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UNIVERSIDAD DE MANILA

(City College of Manila)


College of Nursing

FAMILY NURSING
TYPOLOGY
(COPAR)

January 14, 2011

I. Introduction
1

A family is the basic unit of the society. It is where an individual first


socialize upon the entry of life. In this, one learns the basic concepts of life,
how it goes, and what will his/her role may be. Family structure involves
system boundaries, roles, sanctions, attitudes, and values that guide family
members. Furthermore, it is a domestic group of people, or a number of
domestic groups linked through descent (demonstrated or stipulated) from a
common ancestor, marriage or adoption. In most societies, it is the principal
institution for the socialization of children. Extended from the human "family
unit" by affinity, economy, culture, tradition, honor, and friendship are
concepts of family that are metaphorical, or that grow increasingly inclusive
extending to nationhood and humanism.
In order to survive in our daily problems, individuals should establish a
relationship to each other whereby caring is perceived, in order to cope with
situational events. Nursing is the care of human beings. Thus, it is a process
of action, reaction, and interaction whereby nurse and client share
information about their perception in the nursing situation. The nurse and
client share specific goals, problems, and concerns and explore means to
achieve a goal.
Health is a right of every human being. According to Imogene King,
health is a dynamic life experience of a human being, which implies
continuous adjustment to stressors in the internal and external environment
through optimum use of ones resources to achieve maximum potential for
daily living. On contrary, disease refers to any conditions that disturbs the
normal functioning of an organism or failure to adapt to its environment. To
prevent such alteration, all members of the family are empowered to
maintain their health status. They must be free from disease or infirmity with
no disabilities, and this is done by proper caring and proper use of health
services in the community and acquiring chech-ups for the family.
The family's definition of health and illness and the meaning they give
to it, contributes to their ability to set boundaries around a health problem.
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Finding the appropriate place for the illness so that it does not become the
central focus of the family serves to limit the boundaries of the disease.
When boundaries are not established and maintained, the illness invades all
aspects of the family system and the family becomes uni-focused. The
individual's physical limitations become the family's limitations. When an
illness compromises the diagnosed member's physical capabilities and
personality characteristics, there is a constant struggle on the part of the
person to maintain equilibrium. In some cases, this struggle creates growth,
development, new closeness and trust in the family relationships as needed
shifts in roles, power and responsibilities emerge. However, in other cases,
as the person's self care capabilities decrease, resentment, jealousy, or
feelings of overburdenedness may occur as the family relationships
deteriorate. The task of maintaining the family support and intimacy is
ongoing for all members. In order to effectively accommodate and regain
equilibrium, it is helpful for family members challenged by serious illness to
receive information about the expected patterns of the particular disorder or
illness and the resultant practical and emotional demands these patterns
may create for them over time.

II. General Objective:


To utilize family resources to establish and improve their health in
order to have a healthy lifestyle and to eradicate problems and/or illnesses.

Specific Objectives:
1. to assess the current health of family members
2. to be able to plan and set goals for the problems identified within the
family.
3. to provide and implement specific management or interventions in
those problems identified.
4. to evaluate the outcomes of the treatment modalities used in
managing the identified problems.

III. Family Nursing Assessment

Family Structure, Characteristics, and Dynamics

Head of the Family: Mr. B


Address: 1012-B Leyte del Sur, Sampaloc, Manila
Type of family: Nuclear

Name of
Househ
old
Member
s

Position
in the
family

Sex

Mr. B

father

male

Mrs. A

mother

Brother
1
Brother
2
Brother
3

eldest

femal
e
male

second
third

Birthdate

Month
July

Day
1

August

15
10

male

Novemb
er
July

male

March

26

Year
196
6
196
6
198
9
199
1
199
8

28

Age
(yrs.
)

Civil
Status

Religio
n

Highest
Education
al
attainment

44

19

single

12

single

catholi
c
catholi
c
catholi
c
catholi
c
catholi
c

vocational

20

marrie
d
marrie
d
single

44

high
school
college
college
high
school

Mr. B, as the head of the family is also the dominant one in terms of
decision-making for the family especially in financial and health matters. Mrs.
A, as a housewife, is the one that control or budget the income of the family
for expenses. They have three dependent children that reside on them. Their
family is nuclear and patriarchal. The primary dialect they use is tagalong,
although Mr. B and Mrs. A both know how to speak Bisaya and Ilonggo
because they were born in Visayas region. The family lives peacefully and
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united. Whenever there is problem between members happen, mostly


misunderstanding, they handle it by means of having an open forum or
family confrontation.

Socio-economic and Cultural Characteristics


Mr. B is a vocational graduate. He worked as an employee in a

company. On the other hand, Mrs. A only finished high school due to lack of
financial support during her time. Brother 1 and Brother 2 are currently
attending college in different universities, one in Quezon City and the other is
in Manila. Brother 3 is currently a freshmen student in high school. As a head
of the family, Mr. B is the one that support the family financially. His monthly
income is approximately P40, 000.00. Their income is wisely budgeted by
Mrs. A, so that it will fit their needs every month such as in food, clothing,
education, health and even recreational activities. All of the members of their
family are Roman Catholic, and they go to church every Sunday and they
consider it as form of recollection and a bonding moment. Both parents and
their two eldest sons are active registered voters of their barangay. They do
not have any problem in their community; in fact, the family has many
friends around them. They live happily and peacefully in their community.
MONTHLY BREAKDOWN OF EXPENSES
Expenses

Amount

Electric bill
P 1,000 1,500
P 500 600

Water bill

Food

P 6,000
(estimated)

Education

P 20,000
(estimated)

Health

P 1,000 2,000
Total

P 28,500
30,100

This is an estimated monthly expenses of the family. There are five


main areas where the family attributed their earned salary: electrical
bill, water bill, food, education, health. The highest expense goes to
the education of the children and the least expense in the health area
because the family rarely experience illness and they often have their
check-ups. They saved the left money in the bank for future

Home and Environment


The family resides in a two-storey house made of cement and wood.

The house has an adequate space for the family. There are two bedrooms, a
living room, comfort room, a kitchen and a small balcony. The couple sleeps
in one bedroom and the three children in the other one. The stairs are made
of wood, and protruding nails are usually present, and these are sometimes
the cause of accident in the family. The house is well-ventilated using stand
fans. It is also well lighted of fluorescent lamps. The members of the family
walk inside the house with flip flops, but they often shared one another.
Mosquitoes, cochcroaches, flies, and rats are present in the house. The
family use insecticides and food traps to kill these vectors of diseases. Mrs. A
raised three lovebirds outside their house. They clean their house everyday.
The source of their drinking water supply is from waterworks system or
individual house connection (Manila Waters). They store their water in a large
container, but most of the time directly to the faucets. They used LPG in
cooking; their foods are usually stored in refrigerator, cabinet and
tupperwares. They put their waste in an open container, because garbage

collection is their method of disposal. They have water-sealed toilet facility


and closed drainage facility. Their residence is surrounded by near living
neighborhood.

They

used

jeepneys

and

trains

as

their

means

of

transportation and cell phone for communication matters.

Health Status of each Family Member


Mr. B is often experiencing hypertension while Mrs. A lives a healthy

wife. Brother 1 has a presence of fungal disease on his feet. Then, Brother 3
is an obese individual. Unlike, his siblings, Brother 2 do not have any problem
in his body, because he is conscious with his health and he is afraid of having
illness. The family primary source of care is the hospital. They usually have
their monthly check-up and dental check-up every six months. They family
loves to eat. They usually eat several times a day. They have many fruits on
their table always. Mr. B often have his form of exercise before going to work,
this is lifting heavy weights in a form of barbells. Mrs. A loves to dance, and
she often walks in the morning. Their children have no form of exercise
except walking. The children take supplemental vitamins everyday. Brother 1
and brother 3 rarely experiencing flu, fever, and cough. In addition, they both
had dengue several weeks ago.
None of the family experienced serious accidents. They also believed
in effects and benefits of some herbal medication like the use of lagundi to
treat cough and guava leaves as an antibiotic agent. Moreover, if one of their
family members is sick and not responding in herbal meds and folk remedies,
they just go directly to hospital and seek for some scientific explanation.
None of the family is smoking, but all male members of the family are mild
alcohol drinkers.
Name of family
member
Mr. B
Mrs. A

Height
(cms)
163
163

Weight
(kgs)
69
65
8

BMI
26
24.5

Normal
Values
18.6
22.9

Brother 1
Brother 2
Brother 3

170
165
168

54
60
83

18.7
22
29.4

The table shows the computed body mass index of each member of the family. Mr.
B has a BMI of 26, which classified as Obese I, and this may contributes to his
hypertension case. Though Mrs. A has a BMI of 24.5, she doesnt experiences any
problems because she maintain herself healthy. Brother 1 & Brother 2 is in normal
BMI. Brother 3 has the highest BMI result of 29.4, which classified as Obese I but is
severe and is highly risk for health problems.

Values, Habits, Practices on Health Promotion, Maintenance and Disease


Prevention
All the family members received complete immunization during their

childhood. Their healthy lifestyle practices are eating nutritious foods,


maintain proper hygiene and clean the surroundings. They sleep about 7-8
hours at night and take household chores as a form of exercise. There are no
deviations in sleeping. As a form of relaxation, they just watch television.
They take vitamins as a promotive or preventive way to maintain good
health.

IV. Family Nursing Typology


Cues and Data

First Level Assessment

44 yrs. old Mr. B with Hypertension as health


deficit
BP 140/100 mmHg
Mr. B work as a fulltime employee in a
surveillance
department of a
company
He verbalized I
easily get tired at

Second Level
Assessment
Inability to make
decisions with
respect to taking
appropriate health
actions due to:
a) failure to
comprehend the
nature/magnitude
of the problem.
b) lack of adequate

workplace, and often


have pain on the
back of my neck,
this is maybe
because of
exhausting things
that I does at work...
whenever I got
home, I rest for few
hours...then Ill ask
my son who is a
student nurse to
take my BP. There
are times that the
result is high but
sometimes it
Obesity as health threat
remains at normal
level.

A 12 yrs old child,


Brother 3, weighing
83 kls. & heighs 56
with a BMI= 29.4
Mrs. A verbalized,
Brother 3 eats more
than three times a
day. He loves to eat
chocolates, ice
Presence breeding sites
cream, cakes,
buttered sandwiches of vectors of diseases
and other oily and
fatty foods.

Presence of cans
and other materials
filled with water are
found around the
house.
Large containers
filled with water are
stored for longer

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knowledge as to
alternative courses
of action open to
them.

Inability to recognize
the presence of
obesity in a
dependent member
due to lack of
inadequate
knowledge.

Inability to provide a
home environment
conducive to health
maintainance and
personal
development due to
inadequate
knowledge of
preventive
measures.

time for the purpose


of water scarcity.
Mrs. A verbalized,
My two sons had
high-grade fever,
cough & colds three
weeks ago on a
rainy season.

Fungal disease as health


threat

Eldest son, Brother 1


have fungal disease.
Brother 1 verbalized,
My feet are easily
get diaphoretic... so
whenever I take off
my shoes, because
of its close-fitted
ties, foul smell
comes out due to
cracking skin on my
feet...days passed it
Accident Hazard:
turned to lesions
Protruding nails as
until it scattered
health threat
between my toes &
soles of feet.
Mrs. A verbalized,
we just have few
flipflops inside the
house & we use to
share it with one
another.

Mr. B verbalized, we
bought the house 3
yrs ago, upon that, I
noticed that theres a
lot of nails which
were not hammered
thoroughly...but Im
busy on my job, I
have no time to

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Inability to provide
adequate nursing
care to dependent
member with fungal
disease due to:
a) Inadequate
knowledge about
the disease.
b) Lack of
knowledge of the
nature and
extent of nursing
care needed
c) Inadequate
family resources
for care:
Absence of
responsible
member
Physical
resources, i.e.,
isolation room

Inability to
recognize the
presence of
condition of
problem due to lack
of knowledge

repair it.
Mrs. A verbalized,
my younger son got
small wound when
he fell down the
stairs.

V. Problem Identified
Hypertension
Obesity
Presence of Breeding Sites of Vectors of Disease
Fungal Disease
Accident Hazard: Protruding Nails

VI. Scoring

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Hypertension
Criteria
1. Nature of the
Problem

Computation
3/3 x 1

Actual Score
1

2. Modifiability
of the
Problem

1/2 x 2

1/2

3. Preventive
Potentials

3/3 x 1

4. Salience of
the Problem

2/2 x 1

Justification
The problem is a
health deficit and
it needs
immediate
intervention to
prevent the
occurrence of
complications.
Intervention
focus on
decreasing blood
pressure should
be utilize such as
monitoring BP
and decresaing
salt intake in the
diet.
The problem can
be prevented by
immediate
implementation
of actions
concerning the
problem.
The family know
the interventions
needed for the
problem and are
willing to take its
measures.

Total Score

3 1/2

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Obesity
Criteria
1. Nature of the
Problem

Computation
2/3 x 1

Actual Score
2/3

2. Modifiability
of the
Problem

2/2 x 2

3. Preventive
Potentials

3/3 x 1

4. Salience of
the Problem

1/2 x 1

1/2

Justification
Obesity is a
health deficit that
requires
immediate
management to
eliminate
untoward consequences
The problem is
modifiable since
the sources are
available; family
can do budgeting
of foods,
selecting
nutritious foods
and do a feeding
pattern.
The problem
should be
eradicated to
prevent other
severe disease
brought by the
present
conditiion; thus
achieving a
normal body
structure.
The family are
aware of the
condition and are
ready to follow
actions to solve
the problem.

Total Score

4 1/2

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Presence of breeding sites of vectors of diseases


Criteria
1. Nature of the
Problem

Computation
2/3 x 1

Actual Score
2/3

2. Modifiability
of the
Problem

1/2 x 2

3. Preventive
Potentials

2/2 x 1

4. Salience of
the Problem

2/2 x 1

Justification
It is a health
threat that needs
attention and
proper
management
because it may
increase the rate
of possible onset
of disease within
the family
because insects
are known
vectors of
diseases.
Interventions are
practicable.
Current
knowledge and
resources are
available to solve
the problem.
Through health
teachings such
as always clean
their house and
provide cover to
their water
storages.
The possibility of
having dengue or
malaria can be
prevented.

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The family is
well-aware about
the problem and
is open for health
care attention.
Total Score

3 2/3

Fungal Disease
Criteria
1. Nature of the
Problem

Computation
2/3 x 1

Actual Score
2/3

2. Modifiability
of the
Problem

2/2 x 2

3. Preventive
Potentials

3/3 x 1

4. Salience of
the Problem

0/2 x 1

Justification
Skin disease is a
health deficit
because it
reduces wellness.
It is moderately
modifiable
because the
financial
resources are
inadequate
although it can
be prevented
through proper
nursing
interventions and
health teachings.
The problem is
highly preventive
because
complications
such as infection
can be prevented
if the problem
will be solved
properly.
The community
recognized it as a

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problem but they


do not do any
intervention to
solve/lessen the
problem.
Total Score

3 2/3

Protruding Nails
Criteria
1. Nature of the
Problem

Computation
2/3 x 1

Actual Score
2/3

2. Modifiability
of the
Problem

2/2 x 2

3. Preventive
Potentials

3/3 x 1

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Justification
It is health threat
that requires
immediate
intervention to
eliminate the
possible injury to
the members of
the family.
The problem can
be easily
modified by
educating and
advising the
family to utilize
the available
resources present
in their
surroundings.
Advice the family
to provide a
storage for their
sharp materials
to protect the
safety of every
family member.

4. Salience of
the Problem

0/2 x 1

0
Providing storage
for sharp objects
can prevent
accidents.
The family has
recognized the
problem and has
implemented
actions to resolve
it like creating
storage for those
sharp objects.

Total Score

3 2/3

VII. Problem Prioritization


The list of health condition or problems ranked according to priorities is
presented:
Problems identified

Score

Obesity

4 1/2

Hypertension

Presence of breeding sites of vectors


of diseases

3 2/3

Fungal Disease

3 2/3

Accidental hazards: Protruding Nails

3 2/3

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VIII. Family Health Tasks


With the presence of obese member in the group, the family will:
Plan an appropriate meal, concerning to include nutritious foods which
are high in vitamins and minerals especially vegetables and fruits and
avoidance of those oily and fatty foods that are primary reason of
developing obesity.
Develop exercise program or have a recreational activity that will
encourage family member to have a physically fit body; which in turn
help to prevent obesity.
Have a daily monitoring of weight to assess the effectiveness of the
treatment modalities.
With the presence of hypertensive member in the group, the family will:
Monitor the blood pressure of the hypertensive member daily to
provide a bases of improvement with regards to his health.
Provide proper meal planning that is appropriate for his condition.

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Encourage the sick member to have a moderate exercise and take an


hours of rest to prevent exhaustion that could trigger his condition.
Encourage the hypertensive member to take drugs when increased in
BP occur.

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IX. Family Nursing Care Plan


Intervention Plan
Health
Problem

Obesity

Family
Nursing
Problem

Inability to
recognize
the
presence
of obesity
in a
dependent
member
due to
lack of
inadequat
e
knowledge
of the
condition.

Goal Of Care

After nursing
intervention
the family
will recognize
the presence
of condition
and with take
measures to
eliminate the
condition
prior to
interventions.

Objectives Of
Care

After nursing
intervention the
family will:
a) Be able to plan
for a balanced
meal for
brother 3.
b) Encourage
exercise to
reduce the risk
of having the
condition.
c) Minimize the
intake and
buying of
foods that are
unnutrious.
d) Monitor the
loss of weight
of brother 3
within a
month.

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Nursing
Interventions

Discuss the
possible
consequence
s of the
condition to
brother 3.
Encourage
the family to
have an
exercise
program or
recreation to
minimize
overweight.
Promote
balanced
meal for the
family which
should be
include
vegetables,
fruits, and

Method of
NurseFamily Contact

Resources
Required

Home Visit

Material
Resources:
Visual
Aids,
example
of food
stuff for
demonstra
ting a
balanced
meals,
supplies
and
equipment
for
cooking
demonstra
tions.
Time and
effort on
the part of

e) Be
knowledgeable
of the
complications
that may occur
to brother 3.

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avoiding oily
and high in
fats foods.
Cite other
available
resources to
solve the
condition
present.

the nurse
and family
Expenses
for
teaching
aids.

Intervention Plan
Health
Problem

Family
Nursing
Problem

Goal Of
Care

Hypertensi
on

Inability to
make
decisions with
respect to
taking
appropriate
health actions
due to:
failure to
comprehen
d the
nature/mag
nitude of
the
problem.
lack of
adequate
knowledge
as to
alternative
courses of
action
open to
them.

After
nursing
intervention
the family
will take the
necessary
measures to
properly
manage,
control and
lessen the
risk factors
of
hypertensio
n.

Objectives Of
Care

After nursing

intervention the
family will:
a) have
adequate
knowledge
about proper
nutrition that
will help
reduce

hypertension
and prevent
to occurence
of relative
complications
in the future.
b) be able to
determine
the risk
factors that
contribute to
hypertension
c) practice
proper
lifestyle with
regards to
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Nursing
Interventions
Discuss the
nature, signs,
symptoms
and
complication
s that might
arise due to
hypertension
.
Discuss with
the family
the risk
factors of
hypertension
such as
family
history, age,
salt and
alcohol
intake and
obesity.
Promote a
healthy
lifestyle such
as:

Method of
NurseFamily Contact

Resources
Required

Home Visit

Material
Resources:
Visual
Aids,
materials
and lowcost
supplies
needed for
demonstra
tion
Time and
effort on
the part of
the nurse
and family
Expenses
for
teaching
aids.

nutrition and
physical
fitness.

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a) encouraging
proper food
intake like
reduced salt
and fatty
foods.
b) Prevent
obesity
through good
nutrition and
exercise.
c) Smoking
cessationtobacco or
nicotine
promotes
atheroscleros
is that may
contribute to
hypertension
both passive
and active
smoker
Encourage
check-ups
and provide
referral with
a medical
practitioner
to lessen
hypertension
and modify
risk-factors.

Intervention Plan
Health
Proble
m

Family
Nursing
Problem

Goal of Care

Presenc
e of
Breedin
g Sites
of
Vectors
of
Disease
s

Inability to
provide a
home
environment
conducive to
health
maintenance
and personal
development
due to
inadequatea
knowledge of
regarding
preventive
measures

After nursing
intervention
the family
will be able to
eradicate the
presence of
these
unwanted
sites of
vectors
causing
diseases and
therefore will
maintain a
home
environment
conducive to
health.

Objectives of
Care

After nursing
intervention the
family will:
a) be aware and
be more
knowledgeabl
e about the
importance of
proper
sanitation
especially at
home;
b) be able to
eliminate the
presence of
these
breeding sites
of vectors
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Nursing
Interventions

Method of
NurseFamily Contact

Resources
Required

Discuss the
importance
and purposes
of proper
sanitation
Cite the causes
and effects of
the prevalence
of these
unwanted
pests around
the home.
Suggest
alternatives/
methods that
would
eliminate the

Home Visit

Material
Resources:
Visual Aids,
materials
and low-cost
supplies
needed for
demonstrati
on
Time and
effort on the
part of the
nurse and
family
Expenses

c) recognize the
causes of
breeding sites
such as to
prevent the
occurence of
diseases.

26

breeding sites
of vectors
Explore with
the family the
ways of
improving
home
sanitation
considering its
limited
resources:
a) emphasize to
the family
the proper
storage of
food that
may attract
vectors
b) instruct all
family
members to
prevent
accumulation
of stagnant
water around
their home
since this is a
good
breeding
place for
insects.

for
teaching
aids.

Intervention Plan
Health
Problem

Fungal
Disease

Family
Nursing
Problem

Goal Of Care

Inability to
provide
adequate
nursing care
to dependent
member with
fungal
disease due
to:

After nursing
intervention,
the fungal
disease will
be
eradicated.

Objectives Of
Care

After nursing
interventions, the
family will be able
to provide
measures
including skin
care and applying
treatment to
manage
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Nursing
Interventions

Discuss the
nature, signs
and
symptoms,
and the
proper care
needed for
the disease.
Discuss with

Method of
NurseFamily Contact

Resources
Required

Home Visit

Material
Resources:
Visual aida
and low
cost
supplies to
manage/tr
eat fungal
disease.

d) Inadequat
e
knowledge
about the
disease.
e) Lack of
knowledge
of the
nature
and extent
of nursing
care
needed
f) Inadequat
e family
resources
for care:
Absence
of
responsibl
e member
Physical
resources,
i.e.,
isolation
room

adequately the
existing disease
and to prevent
the spread of it.

28

the family
the
appropriate
treatment for
fungal
disease
utilizing less
expensive
drugs and
supplies.
Emphasize
the
importance
of personal
hygiene and
proper use of
flipflops for
the
prevention of
disseminatin
g the
disease.
Encourage
the family to
consult
medical
specialist for
the disease
present for
the
prevention
and proper
management

Time and
effort on
the part of
the nurse
and family.
Expenses
for
teaching
aids.

Intervention Plan
Health
Problem

Family
Nursing
Problem

Goal Of Care

Objectives Of
Care

29

Nursing
Interventions

Method of
NurseFamily Contact

Resources
Required

Accident
Hazard:
Protrudin
g Nails

Inability to
recognize the
presence of
condition or
problem due
to lack of
knowledge

After nursing
intervention
the family
will be able
to fix the
rusty
protruding
nails and
therefore
prevent the
dangers it
encompasses
.

After nursing
intervention the
family will:
a) be able to
remove the
protruding
nails and thus
minimize the
possibility of
accidents at
home
b) recognize the
prevalence of
the dangerous
debris hanging
on their walls
that they
would inspect
further to
remove other
possible
dangers in
their home.
c) know the
importance of
a home free
from danger
and thus
conducive to
health and
living.
d) be
30

Discuss with
the family
the possible
effects of
protruding
nails such as
puncture,
tetanus and
other
wounds.
Encourage
home
inspections
for other
dangers so
that
immediate
action will be
applied at
once.
Suggest the
family to fix
the
protruding
nails as soon
as possible
to prevent
the dangers
that they
might
experience if
not acted

Home Visit

Material
Resources:
Materials
and lowcost
supplies
needed to
eliminate
problem.
Time and
effort on
the part of
the nurse
and family.
Expenses
for
teaching
aids.

knowledgeable
of injuries and
other dangers
that is caused,
not only by
protruding
nails but other
accident
hazards that
are present in
their home.

31

upon
immediately.
Cite
available
resources to
resolve the
problem.

32

X. Evaluation
The planning of interventions for different family problems concerning
there health have met the desired goal which was to utilize the family
resources in order to establish and improve their health and to eradicate
problems and/or diseases. The family have learned knowledge about those
identified problems and participated in different management measures
implemented. The willingness of the family in treatment regimens have
facilitated

the

achievement

of

the

goal;

the

continuation

of

those

managements will help the family members to minimize and/or prevent the
occurrence of problems or diseases again.
Thus, the love, proper care and concern of each family member to one
another uplifted the betterment of the family in terms of their health,
relationship, and communication to one another.

33