Family Nursing Care Plan Part 2 HEALTH HISTORY A. BIOGRAPHIC DATA The client’s name is JCP, 17 years old, single, female, and lives at 1037 J. B. Miguel St. Bambang, Pasig, City. She is a Roman Catholic although she was born on October 10, 1989 in the Kingdom of Saudi Arabia. The client is a pure Filipino citizen who can speak Filipino as well as English. She is currently a 2nd year college student at Far Eastern University taking up BS Nursing. Her parents and guardians are her source of finances with regards to health care and medical needs. B. PRESENT HEALTH HISTORY The client stated that she is not experiencing any problems or disease at present times. She also said that she rarely acquire a disease. C. PAST HEALTH HISTORY The client had chicken pox when she was 7 years old and received medical treatments but she doesn’t anymore remember the medications that were given to her. She said that according to her mother, she had received OPV, DPT, and BCG immunizations during childhood. The client has occasional rashes on the chest due to hot weather. Her dermatologist prescribed her Stiemycin as a treatment. She also applies acne gel (applied every other day), tretinoin cream and bleaching cream (both applied every other night) on her face in order to treat pimples. So far, the client has not experienced any side effects while using the said drugs/medications. D. FAMILY HISTORY OF ILLNESS The client’s father, who’s 38 years old, has diabetes while her mother, who’s 37 years old, has asthma. The grandfather of the client on her mother side, still living and is 81 years old, has tuberculosis while her grandmother still on the mother side is 70 years old and has arthritis. The client’s two other younger siblings, whose ages are 11 and 14, have currently no diseases inherited from their parents. The client also said that she at present has no diseases. 3 DAYS DIET RECALL Name of the client: Jenileen Carlette T. Peronilla ELIMINATION PATTERN The client conducts bowel elimination everyday in the morning after waking up or sometimes at night before bathing. Her stool usually is a formed one that is brownish in color and has regular diameter of not less than 1 inch. She does not experience pain or discomfort. The client also conducts urine elimination at least 3 times a day with varying time. Her urine is often yellowish to whitish color and is not aromatic in smell but does not have a strong foul odor. She also does not experience pain or discomfort. She tends to perspire quickly especially of doing activities that require much movement such as dancing. She does not have a strong smell or body odor. H. ACTIVITY - EXERCISE PATTERN The client’s usual activities include going to school and studying. She is also a member of the FEU Dance Troupe adds on to her being happy and content. She engages in light exercise and dance workshops. She is satisfied with the amount of exercise that she gets which is having it 3 times a week with duration of 30 minutes per exercise. She noticed that her alertness level increased and makes her feel energized. Inside the classroom, the usual activities that she does are to just sit around and listen to the professor in front. The activities of the client that needs to be done are going to school, attending dance troupe rehearsals, having I shod exercise (stretching) and engaging in household chores. The client commonly has sufficient energy to do all the mentioned tasks. She brought up that she has a desire to do certain extreme sports like bungee jumping and rappelling but worries that she might not have the time, not really the energy, to accomplish my desires. The client is also able to do activities of daily living (i.e. bathing, toileting, grooming, etc.) by herself. She spends her spare time by watching television, listening to music, dancing, or playing board games. She is satisfied with the way on how she spends her leisure time. These activities keep the client from boredom and are exercising her brain capacity. Though the client said that she is satisfied with the amount of activities that she’s getting, she proclaimed that she is not managing her time very well. She does things whenever she likes doing it. CLIENT’S DAILY ACTIVITIES I. SLEEP - REST PATTERN The client sleeps for about 3-4 hours every night ever since second year in college started because of lots of requirements asked from the students by all subjects. Usually, she sleeps at 2am and wakes up at 4am. The sleep is not continuous, does wake up in the middle of the sleep. The client is not satisfied with the amount of sleep because it lessens her body’s time to recuperate from all the stress that she accumulated the entire day. The client does not feel refreshed when she wakes up because of inadequate amount of sleep. The client’s sleeping environment is comfortable. She shares the bed with her aunt. She is not really particular on the number of pillows beside her. She is sometimes more comfortable without a pillow on her head and rather prefer to put a pillow on her lower back because she wants to improve its curve. The client’s desired sleeping environment is a bedroom of her own. The client drinks a glass of water before going to bed and makes sure that she has already voided. She does not have problems falling asleep. The client does not require any help falling asleep including back rubs or massages or sleeping pills. The client does not take naps. For relaxation, the client watches TV, reads something, surfs the net, etc. She finds them helpful when relaxing. J. COGNITIVE - PERCEPTUAL PATTERN The client’s hearing is normal for both ears. Her Weber’s test is normal that she can hear vibrations equally on both ears and her Rinne’s test also indicates that her air-conducted hearing is greater than the bone-conducted hearing which is normal. No changes had occurred lately. The client has astigmatism and her visual acuity is 20/40. She used to wear glasses but it got broken and she is still looking for someone who can fix it. Her last visit to the doctor was last year. The client’s memory is good which means that both her shod term memory works as well as her long term memory. For her, the easiest way to learn is to have someone demonstrate the topic in a much simpler approach. The client does not experience learning difficulties and prefers a teacher to just be the one to discuss the topic. The client does not have any problems speaking, reading or writing. No changes in smell or taste. The client is doing well in school. K. SELF-PERCEPTION - SELF-CONCEPT PATTERN The client described herself as an optimistic individual, jovial, and easy to deal with. She also added that she is a great dancer and also does well in school. She feels good about herself most of the time and is happy about herself. No physical alterations in her body. No changes about the way she feels about herself. The client thinks that she is just as equal with other people because there are traits, features and characteristics that she have that other don’t have and vice versa. She expressed her thought about other people more often in non- verbal than through verbal. For example, she saw something bad about an acquaintance; she would rather keep it to herself than to talk to her personally and point it out on that person. In the next five years, she sees herself successful in the field of showbiz industry. The client plans to achieve it by trying out in talent searches preferably PBB Teens if there would still be one. The client is often moody, sometimes she is happy one moment, and then depressed the next. She cannot clearly say why she feels that way. Things that make her angry are people who are constantly irritating her like those bugging her questions about what she will be doing for the entire day, who will be with her, what time will she go home, what is the telephone no. of your classmates, and a lot more. The client feels this way because she does not want people who act like they are working in the NBI and surveillances her every move as if she is a most wanted criminal. Having her friends around and going out with them really helps her so much. She cannot control herself at times and answers back without even thinking about what she is going to say. The client is not satisfied with her mood because people can be intimated. L. ROLE RELATIONSHIP PATTERN The client lives with her guardians (grandmother, grandfather, uncle, aunt) and 2 younger siblings. Her parents are working in K.S.A. The client’s family is apart from other families. She stressed that their family is a loud family because of her grandmother that does not seem to get tired of ranting about things. Obviously, the client does not get along well with her grandmother because of her self-centered attitude as she said. The client is the eldest in the three of them. She has the responsibility to check if they have done all their tasks correctly and she is able to fulfill it. Problems in the client’s family have not reached its height that is why we can live up with that everyday. Her grandmother usually has the final word about a certain family issue. The client thinks that voicing out opinions serve as an outlet to enhance your thought processes. She feels powerful and functional when it comes too voicing out opinions. The client sees a true friend as someone who will always be there for you when the whole world turns their back at you. She feels this kind of friendship among her high school classmates and high school best buds. Her friends are a rare find because despite distance and lack of time, they see to it that they still have communication with one another. The client’s college life goes very well. She feels satisfied that she is studying in FEU. M. SEXUALITY - REPRODUCTIVE PATTERN The client first experienced menstruation when she was in grade 6, age 12. Her menstruation cycle is regular with an interval of 30 days. Her menstruation lasts from 4-5 days. In a day, the client uses 2 pads, one in the morning and one at night. Sometimes it depends on the heaviness of flow. The client does not experience dysmenorrheal. The client firmly believes that she is feminine. She would of course like to have the opposite sex as her partner. The client is not currently engaged in an intimate relationship and likewise she is not involved in premarital sex. N. COPING - STRESS TOLERANCE PATTERN The client perceives major exams in subjects like anatomy, healthcare, and physics as a good source of large amounts of stress. The stress that she experiences is great because of lots of memorization and analysis to be done. She rarely spends her time alone because she is an outgoing and very friendly person. The client handles stress or pressure by just facing those stressors and takes it as a challenge. She said that it is effective for her. Her friends are the people helping her a lot in coping up during stressed times. When faced with big problems, she just does her best to act upon it and hope for the betterment of the situation. She considers it successful because she will not have regrets later on that she did not do a certain action to solve the problem. O. VALUE - BELIEF PATTERN The client says that a person is healthy if she can fulfill her duties and responsibilities very well despite all odds. Health is as important as life, more important than any material being on earth for the client. The client considers health as an important thing because no matter how rich or famous we might be, when it comes to health, we are all equal because we are all humans, susceptible to different diseases. Religion is important in the client’s life because it can help an individual to have a certain direction in life. According to her, it gives all of us an assertion that we are on the right tract in facing these obstacles towards a problem-free state. The client is not sure about social values that she grew up with. In relation to society, the client perceives herself as a student whose role is, of course, to study and graduate and therefore to contribute to the man power of society. SAMPLE INITIAL DATA BASE - HEALTH CARE II ARIZALA FAMILY Age Juvy Arizala 26 Helen Arizala 30 Jana Arizala 1 Sex M F F Civil Status Married Married Single Occupation Construction Worker Housewife None A. Family Structure, Characteristics and Dynamics The Arizala Family is a typical nuclear type of family consists of the father, Mr. Juvy Arizala who is a construction worker. Mrs. Helen Arizala, a full time housewife and their 1 year old baby girl Jana Arizala. Mrs. Helen is currently 7 months pregnant and is expected to give birth on the first week of June. Mr. and Mrs. Arizala don’t have a hard time in terms of decision making because each of them tend to consider each others opinion first before coming up with the final decision especially regarding health matters. The father is the head and breadwinner of the family while the mother takes care of the household chores and their first born baby girl Jana. B. Socio-Economic and Cultural Characteristics Low educational background seems to be an obstacle for Mr Arizala to get a good job. He never finished elementary education and was forced to work as a construction worker receiving only P250 per day. On the other hand Mrs. Helen Arizala was fortunate enough to finish second year high school but decided to stay at home to take good care of their first born child. Mr. Arizala’s monthly income is approximately P5,000 per month just enough to pay for their monthly rent, electricity bill, food and milk allowance and transportation expense. Most of the time, the budget for health maintenance is being sacrifice and not given enough priority due to lack of money. According to Mrs. Helen Arizala, she spends P150 per day to meet their daily basic needs. The Arizala’s are basically from Antique, Aklan. They migrated to Manila hoping for a better life, but unfortunately they found out that the lifestyle in urban offers very little opportunities. The family is not a member of any social organization in the community nor an a active member of the catholic church. C. Home and Environment The family resides in a depressed area in Brgy. Pasong Tamo, Area 3, Quezon City. Their house is made up of wood and light materials. The floor area is approximately 6 sq. meters. The family sleeps together in a wooden bed with foam situated near the entrance door which also serves as their receiving area. They usually sleep very early at around 8 p.m. and wakes up at 7 a.m. The house is not well ventilated and there is inadequate lighting. Breeding sites for mosquitoes, flies, cockroaches, and rodents are inevitable due to open drainage and poor environmental sanitation. Their toilet facility is located at the back of their house which they share with all the families in the compound. There is no water supply in the area so Mr. Arizala is force to fetch water 20 meters away from their house and costs 2 pesos per container. Mrs. Arizala buys their food in the market and stores it in an uncovered cabinet leaving it exposed to germ and bacteria. She usually cooks vegetable and fish dishes. The garbage is collected twice a week by a DPS truck. Tricycles roam around as their means of transportation while public phone for communication are available at the sari-sari store. Carinderias and mini-market are also visible within the vicinity. The overall surrounding of the family is unhygienic and the drainage system is open and very proximate to the houses. Only wooden walls separate them from their neighbors and the electrical connections are entangled and hazardous. D. Health Status of Each Family Member Mrs. Helen Arizala is in a critical stage since she is seven months pregnant to her second child and is expected to give birth on the first week of June. Her first pre-natal check-up was done three months ago and was never repeated due to lack of time and awareness. According to her, she had a hard time delivering her first child due to hypertension. She gave birth at home with the help of a ”hilot“ and plans to do the same with the second child. Her first baby Jana is quite small for her age, though, she was able to walk and stand at the age of 9 months. As of now she is already learning how to speak. She had already taken vitamins during the first three months of her pregnancy but wasn’t able to sustain it due to lack of money. She had her first dose of TT1 last February during her pre-natal check-up. She feeds her baby girl Jana 3 times a day with condensed milk and small amounts of solid foods like a mashed potato and rice with soup. Her husband Mr. Arizala sometimes complain of severe pain at the back of his neck maybe as a sign of hypertension and over fatigue but has no family history of hypertension in the family. The family doesn’t use herbal medicine and goes to the health center when need arises. E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention The family sleeps early to have enough rest and energy for the next day. Mrs. Arizala goes out every morning to walk and exercise outside together with Jana. The family uses bed nets at night to protect them from mosquitoes and other insects while they are sleeping. The first born baby is complete with all the immunization required. Pa-BINGO is held every month at their compound as a form of their relaxation and entertainment. NURSING PROCESS RECORDING I. Personal Data Name: Age: Gender: Civil Status: Educational Attainment: Order/Position in the family: Assessment prior to introduction Helen Arizala 30 Female Married Second Year High School Mother II. The area is congested; there are around 20 families in a compound who is exposing to several health hazards like poor environmental sanitation, open drainage system and inadequate living space. The Arizalas is one of those families living in the area. Mrs, Helen Arizal is busy taking good care of her child who is about to sleep at the time when I arrived for the initial interview. III. Objectives A. Short-term Objectives To be able to achieve integration within the family and to promote health education and active participation in terms of general and distinct health necessities. B. Long-term Objectives To be able to study the conditions of the community with focus on the health aspects. IV. Date, Place, Time and Duration of Nurse-Patient Interaction The interview took place dated April 23, 2005 in front of Mrs. Arizala’s house at exactly 10:10 a.m. It lasted for about 15 minutes and I was very glad that Mrs. Arizala was very accommodating. I did not hesitate to ask relevant questions because she showed a lot of interest in the conversation. V. Brief description of the setting I was able to visit Mrs. Arizala’s place twice and somehow I noticed that their house has no enough lighting and ventilation. I wonder how they manage to stay there for two years without water supply and no private toilet facility. Their house is considered to be a make shift type of house and has inadequate living space. The wooden bed found near the main door serves as the living room area leaving a small space for kitchen. VI. Nurse-Patient Interaction VII. Evaluation Based on my interview, the family needs more orientation and information regarding health issues. They should value or prioritize their health above all. The importance of prenatal check up and malnutrition should be given emphasis to ensure the development of the baby. Inadequate living space and poor environmental sanitation seems to be a threat to the family’s health. Overall, the health requirements of the family are not being met due to poverty and lack of awareness. VIII. Future Plan or Objectives for the next interaction Promotion of health, prevention of diseases together with simple treatment and rehabilitation would be my next objective to help the family alleviate their health status and conditions.