condition, there is a change to the level of patient self-perception and
self-concept due to her illness on her age of life. She now thinks that she can’t function well as
before. Events or situations maychange the level of self-concept overtime illness and trauma can also
affect the self-concept.
8. Role/relationship pattern
Actual Findings:
Patient is married and a farmer. He works in the farm for to satisfy their basic needs. He is also
active and socializes with her friends and neighbors.
Normal Findings:
Individual’s perception may or may not match the evaluation of others who relate to the person.
Roles that individuals follow in given situations involve socialization, to expectations, and standards of
behavior.
Analysis and Interpretation:
He achieves his emotional and moral support from her families and friends, which will help her to
cope with her present condition.
9. Sexuality/reproductive pattern
Actual Findings:
He does not engage in sexuality activity nowadays..
Normal Findings:
Sexual desire varies among individual.
Analysis and Interpretation:
Patient does not engage in sexual activity due to his age and condition.
10. Coping/stress tolerance pattern
Actual Findings:
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When he is anxious
he
wants
to
be
alone and
have
some
rest. When he has
problems she used to communicate and share his problems to his family and friends. He makes himself
busy listening to radio.
Normal Findings:
Can manage stress effectively.
Analysis and Interpretation:
The patient has outlet to let her feelings of stress out by interacting with the family and
friends during visitation hours and the ability of the patient to adapt on his condition to lessen stress.
11. Value/belief pattern
Actual Findings:
He
believes
that
God
will
always
help
them. According to her family they still attend
mass even without him, praying for patient’s faster recovery.
Normal Findings:
Values are enduring beliefs or attitudes about worth of a person, objet, idea, or action. Beliefs are
interpretations or conclusions that people accept as true. They are based more on faith than fact and may
or may not be true.
Analysis and Interpretation:
He believes that everything has a purpose or reason, the patient take his present situation as a
challenge, and with the
supports
of his
families, he
accepted
his
condition
and
she
will seek medical assistance for check-ups for prevention of her illness in the future.
Without a strong opposition with his values and beliefs, treatment would be easier to improve the
client’s condition.
VI. Vital signs/ Measurable Cues
Area
Procedure
Normal Findings
Actual Findings
Height
Use of measuring
device
---
---
Weight
Weighing scale
---
---
Temperature
Use of thermometer
36°C-37.5°C
36.2C
Normal
Pulse Rate
Palpation
60-100bpm
65 bpm
Normal
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Respiratory Rate
Inspection
14-20bpm
18
Normal
Blood Pressure
Use of BP apparatus
120/80 mmHg
100/ 80 mmHg
Normal
Glasgow Coma Scale
Score
Eye Opening Response
Verbal Response
Motor Response
Spontaneous
4
To voice
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sound
2
None
1
Obeys command
6
Localizes pain
5
Withdraws
4
Flexion
3
Extension
2
None
1
Total
15
4
5
6
15/15
Temperature
40
30
temperature
20
10
0
02/15/12 8am
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Pulse Rate
70
60
50
40
30
20
10
0
2/15/12 8am
30
Respiratory Rate
25
20
15
RR
10
5
0
2/15/12 8am
Blood Pressure
200
180
160
140
120
100
80
60
40
20
0
systolic
diastolic
2/15/12 8am
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VII. Physical Assessment
Assessment
Areas
Analysis
Normal Findings
Actual Findings
Inspection and
Normocephalic, no
Normocephalic, no
Palpation
edema, no lesions
edema. No lesion
Technique
&
Interpretation
12. Head
-Skull
NORMAL
should be noted.
-Hair
Inspection
Evenly distributed.
Evenly distributed
NORMAL
-Scalp
Inspection
No dandruff, oily,
No dandruff and
NORMAL
Palpation
even in color.
even in color
Inspection
Symmetrical
-Face
-Eyebrows
Inspection
in
Symmetrical
in
NORMAL
present
NORMAL
facial movement.
facial movement
Normally
the
Are
eyebrows
are
bilaterally,
present bilaterally,
move
symmetrically.
move
symmetrically
the
as
facial
expression
changes,
and
have no scaling or
lesions.
-Eyelashes
Inspection
Evenly distributed
Evenly distributed
along
and
the
lid
margins and curve
NORMAL
curved
outward
outward.
-Eyelids
Inspection
The
upper
normally
lids
overlap
the superior part
Skin
without
is
intact
NORMAL
redness,
swelling, or lesion.
of the iris, and
approximate
completely
with
the
lids
lower
when closed. The
skin
is
without
intact
redness,
swelling,
discharge,
or
lesion.
-Lower
palpebral
Inspection
Pinkish in color
Pinkish in color.
NORMAL
conjunctiva
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-Cornea
Inspection
-Pupils
Inspection
Appears
regular
round,
and
of
equal size in both
Round,
regular
NORMAL
and of equal size
in both eyes.
eyes
-Lacrimal gland
Inspection
No
edema
or
tenderness
over
No
edema
and
tenderness
NORMAL
over
lacrimal gland.
lacrimal gland.
Inspection and
Are
Are
palpation
bilaterally with no
bilaterally with no
swelling
or
swelling
or
thickening,
no
thickening,
no
discharges,
no
discharges,
no
-Eye movement
-Visual acuity
-Ears
-External ear canal
Inspection
equal
sizes
equal
sizes
lesions.
lesions.
No redness and
No
swellingno lesions,
swelling
no foreign bodies,
lesions, no foreign
or discharge.
bodies,
redness
and
NORMAL
NORMAL
no
or
discharge.
-Gross
hearing acuity
-Nose external
Inspection and
Symmetric, in the
Symmetric, in the
Palpation
midline,
midline,
and
in
and
NORMAL
in
proportion to other
proportion to other
facial features.
facial features.
-Internal nares
-Septum
-Lips
Inspection
Lips
should
be
uniform in color,
smooth,
Black
Uniform in color,
NORMAL
smooth, moist.
moist.
persons
normally
may
have bluish lips.
-Gums
Inspection
Gums should look
Gums
pink or coral with a
and
stippled
margins
(dotted)
look
the
surface. The gum
teeth
margins
defined.
at
the
pink
NORMAL
gum
at
are
the
well
teeth are tight and
well defined.
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-Teeth
Inspection
32 teeth for adults,
Has 32 teeth, and
Indicates
white, shiny tooth
has cavities noted.
much
enamel.
-Tongue
Inspection
too
fluoride,
tooth decay
The color is pink
Is pink and even.
NORMAL
It should look pink,
Is
smooth
NORMAL
smooth and moist.
and moist.
Inspection and
No palpable mass,
No palpable mass,
NORMAL
Palpation
not
not tender, uniform
and
even.
The
dorsal surface is
normally
roughened
from
the papillae. A thin
white coating may
be present.
-Buccal mucosa
Inspection
pink,
-Palate, soft and hard
-Uvula
-Tonsils
-Neck
tender,
uniform in color
in color
Quiet
Dull sound at the
Not
&effortless
right affected lung
indicative of fluid
respiration
noted, presence of
accumulation,
crackles noted
Air
13. Thorax & Lungs
-Breathing pattern
Auscultation
rhythmic,
normal;
passing
through fluid or
mucus in any air
passage
14. Heart
Not assessed
15. Breast
Not assessed
-Areola
Not assessed
-Nipples
Not assessed
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16. Abdomen
Inspection
Unblemished skin;
Unblemished skin
Uniform in color.
and
uniform
NORMAL
in
color.
Auscultation
Audible
bowel
sounds,
absence
Audible
bowel
of arterial bruits,
sounds,
absence
absence of friction
of arterial bruits,
rub.
absence of friction
NORMAL
rub.
No
evidence
enlargement
Percussion
of
of
No
evidence
liver or spleen
enlargement
Symmetric
liver or spleen
contour.
Symmetric
of
of
NORMAL
contour.
Flat, rounded, or
scaphoid.
Flat
Palpation
NORMAL
17. Upper extremities
Inspection
No tenderness, no
No tenderness, no
-Hands, fingers, nails,
Palpation
lesion, uniform in
lesion, uniform in
color,
color, capillary refill
wrist,
elbows,
shoulder
7.
capillary
refill 1-2 seconds,
is
1-2
nails are short and
and nails are short
clean
and clean
seconds,
Lower
Inspection
No tenderness, no
No tenderness, no
extremities
Palpation
lesions, uniform in
lesions, uniform in
Thighs, knees, ankle,
color,
color,
foot and distal
deformities
8. Genitatia
no
NORMAL
NORMAL
no
deformities
Not Assessed
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IX. Pathophysiology of Tuberculosis
Inhalation of air – borne nuclei from an infected person is proportional to the amount of time
spent in the same air space
Bacteria are transmitted through the airways to the alveoli
Bacilli are transported via the lymph system and bloodstream
Phagocytes engulf many of the bacteria and TB – specific lymphocytes destroy the bacilli and its
normal tissue
Accumulation of exudate in the alveoli causing bronchopneumonia
(low grade fever, cough)
Macrophages surrounds the Granulomas (new masses of live and dead bacilli) which form a
protective wall
Granulomas are transformed to a fibrous tissue mass called Ghon tubercle
The bacteria and macrophages becomes necrotic forming a cheesy mass
Mass become calcified and form a collagenous scar
(fatigue, weight loss, night sweats, weakness)
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X. Prioritization of identified problem
Health problem
1. Ineffective airway
clearance r/t copious
Cues
Justification
(+) productive cough
Copious secretion obstruct the
(+) blood streaked sputum
airways in many patients with
tracheobronchial
TB and interfere with adequate
secretions secondary
gas exchange.
to pulmonary
Smeltzer, Suzanne et, al. Medical
tuberculosis
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 537
2. Activity intolerance r/t
fatigue
(+) fatigue
Fatigue from excessive coughing,
(+) chest pain
sputum production, chest pain,
generalized state, or cost may
alters patient willingness to eat.
Anorexia, weight loss, and
malnutrition are common in
patients with TB.
Smeltzer, Suzanne et, al. Medical
Surgical Nursing, C: 2004
Lippincot Williams & Wilkins 10th
edition. Vol 2 page 537
3. Deficient knowledge
“Nagtumar a khan una han ak
The patient must understand that
about treatment
knan TB pero yna waray na”.
TB is communicable disease and
regiment and
as verbalized by the patient
that taking medications is the
preventive health
most effective means of
measures and r/t
preventing transmission.
ineffective individual
Smeltzer, Suzanne et, al. Medical
management of the
Surgical Nursing, C: 2004
therapeutic regimen
Lippincot Williams & Wilkins 10th
(noncompliance)
edition. Vol 2 page 537
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Health Problem
Ineffective airway
clearance r/t copious
tracheobronchial
secretions secondary to
pulmonary tuberculosis
Subjective Cues:
“Kinukukuri-an hiya
paghinga. Binabatok it
hiya. “ as verbalized by the
SO
Scientific Rationale
Goals and Objectives
Copious secretions obstruct the
airways in many patients with TB and
interfere with adequate gas exchange.
The tissue reaction results in the
accumulation of exudate in the alveoli,
causing bronchopneumonia. (Medical
Surgical Nursing, Volume I 10th ed.
Smeltzer et. Al, page 537)
Goal: After nursing
intervention, the patient
will be able to maintain
a patent airway.
Objectives:
2. The patient will be
able to
demonstrate
behaviors to
improve airway
clearance.
Nursing Intervention
Rationale
The patient was
able to
demonstrate
behaviors to
improve airway
clearance.

Place the patient in
semi – or high Fowler’s
position. Assist patient
in coughing and deep –
breathing exercises.

Maintain fluid intake of
at least 2500 ml/ day
unless contraindicated.

Administer oxygen if
needed.

Objective Cues:




Difficulty of breathing
Shortness of breath
Non – productive
cough
Presence of crackles
upon auscultation
Evaluation


Positioning helps
maximize lung expansion
and decreases
respiratory effort.
Maximal ventilation may
open atelectatic areas
and promote movement
of secretions in to larger
airways for expectoration.
High fluid intake helps
thin secretions, making
them easier to
expectorate.
Prevents drying of
mucous membranes;
helps thin secretions.
Measurement Cue:
RR – 25 cpm

Administer medications
as prescribed

Be prepared for / assist
with emergency
intubation.

Reduces thickness and
stickiness of pulmonary
secretions to facilitate
clearance.

Intubation may be
necessary in rare cases
of bronchogenic TB
accompanied by
laryngeal or acute
pulmonary bleeding.
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ASESSMENT
FAMILY MEMBER 4:
I. Demographic Profile
Name: Alvarez, Juvy
Date of Birth: May 30, 1979
Age: 33
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Address: Barangay Pagbabangnan, San Julian Eastern Samar
Occupation: Fisherman
Civil Status: Married
Father’s Name: Alvarez, Tarcelo(+)
Occupation: Farmer
Mother’s Name: Alvarez, Estrella (+)
Occupation: Housewife
Educational Attainment: Grade 5
II. Nursing Clinical Abstract
III. Nursing History
1. History of Present Illness
- States he is healthy. “Maupay man it ak pag-abat hit ak lawas yana”.”
2. Past Health History
Injury

Client doesn’t remember any major or minor injury.
Hospitalization

Has never been hospitalized.
3. Immunization

Client states the he has never been immunized.
4. Family health history
Father’s side
Mother’s side
(-) DM
(-) DM
(-) Stroke
(-) Stroke
(-) HPN
(-) HPN
(-) Asthma
(-) Asthma
(-) Arthritis
(+) Arthritis
(-) Cancer
(-) Cancer
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(-) TB
(-) TB
Others: None
Others: None
5. Allergies

No known allergies.
IV. Biophysical Assessment
General Appearance
Parameter
1. Posture/Gestures/Body Movement
Normal Value
Observation
Relaxed, erect posture,
coordinated movement.
Body
frame
appropriate
for
her
age, can stand, sit, and
walk by himself. Has
coordinated
movement.
Speaks in a moderate
2. Language/Diction
Understandable,
tone
moderate pace, exhibit
clarity.
of
voice
with
thought association.
3. Facial Expression
Appropriate
to
the
situation
4. Grooming and Hygiene
Smiles and respond to
questions appropriately
Clean and neat
Takes a bath regularly
in the morning, uses
soap and water. No
presence
of
skin
dryness, itchiness, and
rashes. No presence of
unpleasant odor.
Signs of distress not
5. Signs of Distress
There
should
be
no
noted .
distress noted.
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6. Type of clothing
Appropriate to weather
condition.
7. Thought
process,
perception
content,
and
Logical sequence, makes
sense, has a sense of
reality.
Wearing a ”sando”
and shorts.
Has
no
difficulty
in
hearing and does not
use eye glasses.
V. Gordon’s Typology of 11 Functional Health Pattern
1. Health-perception/ Health-management pattern
Actual Findings:
The client is willing to undergo health management practices to improve his condition.
Normal Findings:
Perception depends on the acuteness of senses. It is the awareness and interpretation of stimuli
that serves as a basis for understanding. Health is a state of physical, mental, and social well-being, and
not merely the absence of disease or infirmity. Health is being free from symptoms of disease and pain as
much as possible (Kozier 2008).
Person has a capacity for a reflective self awareness including assessment of their own
competencies (Kozier 2008).
Analysis and Interpretation:
The client has a good health belief and is willing for consultation at the nearest hospital and to
follow the doctor’s order for the maintenance of his health
2. Nutritional/Metabolic pattern
Actual Findings:
The client eats three meals a day. Consumes 2 cups of rice every meal with fish and vegetables
as their main dish.
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Normal Findings:
People require essential nutrients in food for growth and maintenance of all body tissues and the
normal functioning of all body process.
Fluid: average adult needs 2500mL/day
Analysis and Interpretation:
He should continue to eat a healthy diet, following the recommended portions of the four food
groups, with special attention to protein, calcium, and limiting cholesterol and caloric intake. Adequate
nutrition leads to good health.
3. Elimination Pattern
Actual Findings:
The client defecates everyday. He urinates 4times a day and sometimes arise during night time,
reports no pain when voiding and defecating.
Normal Findings:
Elimination of waste products of digestion from the body is very essential to health.
Normal characteristics of Feces
Color: brown
Consistency: formed soft, semi-solid, moist
Frequency: 1-2 bowel movement/day
Normal characteristics of Urine
Amt.: 1200-1500/ 24 hours
Color: transparent
Glucose, ketones, blood: not present
Analysis and Interpretation:
The excretory function diminishes with age, but usually not significantly below normal levels
unless a disease process intervenes. The capacity of the bladder and it’s ability to completely empty
diminish with age. This explains the need for elderly adult to arise during the night to void.
4. Activity/exercise pattern
Actual Findings: He sometimes takes a walk in their yard early in the morning.
Normal Findings: Regular exercise promotes both physical and emotional health. In general, health
guidelines recommended exercise at least 3x a week for 30-45 minutes.
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Analysis and Interpretation: Brisk walking is an exercise which strengthens the cardiac muscle, good for
brain and bones, helps alleviate symptoms of depression, and improves fitness and physical function.
5. Sleep and Rest Pattern
Actual Findings:
Goes to bed at 10 pm and awaken at 4a.m. States he has no trouble falling asleep.
Normal Findings:
Rest and sleep restores the body’s energy levels and are an essential aspect of stress
management.
Adult: 6-8 hours/day
Analysis and Interpretation:
The patient’s sleep pattern is normal.
6. Cognitive/Perceptual Pattern
Actual Findings:
Speech clear without stutter. Word choice appropriate to education and culture.
Follows verbal cues.
Normal Findings:
No deficit in sensory perception.
Analysis and Interpretation:
He examines ideas clearly and concisely. Recalls past events without
difficulty, orientated to time, place, and person.
7. Self-perception/Self-concept pattern
Actual Findings:
He don't considered himself as a holistic person. She thinks that he can't function well than before.
Normal Findings:
Specific component of self-concept includes; personal identity, body image, self-esteem, and role
performance.
Analysis and Interpretation:
Due to his present condition, there is a change to the level of patient self-perception and
self-concept due to her illness on her age of life. She now thinks that she can’t function well as
before. Events or situations maychange the level of self-concept overtime illness and trauma can also
affect the self-concept.
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8. Role/relationship pattern
Actual Findings:
Patient is married and a farmer. He works in the farm for to satisfy their basic needs. He is also
active and socializes with her friends and neighbors.
Normal Findings:
Individual’s perception may or may not match the evaluation of others who relate to the person.
Roles that individuals follow in given situations involve socialization, to expectations, and standards of
behavior.
Analysis and Interpretation:
He achieves his emotional and moral support from her families and friends, which will help her to
cope with her present condition.
9. Sexuality/reproductive pattern
Actual Findings:
He does not engage in sexuality activity nowadays..
Normal Findings:
Sexual desire varies among individual.
Analysis and Interpretation:
Patient does not engage in sexual activity due to his age and condition.
10. Coping/stress tolerance pattern
Actual Findings:
When he is anxious
he
wants
to
be
alone and
have
some
rest. When he has
problems she used to communicate and share his problems to his family and friends. He makes himself
busy listening to radio.
Normal Findings:
Can manage stress effectively.
Analysis and Interpretation:
The patient has outlet to let her feelings of stress out by interacting with the family and
friends during visitation hours and the ability of the patient to adapt on his condition to lessen stress.
11. Value/belief pattern
Actual Findings:
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He
believes
that
God
will
always
help
them. According to her family they still attend
mass even without him, praying for patient’s faster recovery.
Normal Findings:
Values are enduring beliefs or attitudes about worth of a person, objet, idea, or action. Beliefs are
interpretations or conclusions that people accept as true. They are based more on faith than fact and may
or may not be true.
Analysis and Interpretation:
He believes that everything has a purpose or reason, the patient take his present situation as a
challenge, and with the
supports
of his
families, he
accepted
his
condition
and
she
will seek medical assistance for check-ups for prevention of her illness in the future.
Without a strong opposition with his values and beliefs, treatment would be easier to improve the
client’s condition
VI. Vital signs/ Measurable Cues
Area
Procedure
Normal Findings
Actual Findings
Height
Use of measuring
device
---
---
Weight
Weighing scale
---
---
Temperature
Use of thermometer
36°C-37.5°C
36.2C
Normal
65 bpm
Pulse Rate
Palpation
60-100bpm
Normal
18 cpm
Respiratory Rate
Inspection
14-20bpm
Normal
110/80 mmHg
120/80 mmHg
Blood Pressure
Use of BP apparatus
Normal
Requirement in Related Learning Experiences – Nursing Care Process
Giselle C. Geroy BSN – IV
59 | P a g e
Page 60 of 89
Glasgow Coma Scale
Score
Eye Opening Response
Verbal Response
Motor Response
Spontaneous
4
To voice
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sound
2
None
1
Obeys command
6
Localizes pain
5
Withdraws
4
Flexion
3
Extension
2
None
1
Total
15
4
5
6
15/15
Temperature
40
30
temperature
20
10
0
02/15/12 8am
Pulse Rate
70
60
50
40
30
20
10
0
2/15/12 8am
Requirement in Related Learning Experiences – Nursing Care Process
Giselle C. Geroy BSN – IV
60 | P a g e
Page 61 of 89
30
Respiratory Rate
25
20
15
RR
10
5
0
2/15/12 8am
Blood Pressure
200
180
160
140
120
100
80
60
40
20
0
systolic
diastolic
2/15/12 8am
Requirement in Related Learning Experiences – Nursing Care Process
Giselle C. Geroy BSN – IV
61 | P a g e
Page 62 of 89
VII. Physical Assessment
Assessment
Areas
Analysis
Normal Findings
Actual Findings
Inspection and
Normocephalic, no
Normocephalic, no
Palpation
edema, no lesions
edema. No lesion
Technique
Interpretation
18. Head
-Skull
NORMAL
should be noted.
-Hair
Inspection
Evenly distributed.
Evenly distributed
NORMAL
-Scalp
Inspection
No dandruff, oily,
No dandruff and
NORMAL
Palpation
even in color.
even in color
Inspection
Symmetrical
-Face
-Eyebrows
Inspection
in
Symmetrical
in
NORMAL
present
NORMAL
facial movement.
facial movement
Normally
the
Are
eyebrows
are
bilaterally,
present bilaterally,
move
symmetrically.
move
symmetrically
the
as
facial
expression
changes,
and
have no scaling or
lesions.
-Eyelashes
Inspection
Evenly distributed
Evenly distributed
along
and
the
lid
margins and curve
NORMAL
curved
outward
outward.
-Eyelids
Inspection
The
upper
normally
lids
overlap
the superior part
Skin
without
is
intact
NORMAL
redness,
swelling, or lesion.
of the iris, and
approximate
completely
with
the
lids
lower
when closed. The
skin
is
without
intact
redness,
swelling,
discharge,
or
lesion.
-Lower
palpebral
Inspection
conjunctiva
-Cornea
Inspection
Pinkish in color
Pinkish in color.
NORMAL
&
Page 63 of 89
-Pupils
Inspection
Appears
regular
round,
and
of
equal size in both
Round,
regular
NORMAL
and of equal size
in both eyes.
eyes
-Lacrimal gland
Inspection
No
edema
or
tenderness
over
No
edema
and
tenderness
NORMAL
over
lacrimal gland.
lacrimal gland.
Inspection and
Are
Are
palpation
bilaterally with no
bilaterally with no
swelling
or
swelling
or
thickening,
no
thickening,
no
discharges,
no
discharges,
no
-Eye movement
-Visual acuity
-Ears
-External ear canal
Inspection
equal
sizes
equal
sizes
lesions.
lesions.
No redness and
No
swellingno lesions,
swelling
no foreign bodies,
lesions, no foreign
or discharge.
bodies,
redness
and
NORMAL
NORMAL
no
or
discharge.
-Gross
hearing acuity
-Nose external
Inspection and
Symmetric, in the
Symmetric, in the
Palpation
midline,
midline,
and
in
and
NORMAL
in
proportion to other
proportion to other
facial features.
facial features.
-Internal nares
-Septum
-Lips
Inspection
Lips
should
be
uniform in color,
smooth,
Black
Uniform in color,
NORMAL
smooth, moist.
moist.
persons
normally
may
have bluish lips.
-Gums
Inspection
Gums should look
Gums
pink or coral with a
and
stippled
margins
(dotted)
look
the
surface. The gum
teeth
margins
defined.
at
the
pink
NORMAL
gum
at
are
the
well
teeth are tight and
well defined.
-Teeth
Inspection
32 teeth for adults,
Has 32 teeth, and
Indicates
white, shiny tooth
has cavities noted.
much
too
fluoride,
Page 64 of 89
enamel.
-Tongue
Inspection
tooth decay
The color is pink
Is pink and even.
NORMAL
It should look pink,
Is
smooth
NORMAL
smooth and moist.
and moist.
Inspection and
No palpable mass,
No palpable mass,
NORMAL
Palpation
not
not tender, uniform
and
even.
The
dorsal surface is
normally
roughened
from
the papillae. A thin
white coating may
be present.
-Buccal mucosa
Inspection
pink,
-Palate, soft and hard
-Uvula
-Tonsils
-Neck
tender,
uniform in color
in color
Quiet
Dull sound at the
Not
&effortless
right affected lung
indicative of fluid
respiration
noted, presence of
accumulation,
crackles noted
Air
19. Thorax & Lungs
-Breathing pattern
Auscultation
rhythmic,
normal;
passing
through fluid or
mucus in any air
passage
20. Heart
21. Breast
-Areola
Not assessed
-Nipples
Not assessed
Page 65 of 89
22. Abdomen
Inspection
Unblemished skin;
Unblemished skin
Uniform in color.
and
uniform
NORMAL
in
color.
Auscultation
Audible
bowel
sounds,
absence
Audible
bowel
of arterial bruits,
sounds,
absence
absence of friction
of arterial bruits,
rub.
absence of friction
NORMAL
rub.
No
evidence
enlargement
Percussion
of
of
No
evidence
liver or spleen
enlargement
Symmetric
liver or spleen
contour.
Symmetric
of
of
NORMAL
contour.
Flat, rounded, or
scaphoid.
Flat
Palpation
NORMAL
23. Upper extremities
Inspection
No tenderness, no
No tenderness, no
-Hands, fingers, nails,
Palpation
lesion, uniform in
lesion, uniform in
color,
color, capillary refill
wrist,
elbows,
shoulder
7.
capillary
refill 1-2 seconds,
is
1-2
nails are short and
and nails are short
clean
and clean
seconds,
Lower
Inspection
No tenderness, no
No tenderness, no
extremities
Palpation
lesions, uniform in
lesions, uniform in
Thighs, knees, ankle,
color,
color,
foot and distal
deformities
8. Genitatia
Not Assessed
no
NORMAL
deformities
no
NORMAL
Page 66 of 89
ASESSMENT
FAMILY MEMBER 5:
I. Demographic Profile
Name: Alvarez, Elman
Date of Birth: July 08, 2002
Age: 9
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Address: Barangay Pagbabangnan, San Julian Eastern Samar
Occupation: Fisherman
Civil Status: Married
Father’s Name: Alvarez, Tarcelo(+)
Occupation: Farmer
Mother’s Name: Alvarez, Estrella (+)
Occupation: Housewife
Educational Attainment: Grade 4 level
II. Nursing Clinical Abstract
Mr. Alvarez, 9 y.o. a resident of Brgy. Pagbabangnan, San Julian Eastern Samar is suffering
from cough and colds. No consultation and medications taken.
Medical consultation and increase of fluid intake was emphasized.
III. Nursing History
1. History of Present Illness
The patient is suffering from intermittent cough and colds.
2. Past Health History
Injury

Client doesn’t remember any major or minor injury.
Hospitalization

Has never been hospitalized.
3. Immunization

Client states the he has never been immunized.
4. Family health history
Father’s side
Mother’s side
(-) DM
(-) DM
(-) Stroke
(-) Stroke
(-) HPN
(-) HPN
Page 67 of 89
(-) Asthma
(-) Asthma
(-) Arthritis
(+) Arthritis
(-) Cancer
(-) Cancer
(-) TB
(-) TB
Others: None
Others: None
5. Allergies

No known allergies.
IV. Biophysical Assessment
General Appearance
Parameter
1. Posture/Gestures/Body Movement
Normal Value
Observation
Relaxed, erect posture,
coordinated movement.
Body
frame
appropriate
for
her
age, can stand, sit, and
walk by himself. Has
coordinated
movement.
2. Language/Diction
Understandable,
Speaks in a moderate
moderate pace, exhibit
tone
thought association.
clarity.
Appropriate
3. Facial Expression
to
of
voice
with
the
situation
Smiles and respond to
questions appropriately
4. Grooming and Hygiene
Clean and neat
Takes a bath regularly
in the morning, uses
soap and water. No
presence
of
skin
dryness, itchiness, and
rashes. No presence of
unpleasant odor.
No signs of distress
5. Signs of Distress
There
should
distress noted.
be
no
noted.
Page 68 of 89
6. Type of clothing
Appropriate to weather
condition.
7. Thought
process,
content,
perception
and
Logical sequence, makes
sense, has a sense of
reality.
Wearing a ”sando”
and shorts.
Has
no
difficulty
in
hearing and does not
use eye glasses.
V. Gordon’s Typology of 11 Functional Health Pattern
1. Health-perception/ Health-management pattern
Actual Findings:
The client states that he is healthy and experiences no feeling of illness.
Normal Findings:
Perception depends on the acuteness of senses. It is the awareness and interpretation of stimuli
that serves as a basis for understanding. Health is a state of physical, mental, and social well-being, and
not merely the absence of disease or infirmity. Health is being free from symptoms of disease and pain as
much as possible (Kozier 2008).
Person has a capacity for a reflective self awareness including assessment of their own
competencies (Kozier 2008).
Analysis and Interpretation:
The client has a good health belief.
Page 69 of 89
2. Nutritional/Metabolic pattern
Actual Findings:
The client eats three meals a day. Consumes 2 cups of rice every meal with fish and vegetables
as their main dish.
Normal Findings:
People require essential nutrients in food for growth and maintenance of all body tissues and the
normal functioning of all body process.
Fluid: average adult needs 2500mL/day
Analysis and Interpretation:
He should continue to eat a healthy diet, following the recommended portions of the four food
groups, with special attention to protein, calcium, and limiting cholesterol and caloric intake. Adequate
nutrition leads to good health.
3. Elimination Pattern
Actual Findings:
The client defecates everyday. He urinates 4times a day and sometimes arise during night time,
reports no pain when voiding and defecating.
Normal Findings:
Elimination of waste products of digestion from the body is very essential to health.
Normal characteristics of Feces
Color: brown
Consistency: formed soft, semi-solid, moist
Frequency: 1-2 bowel movement/day
Normal characteristics of Urine
Amt.: 1200-1500/ 24 hours
Color: transparent
Glucose, ketones, blood: not present
Analysis and Interpretation:
The excretory function diminishes with age, but usually not significantly below normal levels
unless a disease process intervenes. The capacity of the bladder and it’s ability to completely empty
diminish with age. This explains the need for elderly adult to arise during the night to void.
Page 70 of 89
4. Activity/exercise pattern
Actual Findings: He morning together with his grandfather and plays basketball with his friends in the
afternoon.
Normal Findings: Regular exercise promotes both physical and emotional health. In general, health
guidelines recommended exercise at least 3x a week for 30-45 minutes.
Analysis and Interpretation: Exercise, which strengthens the cardiac muscle, good for brain and bones,
helps alleviate symptoms of depression, and improves fitness and physical function.
5. Sleep and Rest Pattern
Actual Findings:
Goes to bed at 8 pm and awaken at 6a.m. States he often has trouble falling asleep because of
muscle and joint pain . Sometimes he does not feel rested when she awakens and has difficulty lying flat.
States that he is irritable during night time.
Normal Findings:
Rest and sleep restores the body’s energy levels and are an essential aspect of stress
management.
Adult: 6-8 hours/day
Analysis and Interpretation:
His sleep pattern is normal and appropriate to his age.
6. Cognitive/Perceptual Pattern
Actual Findings:
Speech clear without stutter. Word choice appropriate to education and culture.
Follows verbal cues.
Normal Findings:
No deficit in sensory perception.
Analysis and Interpretation:
He examines ideas clearly and concisely. Recalls past events without
difficulty, orientated to time, place, and person.
7. Self-perception/Self-concept pattern
Actual Findings:
He considered himself as a holistic person
.
Page 71 of 89
Normal Findings:
Specific component of self-concept includes; personal identity, body image, self-esteem, and role
performance.
Analysis and Interpretation:
His self – perception is norm al.
8. Role/relationship pattern
Actual Findings:
Patient is a student and help his parents in doing household chores.
Normal Findings:
Individual’s perception may or may not match the evaluation of others who relate to the person.
Roles that individuals follow in given situations involve socialization, to expectations, and standards of
behavior.
Analysis and Interpretation:
He achieves his emotional and moral support from her families and friends, which will help her to
cope with her present condition.
9. Sexuality/reproductive pattern
Not assessed.
10. Coping/stress tolerance pattern
Actual Findings:
When he is anxious
he
wants
to
be
alone and
have
some
rest. When he has
problems she used to communicate and share his problems to his family and friends. He makes himself
busy in playing basketball.
Normal Findings:
Can manage stress effectively.
Analysis and Interpretation:
The patient has outlet to let her feelings of stress out by interacting with the family and
friends during visitation hours and the ability of the patient to adapt on his condition to lessen stress.
11. Value/belief pattern
Actual Findings:
He
believes
that
God
will
always
help
mass even without him, praying for patient’s faster recovery.
them. According to her family they still attend
Page 72 of 89
Normal Findings:
Values are enduring beliefs or attitudes about worth of a person, objet, idea, or action. Beliefs are
interpretations or conclusions that people accept as true. They are based more on faith than fact and may
or may not be true.
Analysis and Interpretation:
He believes that everything has a purpose or reason, the patient take his present situation as a
challenge, and with the
supports
of his
families, he
accepted
his
condition
and
she
will seek medical assistance for check-ups for prevention of her illness in the future.
Without a strong opposition with his values and beliefs, treatment would be easier to improve the
client’s condition.
VI. Vital signs/ Measurable Cues
Area
Procedure
Normal Findings
Actual Findings
Height
Use of measuring
device
---
---
Weight
Weighing scale
---
---
Temperature
Use of thermometer
36°C-37.5°C
36.2C
Normal
65 bpm
Pulse Rate
Palpation
60-100bpm
Normal
18 cpm
Respiratory Rate
Inspection
14-20bpm
Normal
Blood Pressure
---
---
---
Page 73 of 89
Glasgow Coma Scale
Score
Eye Opening Response
Verbal Response
Motor Response
Spontaneous
4
To voice
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sound
2
None
1
Obeys command
6
Localizes pain
5
Withdraws
4
Flexion
3
Extension
2
None
1
Total
15
Temperature
40
30
temperature
20
10
0
02/15/12 8am
Pulse Rate
70
60
50
40
30
20
10
0
2/15/12 8am
4
5
6
15/15
Page 74 of 89
30
Respiratory Rate
25
20
15
RR
10
5
0
2/15/12 8am
Page 75 of 89
VII. Physical Assessment
Assessment
Areas
Analysis
Normal Findings
Actual Findings
Inspection and
Normocephalic, no
Normocephalic,
Palpation
edema, no lesions
edema. No lesion
Technique
Interpretation
1. Head
-Skull
no
NORMAL
should be noted.
-Hair
Inspection
Evenly distributed.
Evenly distributed
NORMAL
-Scalp
Inspection
No
No
and
NORMAL
Palpation
even in color.
Inspection
Symmetrical
Symmetrical in facial
NORMAL
-Face
dandruff,
oily,
even in color
in
facial movement.
-Eyebrows
Inspection
dandruff
movement
Normally
the
Are
eyebrows
are
bilaterally,
present
bilaterally,
present
NORMAL
move
symmetrically.
move symmetrically
as
the
facial
expression
changes, and have
no
scaling
or
lesions.
-Eyelashes
Inspection
Evenly
distributed
Evenly
along
the
and curved outward
lid
distributed
NORMAL
margins and curve
outward.
-Eyelids
Inspection
The
upper
lids
Skin is intact without
normally overlap the
redness, swelling, or
superior part of the
lesion.
iris,
NORMAL
and
approximate
completely with the
lower
lids
when
closed. The skin is
intact
redness,
without
swelling,
discharge, or lesion.
-Lower
palpebral
Inspection
conjunctiva
-Cornea
Inspection
Pinkish in color
Pinkish in color.
NORMAL
&
Page 76 of 89
-Pupils
-Lacrimal gland
Inspection
Appears
Inspection
round,
Round, regular and
regular and of equal
of equal size in both
size in both eyes
eyes.
No
edema
or
tenderness
over
lacrimal gland.
No
edema
and
tenderness
NORMAL
NORMAL
over
lacrimal gland.
-Eye movement
-Visual acuity
-Ears
Inspection
and
palpation
Are
equal
sizes
Inspection
equal
sizes
bilaterally with no
bilaterally
swelling
or
swelling
or
thickening,
no
thickening,
no
discharges,
no
discharges,
no
lesions.
-External ear canal
Are
No
with
NORMAL
no
lesions.
redness
swellingno
and
No
redness
and
lesions,
swelling no lesions,
no foreign bodies,
no foreign bodies, or
or discharge.
discharge.
Inspection and
Symmetric, in the
Symmetric,
Palpation
midline,
midline,
NORMAL
-Gross
hearing acuity
-Nose external
-Internal nares
Not assessed
-Septum
Not assessed
-Lips
Inspection
and
in
in
the
and
in
proportion to other
proportion to other
facial features.
facial features.
Lips
should
color,
NORMAL
Gums should look
Gums look pink and
NORMAL
pink or coral with a
the gum margins at
stippled
the teeth are well
uniform
in
smooth,
Black
be
color,
Uniform
in
NORMAL
smooth, moist.
moist.
persons
normally may have
bluish lips.
-Gums
Inspection
(dotted)
surface. The gum
defined.
margins at the teeth
are tight and well
defined.
-Teeth
Inspection
32 teeth for adults,
Has 32 teeth, and
Indicates too much
white, shiny tooth
has cavities noted.
fluoride,
enamel.
decay
tooth
Page 77 of 89
-Tongue
Inspection
The color is pink
Is pink and even.
NORMAL
It should look pink,
Is pink, smooth and
NORMAL
smooth and moist.
moist.
and
dorsal
even.
The
surface
is
normally roughened
from the papillae. A
thin white coating
may be present.
-Buccal mucosa
Inspection
-Palate, soft and hard
Not assessed
-Uvula
Not assessed
-Tonsils
Not assessed
-Neck
Inspection and
No palpable mass,
No palpable mass,
Palpation
not tender, uniform
not tender, uniform
in color
in color
NORMAL
2. Thorax & Lungs
-Breathing pattern
Auscultation
Quiet
rhythmic,
Dull sound at the
Not
&effortless
right affected lung
indicative of fluid
respiration
noted, presence of
accumulation,
crackles noted
Air
through
normal;
passing
fluid
or
mucus in any air
passage
3. Heart
Not assessed
4. Breast
Not assessed
-Areola
Not assessed
-Nipples
Not assessed
Page 78 of 89
5. Abdomen
Inspection
Auscultation
Unblemished
Unblemished
skin
Uniform in color.
and uniform in color.
Audible
Audible
bowel
sounds, absence of
arterial
arterial
bruits,
absence of friction
rub.
rub.
of
No
evidence
of
enlargement of liver
enlargement of liver
or spleen
or spleen
Symmetric contour.
Symmetric contour.
Flat,
Flat
rounded,
or
NORMAL
bruits,
absence of friction
evidence
NORMAL
bowel
sounds, absence of
No
Percussion
skin;
NORMAL
scaphoid.
Palpation
6. Upper
extremities
NORMAL
Inspection
No tenderness, no
No tenderness, no
Palpation
lesion,
lesion,
uniform
in
uniform
NORMAL
in
-Hands, fingers, nails,
color, capillary refill
color, capillary refill
wrist, elbows, shoulder
1-2 seconds, nails
is 1-2 seconds, and
are short and clean
nails are short and
clean
7.
Thighs,
Lower
Inspection
No tenderness, no
No tenderness, no
extremities
Palpation
lesions, uniform in
lesions, uniform in
color, no deformities
color, no deformities
knees,
ankle,
foot and distal
8. Genitatia
Not Assessed
NORMAL
Page 79 of 89
Part 2
Family Nursing Care Process
I.
Sketch of Family Living Space
table
living room
kitchen area
bed
comfort room
II. Initial Database for Family Nursing Practice
a. Family structure, characteristics, and dynamics
1. Members of the household and relationship to the head of the family
Line No.
Name of Family Member
1.
2.
3.
4.
5.
Relationship to the head of the
family
Head of the family
Wife
Brother
Son
Grandson
Alvarez, Tarcelo
Alvarez, Estrella
Alvarez, Benito
Alvarez, Juvy
Alvarez, Elman
2. Demographic data
Name of Family
Member
Alvarez, Tarcelo
Date of Birth
MM/DD/YY
04/ 24/ 74
Gender
Age
Religion
74
Civil
Status
Married
Male
Alvarez, Estrella
06/ 30/ 41
Female
71
Married
Catholic
Alvarez, Benito
03/ 02/ 58
Male
54
Single
Catholic
Alvarez, Juvy
05/ 30 / 79
Male
33
Single
Catholic
Catholic
Place of
Origin
Brgy.Pagba
bangnan,
San Julian
E. Samar
Brgy.Pagba
bangnan,
San Julian
E. Samar
Brgy.Pagba
bangnan,
San Julian
E. Samar
Brgy.Pagba
Page 80 of 89
Alvarez, Elman
07/ 08 / 2002
Male
9
N/A
Catholic
bangnan,
San Julian
E. Samar
Brgy.Pagba
bangnan,
San Julian
E. Samar
3. Place of residence
- The family is residing at Purok 4, Barangay Pagbabangnan, San Julian Eastern
Samar.
4. Type of family structure
- Extended family
5. Dominant family members in terms of decision making
- Alvarez, Tarcelo
6. General family relationship/dynamics
- No presence of obvious/ readily observable conflict noted
B. Socio-economic and cultural characteristics
1. Income and expenses (occupation, place of work and income of each working members, adequacy to
meet basic necessities)
Name of Family
Member
Alvarez, Tarcelo
Alvarez, Estrella
Alvarez, Benito
Alvarez, Juvy
Alvarez, Elman
Occupation
Farmer
Housewife
None
Fisherman
Student
Place of Work
Pagbabangnan
None
None
Pagbabangnan
N/A
Income
3,000.00/month
None
None
None
N/A
Expenses
2,000/month
2,000/month
500/ month
500/month
2. Educational attainment
Name of Family Member
Alvarez, Tarcelo
Alvarez, Estrella
Alvarez, Benito
Alvarez, Juvy
Alvarez, Elman
Educational Attainment
Grade 5
Grade 6
Grade 2
Third year high school
Grade 4 level
3. Ethnic background and religious affiliation
i. Each member of the family is all Filipino Citizen and Roman Catholic.
4. Significant others
ii. They all play significant roles in each other’s life.
5. Relationship of the family to the larger community
iii. They do not participate in any community activities
C. Home and Environment
1. Housing:
a. Adequacy of Living Space
- The total area of the house is 15x20sq.meter.
b. Sleeping Arrangement
- Mr. and Mrs. Alvarez are sleeping together in a room with their grandson Elman
while Mr. Benito, and Juvy sleeps on the other room.
c. Presence of Breeding or Resting Sites of Vectors of Disease
- Presence of mosquitoes and cockroaches.
d. Presence of Accident Hazards
- There are lumbers that have nails that were protruding.
e. Food Storage and Cooking Facility
Page 81 of 89
-
The family is using wood in cooking and they store up their food in a basket or in the
cabinet just near there dining area outside their house.
f. Water Supply
- For their general use they get their water in the artesian well while their drinking
water is obtained from Nawasa.
g. Toilet Facility - flushed-type toilet facility.
h. Garbage/Refuse Disposal - burning, dumping
2. Kind of neighborhood – not congested
3. Social and health facilities available – presence of Brgy. Health Center
4. Communication and transportation – none
D.
Health status of each family member
1. Medical and nursing history indicating current or past significant illnesses or beliefs and
practices conducive to health and illness
- Mrs. Alvarez was diagnosed PTB last Feb. 2012
2. Nutritional assessment
a. Anthropometric data: BMI, Waist Circumference, WHR,
- Not assessed
b. Dietary history
- Usually consumes three meals a day.
c. Eating/feeding habits/practices
- They are not fond of eating meats.
3. Developmental Assessment of infants, toddlers, and preschoolers, e.g. MMDSR (if available)
- N/A
4. Risk factor assessment
- Risk for spread of infection, sedentary lifestyle, smoking, alcohol drinking,
inadequate fiber intake
5. Physical assessment of indicating presence of illness state
6. Results of laboratory/ diagnostic and other screening products
- No data gathered
E. Values, habits, practices on health promotion, maintenance, and disease
prevention
1.
Immunization status of family members
 Alvarez, Tarcelo – Not immunized
 Alvarez, Estrella – Not immunized
 Alvarez, Benito – Not immunized
 Alvarez, Juvy – Not fully immunized
 Alvarez, Elman – Fully immunized
2. Healthy lifestyle practices
- Eating green leafy vegetables and fish.
3. Adequacy of :
a.
Rest and Sleep
- Family members mostly acquires 8 hours of sleep.
b.
Exercise / Activities
- No schedule of exercises.
c.
Use of protective measures
- Use of mosquito nets and insect repellants
d.
Relaxation and stress management
- Listening to music, and chatting with friends
4. Use of protective – preventive health state
- Has no health insurance obtained
Page 82 of 89
III.
List of Identified Problems
Health Problem
1. Inadequate Medical
Attention
Cues/ data
“Maiha na kami nga waray
pagpapacheck – up”.
Family Nursing Problems
Poor Health Seeking Behavior
2. Unsanitary waste Disposal
“Dire pa maupay it am CR asya
dda la anay kmi hit am libong”.
Poor Environmental Sanitation
3. Improper garbage/ refuse
disposal
“It amon basura ginkakada la nam
hit am luyo”.
Poor Environmental Sanitation
4. Alcohol Drinking
“Mga 3 ka baso ak naiinom nga
alak kada adlaw”.
Unhealthy lifestyle and personal
habilts/ practices
5. Cigarette Smoking
“Usa ka kaha ak nauubosnga
sigarilyo hit usa ka adlaw”.
Unhealthy lifestyle and personal
habilts/ practices
6. Family member with
communicable disease
“Nagpacheck – up kami hadto an
cring han doctor meda ko TB”.
“Dri kami nag.eexercise danay la
ngin nahihinumdom”.
Threat of cross infection from a
communicable disease case
7. Lack of exercise/ physical
activity
II.
Unhealthy lifestyle and personal
habilts/ practices
Priority Setting and Justification
Health problem 1: Inadequate medical attention
Criteria
1. Nature of the
Problem
Computation
3/3 x 1
Actual Score
1
2. Modifiability of the
Problem
1/2 x 2
1
3. Preventive potential
2/3 x 1
2/3
Justification
It is a health deficit.
It is partially modifiable
through dissemination of
information.
Possibility of preventing
the existence of problem
is high with proper
implementation of
services offered in BHS.
The does not recognize
the existence of the
problem.
4. Salience of the
Problem
0/2 x 1
Total Score
0
2 2/3
Health problem 2: Unsanitary Waste Disposal
Criteria
1. Nature of the
Problem
2. Modifiability of the
Problem
Computation
2/3 x 1
Actual Score
2/3
1/2 x 2
1
Resources are available
and interventions are
feasible..
3. Preventive potential
1/3 x 1
1
Communicable diseases
can be reduced or
minimized.
It is not a felt problem by
the family..
4. Salience of the
Problem
0/2 x 1
0
Total Score
2 2/3
Justification
It is a health threat.
Page 83 of 89
Health Problem 3: Improper garbage/ refuse disposal
Criteria
1. Nature of the Problem
Computation
2/3 x 1
Actual Score
2/3
1x2
1
2. Modifiability of the
Problem
3. Preventive potential
1/3 x 1
4. Salience of the
Problem
No data available
Total Score
1
Justification
It is a health threat.
It is partially modifiable
since intervention may
result in people’s
awareness to the threat.
Communicable diseases
transferred by the insects
and rodents can be
prevented.
No data available
2 2/3
Health problem 4 : Alcohol Drinking
Criteria
1. Nature of the Problem
2. Modifiability of the
Problem
Computation
2/3 x 1
Actual Score
2/3
1/2 x 2
1
1/3 x 1
1/3
3. Preventive potential
4. Salience of the
Problem
1/2 x 1
Total Score
1
2
Justification
It is a threat .
It is culture, attitude and
behavior that identify this
problem.
Possibility of preventing
the problem is low
because of absence of
political will to ban
manufacture of
beverages.
Presence of alcohol
drinkers does not directly
affect the health of other
people in terms of their
health status.
Page 84 of 89
Health problem 4 : Cigarette Smoking
Criteria
1. Nature
of
Problem
Computation
2/3 x 1
Actual Score
2/3
2. Modifiability of the
Problem
0/2 x 2
0
3. Preventive potential
1/3 x 1
1/3
4. Salience
Problem
2/2 x 1
1
of
the
Justification
It is a threat .
It is culture, attitude and
behavior that identify this
problem.
the
Possibility of preventing
the problem is low
because of absence of
political will to ban
cigarette smoking and/
manufacture
of
cigarettes.
Presence of smokers
increase the possibility of
secondary smokers or
passive smokers which
will in turn threat the
health of these people.
Total Score
2
Health problem 5: Family member with communicable disease(Tuberculosis)
Criteria
1. Nature of the
Problem
2. Modifiability of the
Problem
3. Preventive potential
4. Salience of the
Problem
Computation
2/3 x 1
Actual Score
2/3
1/2 x 2
1
3/3 x 1
1/1 x 1
Total Score
1
1
3 2/3
Justification
It is a health threat.
The family does not have
adequate resources to
solve the problem.
Inadequacy and
availability of treatment
regimen in RHU’s are
barriers to achievement
of good health which is
important in the
management and
prevention of pulmonary
tuberculosis.
Transferability of
tuberculosis to other
family members is
reduced or eliminated if
the problem is managed
adequately as soon as
possible. .
The family recognizes it
as a problem. It consulted
the health personnel a
month ago. However, it
does not see the problem
as needing immediate
action.
Page 85 of 89
Health problem 7: Lack of exercise/ physical activity
Criteria
1. Nature of the
Problem
2. Modifiability of the
Problem
Computation
2/3 x 1
Actual Score
2/3
1/2 x 2
1
3. Preventive potential
1/3 x 1
1
4. Salience of the
Problem
0/2 x 1
0
Total Score
III.
Justification
It is a health threat.
Generally, modifying the
attitude of common
people entails both the
effort and time of the
facilitators and concerned
member of the family.
The possibility of
preventing the existence
of the problem is low
because intervening with
person’s ADL would be
hard. Although there is a
health threat, the problem
does not affect directly
the health status. Even if
they do not exercise, still
they can live it up and be
able to perform ADL as
usual.
2 2/3
The Prioritized Health Problems
Health problem
Actual Score
1. Family member with communicable disease
(Tuberculosis)
2. Inadequate Medical Attention
3 2/3
3. Unsanitary waste Disposal
2 2/3
4. Improper garbage/ refuse disposal
2 2/3
5. Lack of exercise/ physical activity
2 2/3
2 2/3
6. Alcohol Drinking
2
7. Cigarette Smoking
2
Page 86 of 89
VI. Family Nursing Care Plan
Health problem
Risk for Infection
Transmission related
to Airborne
Transmission
Exposure
Threat of Cross
Infection from a
communicable
disease case
(Pulmonary
Tuberculosis)
Family Nursing
Problem
1. Inability to make
decisions with
respect to taking
appropriate health
action due to:
a. Failure to
comprehend the
nature/magnitude
of the
problem/condition
b. Lack of/inadequate
knowledge as to
alternative courses
of action open to
them
2. Inability to provide
adequate nursing
care to the sick
member of the
family due to lack
of/inadequate
knowledge about
the disease/health
condition
Goal and Objective
Nursing Intervention
Goal: After the nursing
intervention, the client
will not acquire the
disease
The nurse will:
1. Discuss the nature of
pulmonary
tuberculosis
Rationale: To have a
background of what
causes the disease
and how it develops
a. Caused by
Mycobacterium
tuberculosis
b. May be dormant
or active
c. Destroyed by
antibodies or
engulfed by
macrophages
d. Form tubercles
especially at the
lung apex
e. May be/develop
drug resistant/ce
2. Enumerate the signs
and symptoms of
PTB
Rationale: To detect
the presence of the
disease as early as
possible
a. Cough with or
without sputum
or hemoptysis for
more than 3
weeks
b. Low-grade fever
c. Poor appetite
Objectives: At the end
of the nursing
intervention, the family
members will be able
to:
1. Discuss the nature
of multidrug
resistant
tuberculosis
2. Enumerate the
signs and
symptoms of PTB
3. Explain how the
tubercle bacilli can
be transmitted to
another person
4. Enumerate the
ways of
diagnosing a
person with PTB
5. Recognize the
importance of
compliance with
the treatment
6. Discuss the ways
of preventing
disease
transmission
Demonstrate proper
handwashing
technique
Method of Nurse
Family Contact
Method: Home visit
1. Discussion
2. Demonstration
Resources Needed:
1. Human resources:
Time and effort
both of the nurse
and the family
2. Material
resources:
a. Image of the
human
respiratory tract
with and without
tuberculosis
b. Handout on
proper
handwashing.
technique
Germicidal soap
Resources
Evaluation
The family will be able
to:
1. Discuss at least 3
important concepts
regarding the
nature of multidrug
resistant
tuberculosis
2. Enumerate at least
5 signs and
symptoms of PTB
3. Explain the 2 ways
how the tubercle
bacilli can be
transmitted to
another person
4. Enumerate the 4
ways of
diagnosing a
person with PTB
and give 1
advantage and 1
disadvantage for
each
5. Explain the 2
reasons why it is
important to
comply with the
treatment
6. Discuss at least 5
ways of preventing
disease
transmission
Demonstrate proper
hand washing
technique correctly.
Methods:
1. Asking questions
2. Interview
3. Verbal feedback
4. Discussion
5. Return
Demonstration
Tool: Checklist
Page 87 of 89
d. Weight loss
e. Chest and/or
upper back pain
f. Night sweats
g. Chills
h. Tendency to
fatigue easily
i. Pallor
3. Explain how the
pathogen can be
transmitted to another
person
Rationale: To serve
as foundation for
disease prevention
a. Airborne
transmission –
tubercle bacilli
suspended in dirt
in the air
b. Contact
transmission –
droplet
transmission via
coughing,
sneezing,
speaking, spitting
4. Enumerate the ways
of diagnosing a
person with PTB
Rationale: To be
aware of the various
diagnostic
procedures and their
advantages and
disadvantages
a. Sputum smear
b. X-ray
c. Sputum culture
d. PPD skin test
Page 88 of 89
5. Recognize the
importance of
compliance with the
treatment
Rationale: To reduce
the complications and
cost of treatment
a. Prevent
development of
drug resistance
b. Efficient
treatment
6. Discuss the ways of
preventing infection
transmission
Rationale: To know
the different ways of
preventing the spread
of the infection
a. Isolation
b. Keeping distance
when talking
c. Covering the
mouth when
sneezing or
coughing
d. Proper hygiene
e. Handwashing
f. Use of alcohol or
hand sanitizer
g. Boost immunity
h. Provide adequate
sunlight
i. Provide adequate
ventilation
7. Demonstrate proper
handwashing
technique
Rationale: To
decrease the risk of
Page 89 of 89
contact transmission
8. Discuss ways on how
to boost the immunity
Rationale: To
reinforce the body’s
natural capability to
destroy the pathogen
a. Eat foods rich in
vitamin C
(oranges,
ponkan, apples,
dalanghita,
calamansi,
cabbage)
b. Avoid exposure
to smoke and
dust
Drink adequate amount
of fluids.
VII. References, Recommendations, and Appendices
Reference:
Maglaya, Arceli Nursing Practice in the Community 4th ed. Argonauta company 2005