CLIENT HISTORY:

GENERAL HISTORY OF CLIENT

Name: A.A.
Address: Blk 195 Lot 10 Rodriguez, Rizal
Birthday: April 21, 1987
Gender: Female
Age: 29 years old
Nationality: Filipino
Marital Status: Common Law Wife
Number and Ages of Children: 2 Children 8 & 6
Number and Ages of Siblings: 6 Siblings unrecalled ages
Educational Attainment: High School Graduate
Occupation: Housewife
Religion: Roman Catholic
Primary Language Spoken: Tagalog
Chief Complaint: N/A
RELEVANT HISTORY PERSONAL
A. Previous Hospitalization and Illnesses
Patient denies any previous hospitalizations. She has history of chickenpox, mumps,
measles and ear infection.
B. Education Background
Patient wasnt able to finish college due to financial constraint but was able to graduated
high school. She states that she is a hardworking student and sometimes experience problems
associated with school.
C. Occupational Background
Patient is unemployed and has no history of employment.
D. Social and Support System
Patient likes to keep her problems to herself. She copes by using diversional activities
such as watching t.v. and sleeping.
E. Marital Background

Patient is just a common law wife. She has a good relationship with her children.
F. Sexual Patterns
N/A
G. Stressors/Losses
Patient sometimes experience financial problem.
H. Interest/Abilities/Pleasure
Patient likes to watch t.v. She states that during her spare time she would likely to use it
for sleeping.
I. Substance Use/Abuse
Patient denies use of alcohol and illicit drugs.
J. Values and Beliefs
She goes to church twice a month. She likes to pray most of the time.
K. Cultural Influences
N/A

CUES/DATA

FAMILY NURSING DIAGNOSIS

 A 29 year-old female, mother of two,

living in Block 195 Lot 10 Rodriguez,
Rizal.
Mother verbalized Medyo masakit
yung ulo ko.
Busy with housework and her children,
patient only goes to the Health Center
during illnesses. Has no regular check-

A. Stress-provoking factors specifically,

interpersonal conflicts between family
members
i. members preoccupation with own
concerns.
B. Unhealthful lifestyle and personal
practices:
1. inadequate sleep/rest
2. lack of exercises/physical activity

ups.
Patient reported not doing regular
physical exercises
Patient has experienced ear infections
Patient lives with her two chilldren and
husband.
Source of income is from her husband
who is a construction worker.
Patient reported that she does not open
up her problems to anyone. pag may
problema ako kinikimkim ko lang.

PRIORITIZATION
A. INTERPERSONAL CONFLICTS BETWEEN FAMILY MEMBERS
Criteria
Computation
1. Nature of the 2/3 * 1

Actual Score
0.66

Justification
It is a health threat

Problem
2. Modifiability 2/2 * 2

of the Problem
3. Preventive
Potential
4. Salience of

The problem is easily modifiable

through the use of open

3/3 * 1
2/2 * 1

communication.
The possibility of the problem being

prevented is high.
The patient perceives it as a problem

the Problem

for it affects her personally and

psychologically.

Total Score

4.66

B. UNHEALTHFUL LIFESTYLE AND PERSONAL PRACTICES

Criteria
Computation
1. Nature of the 2/3 * 1

Actual Score
0.66

Justification
It is a health threat

Problem
2. Modifiability 2/2 * 2

This problem is easily modifiable

of the Problem
3. Preventive
Potential
4. Salience of
the Problem
Total Score

since the problem is just sleep and

2/3 * 1
1/2 * 1

0.66

exercise.
This problem will only be prevented

0.5

if other problems will be resolved

The patient does not consider it as
her primary problem.

3.82

List of health conditions ranked according to priorities:

1. Stress-provoking factors specifically,
interpersonal conflicts between family members

4.66

2. Unhealthful lifestyle and personal practices

Family
Health Problem

Nursing

Goal of Care

Problems

3.82

Objectives of
Care

Intervention P
Method of
Nursing

Nurse-

Interventions

Family

1. Stress-

Inability to

After nursing

After nursing

1. Encourage

provoking factors

cope up with

intervention, the

intervention, the

verbalization and

specifically,

stress in

family will be

family:

expression of

interpersonal

relation to

able to identify

a. will be able to

feelings.

conflicts between

family

ways to provide

identify ways

2. Encourage

family members

conflicts

resolution to the

cope up with

emotional support

problem

stress provoking

from other members

problems

of the family.
3. Discuss different
defense mechanisms
to patient.

Contact
Home visit

4. Provide
diversional activities.
5. Emphasize the
importance of having
good communication
inside the house.

Health
Problem

Intervention P
Method o

Family
Nursing

Goal of Care

Objectives of Care

Problems

Nursing

Nurse-

Interventions

Family

Contact
Home visi

2. Unhealthful

Inability to

After nursing

After nursing

1. Discuss different

lifestyle and

give

intervention, will

intervention, the

ways to promote a

personal

importance in

be able to

family:

healthy lifestyle.

practices

achieving

recognize

a. will have a good

2. Discuss the

healthy

importance of

understanding of

advantages of

lifestyle

having a healthy

having a healthy

having a healthy

lifestyle

lifestyle

lifestyle.

b. can enumerate

3. Enumerate

various ways of

different health

maintaining a

actions.

healthy lifestyle

4. Eradicate

c. will implement

practices that can

agreed upon health

hinder having a

actions

healthy lifestyle.