Initial Data Base for Family Nursing Practice

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

A. Family Structure, Characteristics, and DynamicsMember of the household

Relationship to the head of the family

age sex Civil status

Position in the family

Leland N. de Leon

Father/ husband

45 Male Married Father/husband

Marciana S. de Leon

wife 44 Female Married Mother/wife

Mark Leland S. de Leon

Son 19 Male Single Eldest child/son/brother

Elaine S. de Leon

daughter 18 Female Single Youngest child/daughter/sister

Member of the household

Place of residence of each member of the family

Type of family structure

Dominant family members in terms of decision making

General family relationship or dynamics

Leland N. de Leon

Living independently

Patriarchal/nuclear

Short temper/ easily irritated

Marciana S. de Leon

Living independently

Patriarchal/nuclear

Good listener


Living with parents

Patriarchal/nuclear

Joker

Elaine S. de Leon

Living with parents

Patriarchal/nuclear

Easily irritated

B. Socio-economic and Cultural CharacteristicsMember of the household

Income and expenses

occupation Place of work

Income of each working member

Adequacy to meet basic necessities

Who makes decisions about money

Leland N. de Leon

Production manager

Bulacan P15,000.00/mo Adequate

Marciana S. de Leon

Landlady Manila P4,000.00/mo Adequate


BTM student

PUP

Elaine S. de Leon

BSN student

UERMMMC

C. Home and Environment

The de Leon Family’s House is made of concrete and has three bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. Every member of the family has their own bedrooms. Mr. and Mrs. de Leon share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and roaches present in de Leon family’s house. Their foods are stored in closed door cabinets and the refrigerator. The de Leon’s’ water supply comes from deep well and not from NAWASA. They use water septic tank for their water supply. The water coming from the septic tank is used for washing, cleaning, and bathing and not for drinking purposes. The de Leon family buys distilled water from water refilling stations. The de Leon family has their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by Mrs. de Leon and sometimes the siblings. Their garbage is taken out everyday and collected by garbage trucks everyday. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Mr. de Leon built a poso negro near the laundry area and is been cleaned every once in a while to check for clogs. Their neighborhood is not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility.

D. Health Status of Each Member


Medical and nursing history

Nutritional assessment Risk factor assessment

Dietary history

Eating habits and practices

Leland N. de Leon

4x a day Meat, fruits and vegetables

Cigarette and tobacco smoking

Marciana S. de Leon

Rheumatic heart disease

2x a day Sea foods


4x a day Meat, fish, fruits and vegetables

obesity

Elaine S. de Leon

dengue 3x a day meat, fruits, less vegetables and fish

stress

E. Value, Habits, Practices on Health Promotion, Maintenance and Disease Prevention


Immunization status of family members

Healthy lifestyle Practices

Leland N. de Leon complete Biking everyday

Marciana S. de Leon complete Stretching and eating fruits

Mark Leland S. de Leon complete Basketball (occasionally)

Elaine S. de Leon complete Badminton, Walking and eating fruits

Adequacy of :


Rest/ sleep

Exercises/ activities

Use of protective measures

Relaxation and other stress management activities

Leland N. de Leon

9 hours

10-20 minutes

Uses jacket Rest or watch TV or listen to jazz music

Marciana S. de Leon

8 hours

5-10 minutes

Uses slippers in and out the house and umbrella

Rest and watch TV


6-8 hours

1 hour Use pads Rest or eat

Elaine S. de Leon

6 hours

1 hour Use umbrella when raining, and handkerchiefs

Rest and watch TV or surf the internet

FIRST LEVEL ASSESSMENT

SMOKING

Structured Questions:

1. Why do you smoke?

I smoke because it relieves my stress and it’s already been a habit and a part of my everyday practice.

2. Do you know the consequences of smoking?

I know that smoking is dreadful for the health especially for the lungs but smoking has already been a habit for me.

3. Did you try to stop smoking?I did not try to stop smoking.

STRESS


1. Why are you always stressed out?

There are a lot of things I have to do so I sleep late and have to wake up early to go to school.

2. Do you have enough rest or sleep?

No, because now that I’m in college. I usually sleep only for about 5 or 6 hours.

3. How do you relieve stress?

Whenever I came home from school, I tried to rest for an hour or just lay back and watch TV

RHEUMATIC HEART DISEASE


1. What do you do to improve your health?

I drink my medicine on time and eat right amount of food.

2. Do you have regular check-ups with your doctor?

I usually go to heart center on the date that the doctor asked me to come back

3. Do you take in alternative medicines or other herbal medicines you think that will improve you current health?

I intake herbal drink and herbal supplements from recommendations from friends and relatives. I also drink multivitamins and vitamin C tablets.

PRIORITIZATION

SMOKING

Criteria Computation Actual Score Justification1. Nature of the

Problem2/3 x 1 0.66 It is a health threat

that does not demand immediate action

2. Modifiability of the Problem

2/2 x 2 2 Resources are available and interventions are feasible

3. Preventive Potential

3/3 x 1 1 Smoking can be reduced or minimized

4. Salience of the Problem

1/2 x 1 0.5 The family recognizes it as a problem. It does not seem the problem as needing immediate action.

TOTAL SCORE 4.16

2. STRESS


Problem2/3 x 1 0.66 It is a health threat

that does not demand immediate action


2/2 x 2 2 Resources are available and interventions are feasible.

3. Preventive Potential

3/3 x 1 1 Stress can be reduced or minimized


1/2 x 1 0.5 The family recognizes it as a problem but does not required immediate action

TOTAL SCORE 4.16

3. RHEUMATIC HEART DISEASE


Problem3/3 x 1 1 It is a health deficit

that requires immediate attention and adequate management.


1/2 x 2 2 Current knowledge, interventions and

resources are available to solve

the problem3. Preventive

Potential3/3 x 1 1 Disease can be

prevented.


2/2 x 1 1 The family perceives it as a serious problem

needing attention.TOTAL SCORE 5

THE PRIORITIZED HEALTH PROBLEMS:

RANK 1 RHEUMATIC HEART DISEASE

5

RANK 2 SMOKING 4.16RANK 3 STRESS 4.16

FAMILY NURSING DIAGNOSISforget

HEALTH PROBLEMFAMILY

DIAGNOSIS

GOAL OF CARE

OBJECTIVES NURSING INTERVENT

ION

EVALUATION

Smoking1. inability

to recognize the presence of the condition or problem due to: attitude/philosophy in life which hinders recognition/acceptance of a problem

2. inability to make decisions with respect to taking appropriate health action due to: failure to comprehend the nature, magnitude and scope of

To improve the condition of the client

General:To eliminate or minimized smoking habits.

Specific:1. to educate

about the cause and effects of smoking.

2. to provide activities that will disregard from smoking.

3. to give appropriate medication and counseling for the client

1. Health Teaching

2. Guide the family as motivational strategy.

3. discus with the family the cause and effects of smoking and how does it affects one’s health

1. the client will be able to recognize the bad effects of smoking.

2. the patient will be able to eliminate or minimized smoking.

the problem

3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk member of the family due to: lack of knowledge about the health condition

4. inability to provide a home environment conducive to health maintenance and personal development due to; negative attitude / philosophy in life which is not conduciv

e to health maintenance and personal development

5. Failure to utilize community resources for health care due to: lack of inadequate knowledge of community resources for health care

HEALTH PROBLEMFAMILY

DIAGNOSIS

GOAL OF CARE

OBJECTIVES EVALUATION

Stress1. inability to

recognize the presence of the condition or problem due to: lack of or inadequate knowledge

2. inability to make decisions with respect to taking

appropriate health action due to: failure to comprehend the nature/magnitude of the problem/condition

3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk member of the family due to:

4. inability to provide a home environment conducive to health maintenance and personal development due to;

5. Failure to utilize community resources for health care due to:

HEALTH PROBLEMFAMILY DIAGNOSIS

GOAL OF CARE

OBJECTIVES

NURSING INTERVENTI

ON

EVALUATION

Rheumatic Heart Disease

1. inability to recognize the presence of the

condition or problem due to:

2. inability to make decisions with respect to taking appropriate health action due to:

3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk member of the family due to:

4. inability to provide a home environment conducive to health maintenance and personal development due to;

5. Failure to utilize community resources for health care due to:

Initial Data Base for Family Nursing Practice

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