FNCP New
FNCP New
FNCP New
PHYSICAL ASSESSMENT
I.DEMOGRAPHIC PROFILE:
Name: Carolina Aguilar
Height: 53feet
Age: y/36o
Weight:50kg.
Gender: Female
c. Respiratory Rate: 18
d. Pulse Rate: 78 beats/ minute
NORMAL FINDING:
18.5 24.9
ACTUAL FINDING:
19.08 normal
NORMAL RESULTS:
ACTUAL RESULTS:
ANALYSIS:
Mouth
No tenderness/redness
of tonsils, presence of
moist in lips and buccal
mucosa
No tenderness/redness
of tonsils, presence of
moist in lips and buccal
mucosa.however,there is
tooth decay on the left
molar
Trachea is on
midline,lymph nodes are
slightly palpable
Upon palpating,there is a
nodule on the left
sternomastoid muscle.
B.CHIEF COMPLAINT
Masakit po yung yung kaliwang ngipin ko at parang may bukol sa kaliwang leeg ko as
verbalized by the client.
C.HISTORY OF PRESENT ILLNESS
For the clients present illness, as diagnosed, he is having tooth decay that causes her left
sternomastoid muscle to have nodule.
Age:_36_ y/o
Gender: Female
Mrs.CAB is a jolly,cooperative and expressive person, she stated all the health ncondition
of her childre. shes eating pattern is regular three times a day. she have normal elimination
pattern.however,she is not active when it comes to physical activities .. Although he belongs to
Roman Catholic religion, he is not that very much active in attending mass.
PHYSICAL ASSESSMENT
I.DEMOGRAPHIC PROFILE:
Name: Prince Justine Charles Aguilar
Height: 97.5cm
Age: 4y/o
Weight: 13kg
GenderMale
NORMAL FINDING:
18.5 24.9
ACTUAL FINDING:
13.7- below normal,underweight
NORMAL RESULTS:
Patency of both nostrils,
no tenderness/ redness
of sinuses
No tenderness/redness
of tonsils, presence of
moist in lips and buccal
mucosa
ACTUAL RESULTS:
Prescence of excessive
mucus on the nosetrils,
No tenderness/redness
of tonsils, presence of
moist in lips and buccal
mucosa but has
excessive phlegm
ANALYSIS:
The patient has colds
The patient has cough
Skin
Absence of any
lesion,symmetric,no
swelling or edema,no
palor
B.CHIEF COMPLAINT
nilalagnat po ang anak ko.sinisipon din po sya at inuubo as verbalized by
Age:_4_ y/o
Gender:___Male____
The client is an active health seeker. Every time that she feels something different,
the mother consults it to the nearby health center.. his elimination pattern is once a day
accompanied by complete passage of stool. Her sleeping pattern is about 9-11hours ,
commonly, she sleeps at 9pm and awakens at 7am. The client is very hyper-active when it
comes to playing. he plays the role as the youngest child in the family.
PHYSICAL ASSESSMENT
I.DEMOGRAPHIC PROFILE:
Name: John Paul Aguilar Age: 18 y/o
Height:131 cm
Gender: Male
Weight: 32 kgs
NORMAL FINDING:
18.5-24.9
ACTUAL FINDING:
18.60- normal
NORMAL RESULTS:
Skin
Symmetric, absence of
any lesions, no edema
and swelling.
Eyes
Symmetric, no lesions,
No clouding of cornea.
Nose
ACTUAL RESULTS:
ANALYSIS:
Normal condition
Blurred vision
Normal finding
condition and no
suspected
deviation
Mouth
Normal finding
condition
B.CHIEF COMPLAINT
Masakit ang lalamunan ko. Inuubo din ako as verbalized by the patient.
Age: 18 y/o
Gender:Male
The patient manages his health by having medications, drinking 8 oz of water every day
to prevent sickness. He is eating enough foods when needed but most of the times 1 cup of rice
every meal to maintain his diet. Normal elimination pattern, he hasnt experienced constipation. His
exercise is playing basketball, and walking daily. He has 7 hours of sleep regularly. He is not experiencing
pain. And when he feels it he just verbalized it to relieve the pain. He has a good relationship with his
family and friends. And for his family he is a kind and supportive older brother for them. He is very
responsible with his role. He has a good understanding about sexuality, and knowledge how to prevent
infectious disease. But now, he is still a student he is not yet ready for sexual activity although he has a
girlfriend right now. He can manage his stress by talking or chatting with his friends. He believes in God
and he is Catholic. He always pray and has a good relationship with the Father.
PHYSICAL ASSESSMENT
I.DEMOGRAPHIC PROFILE:
Name: Jhona Marie F. Molinar
Height: 62 inches
Age: 17y/o
Weight: 45kg
Gender: Female
NORMAL FINDING:
ACTUAL FINDING:
45/2.4025=18.7304
18.5 24.9
18.73- normal
NORMAL RESULTS:
ACTUAL RESULTS:
Anteroposterior to
transverse diameter in
ratio of 1:2; spine is
straight and in the
midline; chest
symmetric on both side;
uniform temperature;
full chest expansion;
vesicular and bronchovesicular breath sound;
symmetrical tactile
fremitus and full
respiratory excursion
Anteroposterior to
transverse diameter in
ratio of 1:2 and no
presence of masses and
lesion. Spine is
vertically aligned and
uniform skin color.
Chest symmetric on
both sides. Uniform
temperature and no
tenderness upon
palpation. Has a full
chest expansion and
bilateral tactile fremitus.
Full symmetric
excursion; thumbs
separate 3 cm. Crackle
sound is audible upon
auscultation on the right
lower lung lobe.
ANALYSIS:
Age:_17_ y/o
Gender:___Female_____
The client upon the interview process stated that currently, she has a good health
management pattern though she has been diagnosed of Iron Deficiency Anaemia. The client is
taking multivitamins along with three times a day eating. She eats well every time shes hungry
and has good bowel movement. She doesnt have time for exercise but instead walks as an
alternative. Her sleeping pattern is irregular because sometimes theres a need for her to study
late at night. Although she has sleepless nights, she still manages to smile and think clearly. She
is alert, awake and enthusiastic during the interview. In terms of sexual-reproductive pattern,
since she doesnt have any boyfriend, she doesnt mind it and doesnt have plan yet for this issue.
Has responsible role in the family as a sister and daughter, an optimistic person and believes in
Gods intervening power.
PHYSICAL ASSESSMENT
I.DEMOGRAPHIC PROFILE:
Age: 13y/o
Weight: 48 kg
Gender: Male
NORMAL FINDING:
Normal BMI range 18.5-24.9
ACTUAL FINDING:
Have a normal body mass index
and body appearance is
proportional to the clients age.
NORMAL RESULTS:
ACTUAL RESULTS:
ANALYSIS:
Nose
Mouth
Neck
Anteroposterior to
transverse diameter in
ratio of 1:2; spine is
straight and in the
Anteroposterior to transverse
diameter in ratio of 1:2 and no
presence of masses and lesion.
Spine is vertically aligned and
Normal finding
condition and no
suspected
deviation
Normal finding
condition
Presence of
nodule or
palpable lymph
node for possible
infection
Crackle sound
may indicate
increase mucus
production
Age: 13 y/o
Gender: Male
Civil Status: Single Occupation: Student
B.CHIEF COMPLAINT
Inuubo ako, simula nung Thursday pero, hindi naman masakit. As verbalized
by the patient.
Age: 13 y/o
Gender: Male
The client eats fruits but not all vegetables, he increased his fluid intake of about 7-8
glasses of water a day. He eats for at least three times a day or sometimes more than that. The
client urinates six times in a day and eliminates only once a day. He plays basketball as early in the
morning, at least once a week. His sleeps 7 hrs (most common) everyday .He doesnt have any experience
of trauma. Appears to have high level of self -esteem. He is the youngest member of the family and has a
good communication with his parents and other siblings. He hasnt yet experienced any sexual activity
since birth. Whenever he has problems, he takes a rest and eats a lot of food. For their values and beliefs,
they believe in God and almost every Sunday they are going to church. Most of the time they are not
complete in going to church because of his dads schedule. Its only him, his mother and his sister.
Nature of Problem
Health Deficit
Health Deficit
Health Deficit
Health Deficit
Point Scale
Health Department
Assessed Problems
Justification
Statement
Physical Independence
Therapeutic
Competence
Knowledge of Health
Condition
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
Physical environment
Use of Community
Facilities
Application of
Principles of General
Hygiene
Health Attitudes
Emotional Competence
Family Living
Inadequate exercise
among some members
of
the family
Conflicting Opinions
among Significant
others
Absence of
Responsible member
due to busy schedule in
work
Poor sanitation
specifically presence of
breeding sites as vector
of diseases
Failure to recognize
community resources
for health care due to
inadequate knowledge
of community
resources for health
care
Comments: The family has high competence in meeting different factors regarding their health.
The gathered information manifests only minor problems which can be prevented.
Nurses Signature:
Masakit_ang_lalamunan_ko._Inuubo_din
ako as verbalized by the patient, Mr.NFM.
Inuubo ako at Makati lalamunan ko pero
minsan lang as verbalized by Ms.JFM.
Mother is busy with work and sometimes goes
home very late in the evening.
Family is composed of five members whereby
in terms of living, the father sleeps at his
office due to work needs.
Busy members of the family dont have time
for exercises.
They are not aware of the use of health centres
since they have health insurance which they
use in hospital matters.
There are cockroaches, mosquitoes and rats in
their house.
They used to live in Batangas where there are
lots of relatives lives. They play the role of
being the significant others of the family.
1.
3.3 Scoring
Computing and Justifying the Scores of Health Problems
Problem: Hypertension
Criteria
1.Nature of the
Problem
Standard
Score
Weight
Actual
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
2/3
Easily Modifiable
Partially Modifiable
Not Modifiable
2
1
0
High
Moderate
Low
3
2
1
2/3
2
1
0
2.Modifiability
of the Problem
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
Problem: Diabetes
_3 5/6_
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
and
interventions
needed to
solve the
problem are
available to
the family.
There is
medication to
prevent but it
will not
totally
eradicate the
problem.
The family
recognizes it
as a problem
however, it
does not see
the problem
as needing
immediate
action.
Criteria
1.Nature of the
Problem
Standard
Score
Weight
Actual
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
2/3
Easily Modifiable
Partially Modifiable
Not Modifiable
2
1
0
High
Moderate
Low
3
2
1
2/3
2
1
0
2.Modifiability
of the Problem
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
and
interventions
needed to
solve the
problem are
available to
the family.
There is
medication to
prevent but it
will not
totally
eradicate the
problem.
The family
recognizes the
problem.
_4 1/3_
2.Modifiability
of the Problem
Standard
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
Weight
Actual
Score
2/3
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
and
Easily Modifiable
Partially Modifiable
Not Modifiable
2
1
0
High
Moderate
Low
3
2
1
2
1
0
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
interventions
needed to
solve the
problem are
available to
the family.
Transfer of
this problem
to other
family
members is
reduced or
eliminated if
the problem is
managed
adequately as
soon as
possible.
The family
highly
recognizes the
problem as if
theres a need
for immediate
action.
_4 2/3_
2.Modifiability
of the Problem
Standard
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
Easily Modifiable
Weight
Actual
Score
2/3
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
and
Partially Modifiable
Not Modifiable
1
0
High
Moderate
Low
3
2
1
2/3
2
1
0
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
interventions
are not
available to
the family.
The problem
is not easily
prevented
because it is
concerned
primarily in
the schedule
of the head of
the family.
Since the
members are
mature
enough to
handle some
conflicts, the
problem
doesnt need
immediate
action.
_1 5/6_
2.Modifiability
of the Problem
Standard
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
Weight
Actual
Score
2/3
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
and
Easily Modifiable
Partially Modifiable
Not Modifiable
2
1
0
High
Moderate
Low
3
2
1
2/3
2
1
0
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
interventions
needed to
solve the
problem are
partially
available to
the family.
The problem
can be cured
but not
always
because they
give
significance
to the
relatives
opinions at
times.
For the
familys
opinion, it is
not a problem
for them.
_2 1/3_
Standard
Score
Weight
Actual
Score
1.Nature of the
Problem
Health Deficit
Health Threat
Forseable Crisis
3
2
1
2/3
Justification
It is a health
threat that
does not
demand
immediate
action
2.Modifiability
of the Problem
Easily Modifiable
Partially Modifiable
Not Modifiable
2
1
0
3.Preventive
Potential
High
Moderate
Low
3
2
1
4.Salience of
the Problem
2
1
0
Total Score:
The resources
and
interventions
needed to
solve the
problem are
available to
the family.
Through time
management
allowing
some time for
exercise, the
problem can
surely be
prevented.
The family
doesnt
consider this
as a problem.
_3 2/3_
Problem: Poor home sanitation specifically presence of resting sites as vectors of diseases
Criteria
1.Nature of the
Problem
2.Modifiability
Standard
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
Weight
Actual
Score
2/3
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
of the Problem
Easily Modifiable
Partially Modifiable
Not Modifiable
2
1
0
High
Moderate
Low
3
2
1
2
1
0
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
and
interventions
needed to
solve the
problem are
available to
the family.
The family
has been
trying to
solve this
problem by
using
disinfectants,
etc. Thus, it is
highly
preventable.
They are very
much aware
of the
problem and
is currently
doing
interventions.
_4 2/3_
Problem: Asthma
Criteria
1.Nature of the
Problem
Standard
Score
Health Deficit
Health Threat
Forseable Crisis
3
2
1
Easily Modifiable
Partially Modifiable
3
2
Weight
Actual
Score
2/3
2.Modifiability
of the Problem
Justification
It is a health
threat that
does not
demand
immediate
action
The resources
and
interventions
needed to
Not Modifiable
High
Moderate
Low
3
2
1
2/3
2
1
0
solve the
problem are
not available
to the family.
There is
medication to
prevent but it
will not
totally
eradicate the
problem.
The family
recognizes it
as a problem
however, it
does not see
the problem
as needing
immediate
action.
3.Preventive
Potential
4.Salience of
the Problem
Total Score:
_2 5/6_
3.5 Ranking
Ranking the Health Problems According to Priority:
PRIORITY
PROBLEM
SCORE
4 2/3
4 2/3
4 1/3
3 5/6
3 2/3
2 5/6
2 1/3
1 5/6
IV.
Family Nursing Care Plan
Family
Name of Family:_Aguilar
Family_
FAMILY-HEALTH WORKER CONTRACT
We Second Level Nursing students of Adamson University will conduct an interview to
Aguilar Family for partial fulfilment of the requirements in the subject Community Health Nursing.
Fathers Signature: ________________________________
Mothers Signature: _______________________________
Signature of older siblings: _________________________
_________________________
_________________________
CHN Signature: _________________________
Date:____September 9, 2014, Tuesday____________
Methods of recording to be used: __The data will be gathered and recorded with the use of a tool and a
record sheet that will be presented in a Family Nursing Care Plan format. The group ensures that all
the information gathered will be kept confidential as respect for the right of the family_ .
ADAMSON UNIVERSITY
COLLEGE OF NURSING