Professional Documents
Culture Documents
College of Nursing
RNP Blvd. Carmen Cagayan de Oro City
In partial fulfillment of
NCM501205
Related Learning Experience RLE
Submitted by :
Submitted to:
Clinical Instructor
INTRODUCTION
SPOT MAP
FAMILY PROFILE
Age
Occupation
Date of Birth
Educational Attainment
Birth Place
Height
Weight
Age
Occupation
Date of Birth
Educational Attainment
Birth Place
Height
Weight
Family Information
Religion : Roman Catholic
Nationality : Filipino
Family Income : ↑↓ Ρ 5,000/month
Source of Income : Father – as a Jeepney Driver
Children’s:
Name :
Age
Sex
Date of Birth
Birth Place
Height
Weight
Name :
Age
Sex
Date of Birth
Birth Place
Height
Weight
HEALTH HISTORY
Mrs. Y is 21 years of age, her family originated from Y. She met Mr. X
during a Barangay Dance “disco” and consequently got married and settled. She
is a plain housewife and stays most of the time at home. Both parents of the
maternal side, had diabetes mellitus that is why she is utmost predisposed to
acquiring diabetes. She has been hospitalized twice in X due to Maternal delivery
with her first baby and the second baby.
C, 1 year and 9 months is the eldest of two children. When Mr. X stopped
using condom since it was costly for them, C became the product of their
marriage. He was breastfed when she was an infant and he has completed his
Hepatitis vaccination. No records of hospitalization were revealed by the mother
upon interview except common colds, fever and cough which was just confined
at home.
Baby V, 8 months old is the second child. She came out to this world as a
result when Mrs. Y experienced headache when using Depo (injectibles) and
stopped using it. The mother breastfed her but was not successful due to mixed
feeding or bottle fed. She has not yet completed her Hepatitis vaccination. She
too had not been hospitalized. Once she was sick due to colds, she was just
confined at home.
EENT:
� Impaired vision � blind
� pain � reddened � drainage
� gums � hard of hearing � deaf Teething process
� burning � edema � lesion � teeth
Asses eyes, ears, nose
Throat for abnormality � no problem Colds
RESP.
�asymmetric � tachypnea
� apnea � rales � cough � barrel chest
� bradypnea � shallow � rhonchi
� sputum � diminished � dyspnea
� orthopnea � labored � wheezing
� pain � cyanotic
Asses resp. rate, rhythm, depth, pattern
breath sounds, comfort � no problem
CARDIO VASCULAR
� arrhythmia � tachycardia � numbness
� diminished pulses � edema � fatigue
� irregular � bradycardia � murmur
� tingling � absent pulses � pain
Assess heart sounds, rate, rhythm, pulse, blood
pressure, etc., fluid retention, comfort
� no problem
GASTRO INTESTINAL TRACT
� obese � distention � mass
� dysphagia � rigidity � pain
Asses abdomen, bowel habits, swallowing,
bowel sounds, comfort � no problem
GENITO-URINARY and GYNE
� pain � urine color � vaginal bleeding
� hematuria � discharge � nocturia
Assess urine freq., control, color, odor, comfort/
Gyn-bleeding, discharge � no problem
NEURO
� paralysis � stuporous � unsteady � seizures
� lethargic � comatose � vertigo � tremors
� confused � vision � grip
Assess motor function, sensation, LOC, strength,
grip, galt, coordination, orientation, speech.
� no problem
MUSCULOSKELETAL and SKIN
� appliance � stiffness � itching � petechiae
� hot � drainage � prosthesis � swelling
� lesion � poor turgor � cool � deformity
� wound � rash � skin color � flushed
� atrophy � pain � ecchymosis
� diaphoretic � moist
Asses mobility, motion, galt, alignment, joint function
/skin color, texture, turgor, integrity � no problem
Subjective: Environment • Inability to After nursing After nursing 1. Discussed with the Home visit After the nursing
“Medyo hugaw al sanitation maintain intervention, intervention, family the importance Material intervention, the
gyud ang among as health sanitary the family will the family will of keeping resources: family was able to:
palibot threat environment be able to be able to environment clean and 1. Practiced of
gakapoyan due to recognize the • identify sanitary. keeping
naman gud ko environmental importance of causes or root 2. Explained to the environment or
kay daghan condition such keeping of problem family that keeping Visual aids surroundings clean
pakog buhaton” as flooding of environment regarding environment and sanitary.
as verbalized by water in these clean and environmental conducive for health 2. eradicates /
Mrs. Genevieve areas. sanitary and sanitation helps in the disease Time and effort control of insects,
Rayos •Inability to appreciate the • Will be able prevention. aids and vermins, and
control insects effects. to keep and 3. Encouraged / transportation rodents (if any).
Objective: and vermin due maintain a advised to screen of the student
• House to lack of sanitary windows and doors to nurse.
surrounded by knowledge on environment prevent / avoid insects
murky and importance of conducive for such as mosquitoes
stagnant water eradicating health. and flies to enter the
Expenses for
• Flooding often them. • will be able house and advised to
teaching aids
occurs during to eradicate or kill roaches and other
rainy seasons minimize insects.
• Compost pits presence of 4. Encouraged to
are often insects and properly segregate
dugged shallow vermin on and dispose garbage
leaving garbage surroundings according to kind, and
to over flow. especially in practice it religiously
• Presence of the house. for health promotion
flies and and disease
mosquitoes preventive measures.
flying the house. 5. Made the family
aware of the risks and
effects of not keeping
environment sanitary.
CUES HEALTH RESOURCES EVALUATION
PROBLEM FAMILY GOAL OF OBJECTIVES INTERVENTION METHODS REQUIRED
NURSING CARE OF CARE MEASURES OF NURSE-
PROBLEM FAMILY
CONTACT
Improper • Inability to After the After the 1. Emphasized to Home visit After the nursing
Subjective: Garbage segregate nursing nursing the family the Material intervention, the
Disposal as a garbage due to intervention, intervention, importance of resources: family was able to:
“ Na, wala man health threat lack of the family will the family will throwing their trash 1. Resolutes the
awareness on be able to be able to: in a garbage bag importance of
me kabalo
proper waste appreciate the rather throwing it throwing their trash
unsaun na pag Visual aids
disposal. importance of • Identify and anywhere. in garbage bag
lain-lain ug mga
garbage classify waste rather throwing it
basura”, as
• Inability to segregation. and 2. Educates the anywhere.
verbalized by
the mother appreciate biodegradable, family how to cover Time and effort
garbage non- the trash bags to aids and 2. Classified the
Objective:
segregation biodegradable, minimize the flies. transportation of non- biodegradable,
• Saw empty soft
and recycle. the student biodegradable
drink bottles,
nurse. waste
uncovered • Inability to
containers of decide 3. Reinforced the 2. Practices the
water, and regarding ways •Will be able to family about their proper covering of
leaves which for garbage dispose subdivision rules on Expenses for
garbage can.
could be disposal garbage proper segregation teaching aids
breeding properly. garbage.
grounds for
vectors
• Peeled skin of • Will be able
fruits seen all to identify 4. Increased
over the waste in awareness
backyard practicing regarding of the
proper risks and effects of
disposal. improper disposal.
METHODS OF
FAMILY
HEALTH GOAL OF OBJECTIVES INTERVENTION NURSE- RESOURCES
CUES NURSING EVALUATION
PROBLEM CARE OF CARE MEASURES FAMILY REQUIRED
PROBLEM
CONTACT
Subjective: Low family Inability to At the end of At the end of 1. Discussed to Home visit Material At the end of
“ Gamay ra income as make decisions nursing nursing the family the resources: nursing
among kita , Dili foreseeable with respect to interventions interventions importance of Visual aids, interventions, the
maigo sa among cirisis. taking the family will the family will finding additional examples of food family was able to
upat”, as appropriate find enough be able to ways to earn stuffs for identify some ways
verbalized by health action resources that identify ways money. demonstrating to utilize their
the mother and inability to could sustain to utilize family 2. Explained to preparation of income and was
Objective: decide which family health income wisely the family to learn low-cost menus, able to understand
• Father earns action to take needs. and earn to prioritize needs for cooking the proper way of
5,000 from among a money for of the family. demonstrations. spending or saving
Php/month list of health 3. Educated the Time and effort even just a little
• Mother has no alternatives. civilization. family to aids and amount of money
job to support minimize transportation of everyday.
the basic family unnecessary the nurse.
needs. spending. Expenses for
Absence of 4. Teaches to teaching aids and
basic practice proper transportation of
necessities and budgeting of their the nurse.
other materials income
for first aid 5. Emphasized to
include in their
budget the
money needed
for their health
SOCIAL
>they have superstitious > Belongs to the low economic > do not own the lot.
belief status
Unstable income
generating source
VIII. SCHEMATIC PRESENTATION OF THE FAMILY HEALTH PROBLEM
BIOLOGICAL
GENETIC PHYSICAL
>hypertension (+) on
paternal sid3e
Day 1
X
Orientation Phase
On the very first day of duty in the community, it took us the hard time to find our
own patient and at the same time choosing our family care study patient that will be
visited and assessed by the group. Basically, we have to follow on the criteria given to
us that will qualify a family to be our respective patients. If we are to base on the
problems the family has, the community has less problems that concerns on health
related areas since more of the identified dilemmas were environmentally traces.
Despite of this fact, we patiently took the time in finding our patients that can be of help
to us and we can be a help to them as well as a change agent or an educator in their
humiliating health conditions.
So, as we have tried to move on and grabbed some learning that skillfully
enhances our knowledge in close contact to people and showing them of how to be a
people to people, we were able to select the family based on their needs. Through this
manner, prioritization is being practiced and sharpened.
Day 2
X
Working Phase
As finally decided, I am able to choose the patient that bests seek my support in
their living. Most likely, the need to establish rapport and gauging their interest and
participation is my main goal at this moment of time. Determination of their effort to
participate and sincerest approval to our presence is also a great deal to be cleared and
promoted throughout the entire visit that we are to take with them.
As I begin this contact with them, I initiatively took the step to have personal
contact; I visit them in their households and take some part of their time. I took the step
in taking their data, which in this way, collection of data is performing the procedures
that will be more sharpened as the more we do it.
Day 3
X
Working Phase
Since I have partially collected data by interviews or physical assessment, I
immediately interpret and investigate data by being inquisitive to the family in order to
answer my questions in my mind that will help me increase my critical thinking and
judgment to the data I have on hand. It is indeed necessary to take extra careful in
dealing with what I have collected that perhaps confirmation should be rechecked and
appropriately managed.
All senses were being improved to find flaws and comprehend the application of
learned theories in actual setting by doing health teachings and giving guidelines to be
followed by them. This task took me responsible to what I could bring to the family in so
many ways I can as student nurse.
Day 4
X
Working Phase
This is the step for me to intervene to my patient that requires great skill and
knowledge. As most of us, this activity is believed to take a closer connection to the
family that applications of needed activities require thorough study to prevent errors and
faulty nursing practices. The building of trust may be noticed in time towards the end of
the actual performances.
In response to their short responses, I believe that this has captured and
enlightened their function as a human of their own. Helping them enrich their lives calls
a sense of responsibility and accountability to their selves.
Day 5
X
Termination Phase
On this last visit, everyone wish to help our individual family clients, addressing
their needs and giving them care to what they wish. It is my chance to share my
knowledge through giving health teachings and imparting information for their own
benefits. Most likely, my tasks as student nurse are primarily focused on the basic areas
to be implanted to them in action and words. This may be appreciated once the taught
knowledge will be applied and inhibited. I gladly thank my patients in giving their time
and may they be able to find their position in life as a person.
S
“Sakit ang akong likod og mga kabukogan panalagsa ilabi na kun
gikan og hago na trabaho“ as verbalized by the father
O
Facial Grimace, Guarding, Restlessness,
A
Pain related to exacerbation of muscular strength.
P
At the end of 15 to 30 minutes, the patient will be able to
verbalized comfort and pain is reduced to manageable level.
• Placed on a position of comfort.
I
-to relieve pain.
• Encouraged Deep Breathing Exercises.
-for relaxation purposes.
• Applied Ice Cap on the abdominal area PRN.
-to promote comfort and reduce pain.
• Talked to the patient.
-to divert patients attention with regards to pain.
• Administer pain reliever e.g. tramaadol
-to relieve pain and promote muscle relaxation.
At the end of the intervention, the patient cooperated and
E
decreased pain as evidenced by absence of grimace and
guarding, and showed comfortable aura.
EVALUATION
Although some short comings were not thoroughly anticipated during the
care of the family as well as referral was not very successful due to the
unavailability of the family members to be referred. Still I was able to care to the
concerned family.
There were no difficulties encountered as to the family member’s attitude
because they were participative and accommodating throughout the care
rendered to them. Furthermore, as of other aspects was difficult to plan because
it was not anticipated, such mentioned difficulty was encountered with the father
of the family because of his unavailability during the process of care. The said
father leaves at 6 am and comes home at 7-10pm that is why he was only cared
once because during that day he did not go to work.
Even though the family relies more on herbal treatment rather than
medical treatment, they still go to the nearby health center that is if they
experienced unusualities in their bodies lasting more than 5 days accordingly.
In the client care process, several interventions were done as well as
health teachings. This includes the appropriate care for the disease conditioned,
information drive or further research and education which concerns of health care
and health related conditions. As well as other health tips were emphasized to
the concerned family, these were discussed as to anticipate the care of the
individual and the family as a whole.
Bibliography
2004
ASSESS CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING YES___ NO_√_
CONVULSIONS
ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes__ No_√__
For how long? _5_days No Pneumonia: Cough
and Cold
• Count the breaths for one minute. _32_breaths per minute. Fast breathing?
CHECK THE CHILD’S IMMUNIZATION STATUS Circle immunization needed today Return for next
_√__ _√__ __√_ __√__ immunization on:
BCG DPT1 OPV1 HEPB1
__√__ _√__ __√_ _______ (IMMEDIATELY)
DPT2 OPV2 HEPB2 MEASLES (date)
_√___ __√__ __√___
DPT3 OPV3 HEPB3
CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older Vitamin A needed
Is the child six months of age or older? Yes_√_ NO___ today
Has the child received Vitamin A in the past six months? Yes___ No_√___ Yes_√__ No___
ASSESS CHILD’S FEEDING if child has ANEMIA OR VERY LOW WEIGHT or less than 2
years old.
• Do you breastfeed your child? Yes_ _ No__√__
If Yes, how many times in 24 hours? _n/a__ times. Do you breastfeed during the night? Yes_ __
No_√
• Does the child take any other food or fluids? Yes_√__ No___
If Yes, what food or fluids? _noodles, vegetables, fruits rice and fish_
How many times per day?_3__ times. What do you use to feed the child? _spoon and fork_
If very low weight for age: How large are servings?_minute servings_____
Does the child receive his/her own serving? yes__ Who feeds the child and how?_mother,
spoonfeeding
• During the illness, has the child’s feeding changed? Yes _ _ No_√__
If yes, how?
ASSESS CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING YES___ NO_√_
CONVULSIONS
ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes__ No_√__
For how long? _5_days No Pneumonia: Cough
and Cold
• Count the breaths for one minute. _32_breaths per minute. Fast breathing?
• Look for chest indrawing?
• Look and listen for stridor.
DOES THE CHILD HAVE DIARRHEA? Yes___ No_√_
For how long? ___days
Is there blood in the stools?
• Look at the child’s general condition. No Dehydration
Abnormally sleepy or difficult to awaken?
Restless or irritable?
• Look for sunken eyes.
•Offer the child fluid. Is the child:
Not able to drink or drink poorly?
Drinking eagerly, thirsty?
• Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C or above) Yes__ No_√__
Decide Malaria Risk
• Does the child live in malaria area? No
• Has the child visited a malaria area in the past 4 weeks? No
If malaria risk, obtain a blood smear.
• Look or feel for stiff neck.
• Look for runny nose.
+ Pf Pv - Not done
• For how long has the child had fever? __days
• If more than 7 days, has fever been present every day?
• Has the child had measles within the last 3 months?
Look for signs of MEASLES
• Generalized rash and
• One of these: cough, runny nose. Or red eyes.
……………………………………………………………………………………………………………………………….
If the child has measles now or within the last 3 months:
• Look for mouth ulcers
If yes, are they deep and extensive?
• Look for pus draining from the eye
•
Look for clouding of the cornea.
……………………………………………………………………………………………………………………………….
Decide Dengue Risk: Yes__ No__√_
If dengue risk, then ask:
• Has the child had any bleeding form the nose or gums or in the vomitus or stools? No
• Has the child had black vomitus or black stool? No
• Has the child had abdominal pain? No
• Has the child been vomiting? No
• Look for bleeding from nose or gums. None
• Look for skin petechiae. None
• Feels for cold and clammy extremitites. None
• Check capillary refill ___seconds.
• Perform tourniquet test if child is 6 months or older and has no other signs and has fever for
• more than 3 days.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No__√_
• Is there ear pain? No
• Is there ear discharge? No No Ear Infection
If yes, for how long? ___days
• Look for pus draining from the ear. None
• Feel for tender swelling behind the ear. None
CHECK THE CHILD’S IMMUNIZATION STATUS Circle immunization needed today Return for next
_√__ _√__ __√_ __√__ immunization on:
BCG DPT1 OPV1 HEPB1
__√__ _√__ __√_ _______ (IMMEDIATELY)
DPT2 OPV2 HEPB2 MEASLES (date)
_√___ __√__ __√___
DPT3 OPV3 HEPB3
CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older Vitamin A needed
Is the child six months of age or older? Yes_√_ NO___ today
Has the child received Vitamin A in the past six months? Yes___ No_√___ Yes_√__ No___
ASSESS CHILD’S FEEDING if child has ANEMIA OR VERY LOW WEIGHT or less than 2
years old.
• Do you breastfeed your child? Yes_ _ No__√__
If Yes, how many times in 24 hours? _n/a__ times. Do you breastfeed during the night? Yes_ __
No_√
• Does the child take any other food or fluids? Yes_√__ No___
If Yes, what food or fluids? Milk formula and breast milk _
How many times per day?_per demand__ times. What do you use to feed the child? _bottle fed &
breast fed_
If very low weight for age: How large are servings?_minute servings_____
Does the child receive his/her own serving? yes__ Who feeds the child and how?_mother,
breastfeeding & bottle feesing
• During the illness, has the child’s feeding changed? Yes _ _ No_√__
If yes, how?
ASSESS OTHER PROBLEMS: scabies