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Intoduction To Recommendations 2

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I.

INTRODUCTION

A. Brief Introduction of the case

In the world that we have today, there are many cases in the medical field that shows a

person’s health and how it can affect and change a person’s state physically and mentally, one of

these cases is pregnancy.

Pregnancy or Gestation is the period of development where a fetus starts to grow inside the

womb or uterus of the mother (“Fetal Period”, n.d.). Pregnancy can occur by means of sexual

intercourse or assisted reproductive technology and it usually lasts for about 37- 40 weeks (7 to 9

months) depending on whether the baby is premature or not.

During the gestation period, major events are described in each trimester of a woman.

When a woman is pregnant, her health and the unborn child’s health may be in danger, therefore,

pregnant women are urged to go and have their prenatal check-up. Prenatal care improves

pregnancy outcomes and may include taking extra folic acid, avoiding drugs and alcohol, regular

exercise, blood tests, and regular physical examinations. Complications of pregnancy may include

disorders of high blood pressure, gestational diabetes, iron-deficiency anemia, and severe nausea

and many more.

Due to the substandard living conditions of most mothers and upcoming mothers in our

area, there are chances of women not being able to get the proper health teaching, and prenatal

care that is required to be able to have a good pregnancy outcome. Like improper education on

nutrition, or risk of getting diseases that can affect the woman and the baby because of the living

conditions and lack of education.

According to the World Health Organization “Around 99% of maternal deaths occur in

low-resource settings and most can be prevented. Similarly, approximately 2.6 million babies were

stillborn in 2015, also mainly in low-resource settings. Nevertheless, there is evidence that

effective interventions exist at reasonable cost for the prevention or treatment of virtually all life-

threatening maternal complications, and almost two thirds of the global maternal and neonatal

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disease burden could be alleviated through optimal adaptation and uptake of existing research

findings. But a human rights-based approach is not just about avoiding death and morbidity – it is

about enabling health and well-being while respecting dignity and rights.” (World Health

Organization, 2016, p.1).

A. Patient and the problem

Adequate maternal nutrition is very important to improve nutritional status of the woman

and the fetus and reduce the risk of birth outcomes such as low birth weight and preterm birth.

Patient X is a 25 year old pregnant woman, born on the month of April 1994, single, and is the

third child in their family. The said person stated “Minsan lang po ako kumakain ng gulay at hindi

rin po ako umiinom o nagba-vitamins.” (“I rarely eat vegetables and I don’t drink or take any

vitamins”). Based on her statement, it shows that the patient has unwillingness to eat, muscle

weaknesses, and poor dentition which resulted to unhealthful nutrition which emphasized

inadequate food intake both in quality and quantity as a health threat. A Family Nursing Problem

2nd Level Assessment was conducted to further assess the health conditions and problems of the

patient. First, is the inability to make decisions with respect to taking appropriate health action due

to negative attitude towards health condition or problem. Second, is the inability to recognize the

presence of the condition or problem due to lack of inadequate knowledge, attitude or philosophy

in life which hinders recognition or acceptance of a problem. This was identified last 27th of

August, 2019. In this problem, the healthcare provider should encourage the client to vegetables

and fruits and vitamins if possible so that she will have a healthy pregnancy and most especially a

healthy child.

The patient also said “Nahihirapan akong maglakad papuntang rio kasi pababa yun,

natatakot ako baka madapa ako, doon kasi ako naliligo” (“I am having a hard time walking near

the river because the road is going down and I am scared that I might stumble, I often take a bath

there.”) which is caused by the too slope and slippery area, an accident hazard as a health threat.

Conducting the 2nd level assessment, it shows that the problem was caused by the failure to utilize

community resources for health care due to unavailability of required care or services, to

inaccessibility of required services due to physical inaccessibility. Another is the inability to

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provide a home environment conducive to health maintenance and personal development due to

lack of inadequate knowledge of preventive measures and lack of skill in carrying out measures to

improve home environment. This was also identified last 27th of August, 2019. In this condition,

the client should not exert too much effort and should not stress herself too much. At this term of

pregnancy, she should be encouraged to take her bath in the house or if she insists in taking her

bath to where she used to take her bath, at least, she should have a trusted companion upon going

there and must be very careful.

a. Significance of the study

i. Nursing Education

This case study can help nursing students gain knowledge and gather

information on normal pregnancy. It contributes to the fact that different

issues can hinder the health of normal pregnancy. Thus, implementing and

encouraging students to do more in health promotion and health teachings

in the community setting.

ii. Nursing Practice

This study can further help in the advancement of nursing practices. Health

care facilities or technologies can also affect the evolution of nursing

methods in facilitating pregnant women. This study can help in

accommodating pregnant mothers in providing accessible and efficient

nursing practices without difficulties.

iii. Nursing Research

This case study drives students to observe and research in developing a

more efficient way to provide care to pregnant woman. Researchers can also

benefit from this study by observing problems that might hinder the normal

pregnancy of a mother. Thus, encouraging student to conduct further

research and observation on the study.

b. Objectives

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At the end of this case study, we shall be able to:

i. Acquire and apply the skills, knowledge and attitude in recognizing the

necessary health interventions, maintenance and promotion of health in

maternal and child care.

ii. Identify and prioritize the needs and problems of the client.

iii. Formulate and implement a family nursing care plan to alleviate the client’s

health condition.

iv. Conduct health teachings to the client with regard to the condition identified.

B. Anatomy and Physiology

First Trimester of Pregnancy

(Less than14 weeks 0 days)

Weeks 1 and 2 of Pregnancy

On the first two weeks after the last menstrual period egg follicles mature in the ovaries

under the stimulus of follicle-stimulating hormone (FSH) which is a hormone that is secreted by

the pituitary gland in the human brain. High levels of estradiol produced by the developing egg

follicle will cause the secretion of luteinizing hormone (LH) which is also a hormone from the

pituitary gland that will cause to release egg from the follicle (ovulation). Luteinizing hormone

causes release of the egg from its follicle (ovulation). For women with a 28-day cycles, ovulation

usually occurs on 13 to 15 days.

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Gestational Age: 3 weeks.

Embryonic Age: 1 week.

During the third week, if fertilization will occurs, the fertilized egg (zygote) will

begin to produce a hormone called human chorionic gonadotropin which is known as the

pregnancy hormone. Human chorionic gonadotropin becomes detectable in the woman's

blood and urine between 6 and 14 days after fertilization. Fatigue and swollen or tender

breasts are often known as the first signs of pregnancy.

Gestational Age: 4 weeks

Embryonic Age: 2 weeks

The embryo is the size of a pinhead. Usually, most pregnancy tests will be positive

at this time around.

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Gestational Age: 5 weeks

Embryonic Age: 3 weeks

The brain, spine, and heart of the fetus are beginning to form where by the end of

the week, the heart will be pumping blood. At week 5, the beginning of the embryonic

period lasts from the 5th to the 10th week. It is during this crucial period that many birth

defects will occur in the developing embryo. Most of these birth defects will have unknown

cause or may be due to a combination of factors (multifactorial).

Gestational Age: 6 weeks

Embryonic Age: 4 weeks

The embryo is about the size of a pea at this time. The average crown to rump length

is 0.2 inches or 0.4 cm. The eyes, nostrils, and arms are beginning to take shape. The heart

is beating at about 110 beats per minute and it may sometimes be seen with the use of a

transvaginal ultrasound.

Gestational Age: 7 weeks

Embryonic Age: 5 weeks

The embryo is now about 0.4 inches or 1 cm long. The hands and feet of the fetus

start to form as well as the mouth and face. The heart is beating at about 120 beats per

minute and the movement of the embryo can be detected with the use of an ultrasound. At

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week 7, the trachea and bronchi of the lungs are formed, and the pseudoglandular stage of

lung development begins

Crown–rump length of 7 mm or greater and no heartbeat, or mean sac diameter of 25 mm

or greater.

Gestational Age: 8 weeks

Embryonic Age: 6 weeks

The average embryo at 8 weeks is 0.6 inches or 1.6 cm long and weighs less than

1/2 ounce or 15 grams. The embryo is about the size of a bean where the fingers and toes

are starting to develop. In a process is known as the physiological gut herniation, the

intestine elongates and moves outside of the abdomen herniating into the base of the

umbilical cord and rotate counter-clockwise at around 8 weeks. The intestine returns into

the fetal abdomen by about 12 weeks.

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Gestational Age: 9 weeks

Embryonic Age: 7 weeks

The heart is beating at about 170 beats per minute. The average embryo at 9 weeks

is 0.9 inches or 2.3 cm long and weighs less than 1/2 ounce or 15 grams.

Gestational Age: 10 weeks

Fetal Age: 8 weeks

The embryo's tail has disappeared and it is now known as a fetus. Fingerprints are

starting to form, and bone cells are now replacing the cartilage. The average fetus at 10

weeks is 1.2 inches or 3.2 cm long and weighs 1.2 ounces or 35 grams.

Gestational Age: 11 weeks

Fetal Age: 9 weeks

The fetus is beginning to have breathing movements. It can open its mouth and

swallow. The average fetus at 11 weeks is 1.6 inches or 4.2 cm long and weighs 1.6 ounces or 45

grams.

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Gestational Age: 12 weeks

Fetal Age: 10 weeks

The fetus is beginning to show random movements. The fetus starts to concentrate

iodine in its thyroid and produce a thyroid hormone at this time. The pancreas is starting to

make insulin, and the kidneys are now producing urine. The heart beat can usually be heard

with an electronic monitor around this time. The average fetus at 12 weeks is 2.1 inches or

5.3 cm long and weighs 2 ounces or 58 grams.

Gestational Age: 13 weeks

Fetal Age: 12 weeks

The average fetus at 13 weeks is 2.5 inches or 6.5 cm long and weighs 2.6 ounces or 73

grams. All major organs are now completely formed, but are too immature for the fetus to survive

outside the womb. The physiological gut herniation should be complete by this time. The bladder

of the fetus can be seen consistently using an ultrasound after 13 weeks.

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Second Trimester of Pregnancy

(14 weeks and 0 days through 27 weeks and 6 days)

Gestational Age: 14 weeks

Fetal Age: 12 weeks

The toenails of the fetus are appearing and the gender of the fetus may sometimes be seen.

Average fetus at 14 weeks is 3.1 inches or 7.9 cm long and weighs 3.3 ounces or 93 grams.

Gestational Age: 15 weeks

Fetal Age: 13 weeks

The movement of the may be identified now which is also termed as quickening. There are

mothers who do not feel the fetus as it moves until it reaches about 25 weeks. Average fetus at 15

weeks is approximately 6.4 inches or 16.4 cm long and weighs 4.1 ounces or 117 grams.

Gestational Age: 16 to 17 weeks

Fetal Age: 14 to 15 weeks

The average height of a 16 week fetus is 7.1 inches or 18.3 cm long and weighs 5.2 ounces or 146

grams. Hearing is starting to form. The canalicular period of lung development has begun and will

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last until it reaches 25 weeks. Average height of a 17 week fetus reaches 7.9 inches or 20.1 cm

long and weighs 6.4 ounces or 181 grams. The lung development of pseudoglandular stage will

end at 17 weeks where there are still no alveoli, so respiration will not begin at this time.

Gestational Age: 18 weeks

Fetal Age: 16 weeks

The ears of the fetus are standing out, and it is beginning to respond to sound. The average

height of the 18 week fetus is approximately 8.6 inches (22 cm) long and weighs 7.9 ounces (223

grams). The cerebellar vermis can be shown to be fully formed on ultrasound.

Gestational Age 19 weeks

Fetal Age: 17 weeks

At this stage, the ears, nose and lips of the fetus are now identifiable. The average height of the

fetus at 19 weeks is 9.3 inches or 23.7 cm long and weighs 9.6 ounces or 273 grams.

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Gestational Age: 20 weeks

Fetal Age: 18 weeks

The fetus is protected with fine hair (called lanugo), it also has some scalp hair, and is able

of produce IgG, a class of immunoglobulins including the most common antibodies circulating in

the blood that facilitate the phagocytic destruction of microorganisms foreign to the body, that

bind to and activate complement, and that are the only immunoglobulins to cross over the placenta

from mother to fetus. And IgM, the largest antibody and it is the first antibody to appear in the

response to initial exposure to an antigen. The average height of the fetus at 20 weeks is 9.9 inches

(25.5 cm) long and weighs 11.7 ounces (331 grams).

Gestational Age: 21 weeks

Fetal Age: 19 weeks

At this stage of development, the fetus is now capable to suck and grasp, and may have

sessions of hiccups. There are also women who begin feeling Braxton Hicks contractions during

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this period of time. The average height of fetus at 21 weeks is 10.6 inches (27.2 cm) long and

weighs 14.1 ounces (399 grams).

Gestational Age: 22 weeks

Fetal Age: 20 weeks

The average height of the fetus at 22 weeks is 11.2 inches (28.8 cm) long and weighs 1.1

pound (478 grams). Endurance out of the womb at this age would be estimated to be approximately

9%. Survival without major morbidity among infants surviving to discharge would be expected to

be 0%.

Gestational Age: 23 weeks

Fetal Age: 21 weeks

Rapid eye movements during sleep is established by the fetus. The average height of the

fetus at 23 weeks is 11.9 inches (30.4 cm) long and weighs 1.2 pounds (568 grams). The entire

corpus callosum may not be visible using transabdominal ultrasound before this age. Survival out

of the womb at this age would be estimated to be approximately 33%. Survival without major

morbidity among infants surviving to discharge would be expected to be approximately 2%.

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Gestational Age 24 weeks

Fetal Age: 22 week

The average height of the fetus at 24 weeks is 12.5 inches (32 cm) long and weighs 1.5

pounds (670 grams). The lung development of the terminal saccular stage has begun. Survival out

of the womb at this age would be expected to be approximately 65%. Survival without major

morbidity among infants surviving to discharge would be expected to be approximately 9%.

Gestational Age: 25 weeks

Fetal Age: 23 weeks

The average height of the fetus at 25 weeks is 13.1 inches (33.6 cm) long and weighs 1.7

pounds (785 grams). The lung development of the terminal saccular stage is about to end.

Respiration is possible towards the end of this period. Survival out of the womb at this age would

be expected to be approximately 81%. Survival without major morbidity* among infants surviving

to discharge would be expected to be end of this period. Survival out of the womb at this age would

be expected to be approximately 25%.

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Gestational Age: 26 weeks

Fetal Age: 24 weeks

The fetus can respond to sounds that occur in the mother's surroundings. Its eyelids can

open and close. The average height of the fetus at 26 weeks is 13.7 inches (35.1 cm) long and

weighs 2 pounds (913 grams). Survival out of the womb at this age would be expected to be end

of this period. Survival out of the womb at this age would be expected to be approximately 87%.

Survival without major morbidity among infants surviving to discharge would be expected to be

end of this period. Survival out of the womb at this age would be expected to be approximately

29%.

Gestational Age: 27 weeks

Fetal Age: 25 weeks

The average height of the fetus at 27 weeks is 14.2 inches (36.5 cm) long and weighs 2.3

pounds (1055 grams). Survival out of the womb at this age would be expected to be end of this

period. Survival out of the womb at this age would be expected to be approximately 94%.Survival

without major morbidity among infants surviving to discharge would be expected to be end of this

period. Survival out of the womb at this age would be expected to be approximately 50%.

Third Trimester of Pregnancy

(28 weeks 0 days through delivery)

Gestational Age: 28 weeks

Fetal Age: 26 weeks

At this stage of development, the fetus has eyelashes and its skin is red and covered with

vernix caseosa a waxy substance that is believed to act as a protective film with anti-infective and

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waterproofing properties. The average height fetus at 28 weeks is 14.8 inches or 37.9 cm long and

weighs 2.7 pounds or 1210 grams. Survival out of the womb at this age would be expected to be

94%.Survival without major morbidity among infants surviving to discharge would be expected

to be 59%. Gestational Age 29 to 31 weeks or 6.6 months to 7.1 months. Fetal Age 27 to 29 weeks.

The average height fetus at 29 weeks is 15.3 inches or 39.3 cm long and weighs 3 pounds or 1379

grams. The average height fetus at 30 weeks is 15.8 inches or 40.6 cm long and weighs 3.4 pounds

or 1559 grams. The average height fetus at 31 weeks is 16.4 inches or 41.9 cm long and weighs

3.9 pounds or 1751 grams.

Gestational Age: 32 to 33 weeks

Fetal Age: 30 to 31 weeks

At this stage of development, the fetus is forming muscle and storing body fat. If the fetus

is a boy, his testicles are descending. The average height of a fetus at 32 weeks is 16.8 inches or

43.2 cm long and weighs 4.3 pounds or 1953 grams. The average height of a fetus at 33 weeks is

17.3 inches or 44.4 cm long and weighs 4.8 pounds or 2162 grams. The distal femoral epiphysis

ossification center can usually be seen in 72 % of fetuses at 33 weeks.

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Gestational Age: 34 to 36 weeks

Fetal Age: 32 to 34 weeks

At this stage, the fetus is now considered to be late preterm. The average height of a 34

week fetus is 17.8 inches or 45.6 cm long and weighs 5.2 pounds or 2377 grams. The average

height of a 35 week fetus is 18.2 inches or 46.7 cm long and weighs 5.7 pounds or 2595 grams.

The proximal tibial epiphysis ossification center may be seen in 35 % of fetuses at 35 weeks. The

average height of a 36 week fetus is 18.6 inches or 47.8 cm long and weighs 6.2 pounds or 2813

grams.

Gestational Age: 37 to 38 weeks

Fetal Age: 35 to 36 weeks

The fetus is now considered to be early term at this stage. The average height of a 37 week

fetus is 19.1 inches or 48.9 cm long and weighs 6.7 pounds or 3028 grams. The average height of

a 38 week fetus is 19.5 inches or 49.9 cm long and weighs 7.1 pounds or 3236 grams. The proximal

humeral epiphysis ossification center may be seen at 38 weeks.

Gestational Age 39 to 41 weeks

Fetal Age 37 to 39 weeks

This stage of development is where the fetus is now full term. The average height of a 39

week fetus is 19.8 inches or 50.9 cm long and weighs 7.6 pounds or 3435 grams. The average

height of a 40 week fetus is 20.2 inches or 52 cm long and weighs 8 pounds or 3619 grams. The

average height of a 41week fetus is 20.5 inches or 52.7 cm long and weighs 8.3 pounds (3787

grams).

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II. ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE

Paradise Valley
ADDRESS: ________________________ Pasonanca
__________________________ 1
____________ 9753
FAMILY NUMBER: _______________
Street / Road Barangay Zone

A. FAMILY STRUCTURE, CHARACTERISTICS , & DYNAMICS/RELATIONAL PATTERNS


1. Members of the Household
Birthdate Relationship to the Head of the
Name of Family Member Age Sex Civil Status Position in the Family
Month Year Family
Janissa Jabagat 25 April 1994 F Live-in 1st child in the family Head
Elding Jabagat 21 1998 M Single Eldest child(2nd) Head
Ariel Bautista 16 October 2003 M Single Eldest child (3rd) head
Evel Jane Bautista 14 January 2006 F Single Elder child (4th) head
Eva Bebeluni 45 March 1972 F Married Mother Head of the Family
KC Flores Bautista 11 April 2008 F Single Youngest (5th) Head
Shantal Santillan 6 December 2016 F Single Youngest (6th) Head
Andric Sali 25 October 1994 M Live-in Son-in-law Son-in-law of the Head

2. Socio-demographic data of members not currently living in the household but with major role in resource generation and use

Name of Family Age Birthdate Sex Marital Highest Occupation Relationship to Head of the
Member Month Year Status Educational Family
Attainment Type of Work Place
Eva Bebeluni 45 March 1972 F Married High School Waitress Pasonanca, Head of the family
Graduate Regency
Janissa Jabagat 25 April 1994 F Live-in High School No occupation N/A Head
Graduate
Ancric Sali 25 October 1994 M Live-in High School Merchandiser Shop-o- Son-in-law of the head
Graduate rama

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1. Length of residency 10 years

2. Type of Family Structure and Form

Based on Composition
Based on Locus of Power Based on Place of Residency
Nuclear Family Stepfamily/Blended Patrifocal / Patriarchal Patrilocal

Extended Single Matrifocal / Matriarchal Matrilocal

Beanpole Same-sex/Homosexual Egalitarian Bilocal

Single-Parent Cohabiting/Communal Matricentric

3. Family Dynamics, Communication Pattern/s, Interaction Processes and Interpersonal Relationships.

Criteria Status Additional Information

Observable conflicts between family members None No conflicts observe between the family

Characteristics of communication Open Open communication; Bisaya


communication

Interaction patterns among members Strong Open relationship; strong bond with one another

Others N/A N/A

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B. SOCIO-ECONOMIC & CULTURAL CHARACTERISTICS

Highest Educational Occupation Income


Name of Family Member Ethnic Background Religion
Attainment Nature of Work Place of Work
Eva Bebeluni Bisaya Roman Catholic High School Graduate Waitress Pasonanca, Regency 2,500

Legend for Monthly Family Income


1 – Below 2,500 3 – above 5,000 to 7,500 5 – above 10,000 to 12,500 7 – above 15,000 to 17,500 9 – above 20,000 to 25,000
2 – 2,500 to 5,000 4 – above 7,500 to 10,000 6 – above 12,500 to 15,000 8 – above 17,500 to 20,000 10 – above 25,000

1. Income & Expenses


a. Adequacy to Meet Basic Necessities
___________________________________________________________________________________________________________________________
Not all provided, shortage of basic necessities due to low income.
___________________________________________________________________________________________________________________________

2. Family Traditions, events or practices affecting member’s health or family functioning


The family prefer to go to a manghihilot to check the condition of their baby rather than going to health center or
_________________________________________________________________________________________________________________________________
hospital for prenatal check-up.
_________________________________________________________________________________________________________________________________

3. Significant Others – role(s) they play in family’s life


Name Role & Relation to Family
Eva Bebeluni (Mother) Bread winner
Andric Sali (son-in-law) Bread winner

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4. Relationship of the Family to Larger Community – Nature and extent of participation of the family in community activities
a. Awareness of existing organization Yes Name ________________________________ No
b. Membership in an organization Yes Name ________________________________ No Not involved
Why? _________________________
c. Involvement in an organization Yes Name ________________________________ Not involved
No Why? _________________________
None
d. Potential or Existing leaders ____________________________________________________________________________________________________

C. HOME AND ENVIRONMENT

1. Home

Ownership: owned rented free Constructional material used: light mixed strong

Lighting facilities: electricity kerosene others (specify) ________________________


2
Number of rooms used for sleeping & sleeping arrangement:

__________________________________________________________________________

2. Water Supply

Drinking: Source private public Potability: specify is safe for drinking Safe Unsafe

Storage direct from faucet or pipe covered container with faucet large uncovered without faucet
N/A
Other (specify) _______________________

3. Food storage

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Cooking facility: electric gas stove firewood/charcoal
Normal
Sanitary condition: ___________________________________________________________________________________________________________

Drainage facility: open drainage blind drainage none

4. Water Disposal

a. Refuse and Garbage

 Container covered open none

 Method of disposal: hog feeding open dumping burial in pit composting open burning garbage

collection

b. Toilet

 Type: none overhung latrine open pit privy closed pit privy bored- hole latrine pail system

antipolo type water-sealed latrine flush type other (specify) _____________________________________________


Inside the house
 Distance from the house: ______________________________________
Normal
 Sanitary Condition:

___________________________________________________________________________________________________

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5. Domestic Animals
Kind Number Where Kept
Cat 1 Inside the house

6. The Community in General


Dirty surroundings, poor disposal of wastes, muddy surrounding
a. General sanitary condition: __________________________________________________________________________________________________
b. Housing congestion: Yes
Present
________________________________________________________________________________________________________
c. Presence of breeding or resting sites of vectors of disease:
Basketball court, sari-sari stores
_________________________________________________________________________
d. Recreational Facility:
Yes, Pasonanca Health Center
________________________________________________________________________________________________________
e. Availability of health care services: ____________________________________________________________________________________________
f. Distance of house from nearest health care facility: Near, walking distance
Yes, available
_______________________________________________________________________________
g. Communication & Transportation Facilities available: _____________________________________________________________________________

D. HEALTH STATUS OF EACH FAMILY MEMBER

1. Medical & Nursing History

Family Member Health Status / Health History Family Member Health Status / Health History
Janissa Jabagat Admitted due to urinary tract
infection

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2. Nutritional Assessment

a. Anthropometric Data: Measure of Nutritional Status of Children

Anthropometric Data (Children)

Name of Family Member Weight Height Mid-Arm Circumference


N/A N/A N/A N/A

Anthropometric Data (Adult)


Name of Family Member Weight Height Body Mass Index Waist Circumference Waist Hip Ratio
Janissa Jabagat 65 kg 5”1’ 29.7 38.5 in 40

b. Dietary History specifying quality & quantity of food/nutrient intake per day

Rice, vegetables, protein (normal), ferous sulfate (iron)


______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

c. Eating/Feeding habits/practices

Drinks water before and after eating, use of spoon and fork, use of bare hands when food is fried
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______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

3. Risk factor assessment indicating presence of major & contributing modifiable risk factors for specific lifestyle None
diseases______________________________
______________________________________________________________________________________________________________________________
Normal
4. Result of laboratory/diagnostic & other screening procedures supportive of assessment findings________________________________________________
______________________________________________________________________________________________________________________________

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE & DISEASE PREVENTION

1. Immunization status of family member


Name of Child Immunization Status Remarks
Ariel Bautista Immunized N/A
KC Flores Bautista Immunized N/A
Shantal Santillan Immunized N/A
Evel Jane Bautista Immunized N/A

2. Healthy lifestyle practices


______________________________________________________________________________________________________________________________
___________________________________________________________________________________________________

3. Adequacy of:

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a. Rest & Sleep Yes No

b. Exercise/Activities Yes Walking


specify: _______________________________ No Why ___________________________________________

c. Use of Protective Measures Yes _________________________________ No No first aid kit available


Why ___________________________________________

d. Relaxation & other stress management activities Yes _______________________________________ No

e. Opportunities which enhance feelings of self-worth, self-efficacy and sense of connectedness to self, others and a higher power, essence of

meaningfulness Washing clothes, shopping

Yes specify: _________________________________________________ No

4. Use of promotive – preventive health services Yes specify: ___________________________________


Regular consultation No Why ________________________

5. Use of Family Planning Methods

a. Type

Natural

Abstinence Lactational Amenorrhea Method Basal Body Temperature Cervical Mucus Method

Symptothermal Method Standard Days Method Others: specify ___________________________________________

Artificial

Hormonal

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Oral Contraceptives Specify: Progesterone – Only Oral Contraceptive Low- Dose Combined Oral Contraceptive

Injectable depot medroxyprogesterone acetate / Depo-Provera (DMPA)

Norplant Implants

Barrier

Intrauterine Device Condom Diaphragm Cervical Cap Others: specify __________________________

Permanent

Tubal Ligation Vasectomy

None

Are you willing to practice Family Planning Method? Yes No

What hinders you from practicing Family Planning Method? Biological Psychological Social Cultural

Religion Others, specify: Unfamiliar, lack of knowledge


_____________________

a. Who taught you about Family Planning Method?

PHN/PHM BHW Friend Neighbor Print/Visual Ads Student Nurse None


Others specify: ______________________

Is your husband aware of your usage of Family Planning Method? Yes No

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a. Do you know side effects of family planning method as a result of its use? Yes No

Changes in menstrual bleeding headache nausea weight gain moodiness

Delayed return of fertility dizziness acne in women nervousness change in appetite

Enlargement of ovaries/ovarian cyst hair loss breast tenderness others; specify _________________________________________

b. Do you have misconceptions about Family Planning Methods? Yes No

Some FP Methods cause abortion Using Contraceptives will render couples sterile

Using contraceptives methods will result to loss sexual desire

Others; specify _________________________________________________________________________

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HEALTH CONDITION AND PROBLEM SHEET FORMAT
Supporting Data/ Cues Health Conditions Family Nursing Problem 2nd Level Assessment Date
and Problems Identified Resolved
Subjective data: Unhealthful Nutrition: 1. Inability to make decisions with respect to taking July 06 27, 2019
“Minsan lang po ako kumakain ng Inadequate food intake appropriate health action due to:
gulay at hindi rin po ako umiinom o both in quality and a. Negative attitude towards health condition or problem
nagba-vitamins” as verbalized by quantity as a health 2. Inability to recognize the presence of the condition or
Patient X. threat problem due to:
a. Lack of inadequate knowledge
Objective data: b. Attitude/philosophy in life which hinders recognition/
-Unwillingness to eat acceptance of a problem.
-Muscle weaknesses
-Poor dentition
Weight- 65kg
Height- 148cm
Subjective data: Fall Hazard as a Health 1. Failure to utilize community resources for health care July 06, 2019
“Nahihirapan akong maglakad Threat due:
papuntang rio kasi pababa yun
natatakot ako baka madapa ako, a. Unavailability of required care/ services
doon kasi ako nagliligo” as b. To inaccessibility of required services due to physical
verbalized by Patient X. inaccessibility.

Objective data: 2. Inability to provide a home environment conducive to


-The area is too slope and slippery health maintenance and personal development due to:

a. Lack of/inadequate knowledge of preventive measures

b. Lack of skill in carrying out measures to improve home


environment

29
Subjective data: Poor environmental 1. Inability to provide a home environment which is July 06, 2019
“Maglisud baya mi ug katulog kay condition: conducive to health maintenance and personal
guot kaayu amoang balay unya -Inadequate living development due to:
daghan ra ba kaayu mga lamok” as space and presence of a. Financial constraints/limited financial resources
verbalized by Patient X. breeding sites of b. Limited physical resources
vectors of disease as a c. Lack of/ inadequate knowledge of importance of hygiene
health threat and sanitation

30
SCALE RANKING HEALTH CONDITIONS AND PROBLEMS FORMAT
Unhealthful Nutrition: Inadequate food intake both in quality and quantity as a health threat
Criteria Computation Actual Score Justification
Nature of the Problem 2/3 x1 = 2/3 Health Threat because failure to
2/3 or 0.67 maintain adequate intake of food both
Presented: Health Threat in quality and quantity.

Modifiability of the Problem It is partially modifiable because they


2/2 x1 =1 1 don’t have an adequate source of
income to provide for the needs of the
family.
Preventive Potential Problem can be easily prevented and
2/3 x2 = 1.3 1.3 has many solution with the
cooperation of the family member to
contribute or look for a job and thus
can provide for needs of the family.
Salience The family must be aware that it is a
2/2 x2 2 serious problem and needs immediate
attention because this will not a affect
only on the patient but to the whole
family.
Total: 4.97

31
SCALE RANKING HEALTH CONDITIONS AND PROBLEMS FORMAT
Fall Hazard as a Health Threat
Criteria Computation Actual Score Justification
Health threat because the location of
Nature of the Problem
1/3 x2 =0.66 0.66 the house to the river is risky due to
the slope.
Presented: Fall Hazard as a health
threat
Modifiability of the Problem This problem is partially modifiable
1/2 x1 =1/2 or 0.5 ½ or 0.5 because the family can still provide
water by stocking with some empty
containers for bathing.

Preventive Potential The problem cannot be easily


1/3 x1 =0.33 0.33 prevented because the area is potential
for any accidents to happen.

Salience The family is aware that the area is


2/2 x2 = 2 potential for accidents because they’ve
already witnessed themselves the
accident happened to others.

Total: 3.49

32
SCALE RANKING HEALTH CONDITIONS AND PROBLEMS FORMAT
Poor environmental condition: Inadequate living space and presence of breeding sites of vectors of disease as a health threat
Criteria Computation Actual Score Justification
2/3 x1 =0.66 0.66 Health threat because the living space
Nature of the Problem
is too small and the location of the
house is congested and this may lead
Presented: Poor environmental
to a problem of the breeding sites
condition
vectors of disease
Modifiability of the Problem 2/2 x1 =1 1 The problem is partially modifiable
with some renovation of the house
structure, adequate sanitation of the
surrounding such cleaning the area to
prevent the breeding sites of the
vectors/mosquitos.
Preventive Potential 2/3 x2 =1.33 1.33 The problem can be easily prevented
with the cooperation of the family
member to renovate the structure of
the house, cleaning the surrounding
and provide good sanitation to get rid
of diseases such dengue, and malaria.
Salience 2/2 x2 =2 2 The family is aware that it is a serious
problem and needs immediate
attention because it will affect the
health and condition of the whole
family.
Total: 4.99

33
FAMILY NURSING CARE PLAN
Evaluation Plan
Health Condition/s or Problems and Objectives of Plan of Interventions Outcome Criteria/ Methods/ Tools
Family Nursing Problems Nursing Care Indicators,
Standards

Unhealthful Nutrition: After the nursing 1. Discuss Evaluation Standards: Home Visits
Inadequate food intake both in quality intervention, the a. effects of unhealthy diet and intake of foods Correct demonstration
and quantity as a health threat threat of unhealthful for pregnant mother of appropriate food Health Teachings
Nutrition: intake, eating done last July 24,
Inadequate food b. With the family other effective ways on behavior, and food 2019
1. Inability to make decisions with intake must be providing healthy lifestyle and good nutrition consumptions
respect to taking appropriate health prevented by for the family
action due to: providing healthy
a. Negative attitude towards health lifestyle diet, eating c. The benefits of eating healthy foods and with Performance
condition or problem vegetables and some sort of exercises Criterion/ Indicators:
2. Inability to recognize the presence of adequate Demonstrate
the condition or problem due to: supplements of 2. Develop the skills of family members on appropriate technique
a. Lack of inadequate knowledge vitamins proper food and good nutrition for a lack or excess of
b. Attitude/philosophy in life which some dietary
hinders recognition/ acceptance of a 3. Improve the family’s attitude towards the components from the
problem. importance of good health condition imparted health
teaching

34
FAMILY NURSING CARE PLAN
Evaluation Plan
Health Condition/s or Problems and Objectives of Plan of Interventions Outcome Criteria/ Methods/ Tools
Family Nursing Problems Nursing Care Indicators,
Standards

Fall Hazard as a Health Threat After the nursing Evaluation Standards: Home Visits
intervention, the 1. Discuss Improvement of
1. Failure to utilize community health threat of the a. the availability of health care resources preventive measure Health Teachings
resources for health care due: family members on b. the importance of cooperation between the done last July 24,
accident hazard will family member 2019
a. Unavailability of required care/ be prevented by c. different preventive measures for a conducive
services utilizing resources home environment
b. To inaccessibility of required for health care and
services due to physical inaccessibility. providing a home 2. Develop the skills of the family members in
environment carrying out care with the use of appropriate Performance
2. Inability to provide a home conducive to health alternatives Criterion/ Indicators:
environment conducive to health maintenance and Appropriate action to
maintenance and personal development personal an existing accident
due to: development. hazard
Utilizing community
a. Lack of/inadequate knowledge of resources to provide a
preventive measures safe environment

b. Lack of skill in carrying out measures


to improve home environment

35
FAMILY NURSING CARE PLAN
Evaluation Plan
Health Condition/s or Problems and Objectives of Plan of Interventions Outcome Criteria/ Methods/ Tools
Family Nursing Problems Nursing Care Indicators,
Standards

Poor environmental condition: After the nursing Evaluation Standards: Home Visits
-Inadequate living space and presence intervention, the 1. Discuss Improvement of
of breeding sites of vectors of disease as health threat of the a. the availability of health care resources preventive measure Health Teachings
a health threat family members on b. the importance of cooperation between the done last July 24,
poor family member 2019
1. Inability to provide a home home/environmental c. different preventive measures for a conducive
environment which is conducive to sanitation will be home environment
health maintenance and personal prevented by d. the benefits of home sanitation improvement
development due to: imparting health
a. Financial constraints/limited financial teachings and show 2. Develop the skills of the family members in Performance
resources appropriate carrying out care with the use of appropriate Criterion/ Indicators:
b. Limited physical resources sanitations on the alternatives Appropriate action to
c. Lack of/ inadequate knowledge of environment to an existing accident
importance of hygiene and sanitation prevent diseases, hazard
accidents and failure Utilizing community
realize one’s health resources to provide a
potential. safe environment

36
SERVICE AND PROGRESS NOTES

Health Condition/Nursing Problems Nursing Observations, Actions taken, Responses & Printed Name &
Evaluation of Progress/Outcomes Signature
Date
July 06, 2019 Unhealthful Nutrition:
Inadequate food intake both in quality and quantity Home Visits
as a health threat
Health Teachings done last July 24, 2019
-The patient demonstrated understanding of the unhealthful
1. Inability to make decisions with respect to taking Nutrition threat.
appropriate health action due to:
-The patient was able to exhibit the attitude towards the importance
a. Negative attitude towards health condition or of good health condition by eating healthy foods and exercising.
problem
-Nursing interventions for this goal were effective for attainment
2. Inability to recognize the presence of the of the goal.
condition or problem due to:
a. Lack of inadequate knowledge
b. Attitude/philosophy in life which hinders
recognition/ acceptance of a problem.

37
Health Condition/Nursing Problems Nursing Observations, Actions taken, Responses & Printed Name &
Evaluation of Progress/Outcomes Signature
Date
July 06, 2019 Fall Hazard as a Health Threat Home Visits

1. Failure to utilize community resources for health Health Teachings on Fall Hazard done last July 24, 2019
care due:
- Recommend an appropriate alternative such public shower to the
a. Unavailability of required care/ services barangay officials
b. To inaccessibility of required services due to -The patient was able to verbalize the understanding of the health
physical inaccessibility.
threat of the family members on accident hazard by developing the
skills in carrying out care with the use of appropriate alternatives.
2. Inability to provide a home environment
conducive to health maintenance and personal - The patient demonstrates lifestyle change by utilizing resources
development due to: for health care and providing a home environment conducive to
health maintenance and personal development.
a. Lack of/inadequate knowledge of preventive
measures

b. Lack of skill in carrying out measures to improve


home environment

38
Health Condition/Nursing Problems Nursing Observations, Actions taken, Responses & Evaluation Printed Name &
of Progress/Outcomes Signature
Date
July 06, 2019 Poor environmental condition:
-Inadequate living space and presence of breeding Home Visits
sites of vectors of disease as a health threat
Health Teachings done last July 24, 2019
1. Inability to provide a home environment which is
conducive to health maintenance and personal -The patient demonstrated understanding of the hygiene and
development due to: sanitation importance by verbalizing the benefits of home
a. Financial constraints/limited financial resources sanitation improvement.
b. Limited physical resources
c. Lack of/ inadequate knowledge of importance of -The patient exhibits appropriate sanitations on the environment to
hygiene and sanitation prevent diseases, accidents and failure realize one’s health
potential.

39
A.1. Biographic Data Nursing Health History

I. Biographic Data

A. Name: Patient X

B. Address: Pasonanca, Paradise Valley, Zamboanga City

C. Age: 25 years old

D. Birth Date: April 25, 1994

E. Sex: Female

F. Race: Filipino

G. Marital Status: Single

H. Occupation: None

I. Religious Orientation: Iglesia Ni Cristo

J. Health Care Financing and usual source of medical care: Not Stated

A. 2. Nursing Health History

II. History of Present Illness

The patient was not doing any strenuous activities, only the usual activities such as

walking and sitting. The patient has no present illness.

III. Past History

The patient has complete immunization. She had no experience of allergies. She had no

previous accident. The patient had undergone hospitalization due to urinary tract infection

(UTI) way back on 2016 when she was still on her high school days. The patient usually

takes analgesics and antipyretics to relieve pain and fever.

V. Family History of Illness

The family member of the client had a history of hypertension and diabetes mellitus.

40
III. RECOMMENDATIONS

This study recommends promoting a continued health teaching to clients to prevent having

this kind of health threat and for the family to gain adequate knowledge and understanding on the

effects of lifestyle changes not only to the client but also the family. In addition, health care

providers must advice the client and the family as well, in making appropriate decisions that is

necessary for maintaining health, preventing and managing diseases and reducing disabilities and

premature deaths.

The group recommended for the client and family to improve their environmental

sanitation. In promoting this, health care providers must continue giving health education to the

community and advising putting practice on it such as maintaining proper waste management,

improving personal hygiene, performing proper hand hygiene and the like.

Lack of adequate resources makes it difficult for a family to receive necessary health care

services. Thus, this paper recommends that every family must find a health care provider to whom

they trusts and communicate with; A family must also gain entry in health care system such as

having insurance coverage which can help in financial burdens, prevent unmet health needs and

delay in receiving appropriate care.

41
IV. BIBLIOGRAPHY

1. Office on Women's Health. (2010). Stages of pregnancy. Retrieved May 20, 2016,

from http://womenshealth.gov/pregnancy/you-are-pregnant/stages-of-pregnancy.html

2. American College of Obstetricians and Gynecologists (ACOG). (2015, June). Prenatal

development: How your baby grows during pregnancy. Retrieved May 20, 2016,

from http://www.acog.org/~/media/For%20Patients/faq156.pdf?dmc=1&ts=20120731T1

026504777 (PDF - 70 KB)

3. Prenatal Care and Test. (January 30, 2019). Womens health. Retrieved August 22, 2019,

from https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-

and-tests

4. Staying Healthy and Safe. (March 14, 2019). Womens health. Retrieved August 22, 2019

from https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/staying-

healthy-and-safe

5. About Pregnancy. (January 31, 2017). Nih. Retrieved August 22, 2019 from

https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo

6. Nutrition During Pregnancy. (February 2018). Acog. Retrieved August 22, 2019 from

https://www.acog.org/Patients/FAQs/Nutrition-During-Pregnancy?IsMobileSet=false

7. Ferrous Sulfate Tablet, Delayed Release (Enteric Coated). (n.d). Retrieved August 22,

2019 from https://www.webmd.com/drugs/2/drug-4127/ferrous-sulfate-oral/details

8. Mercedo,R. (October 13, 2019). Drugs for Nursing Students. Retrieved August 22, 2019

from http://drugsfornursingstudents.blogspot.com/2009/10/ferrous-sulfate.html

9. Micromedex, W. (August 1, 2019). Drugs. Retrieved August 22, 2019 from

https://www.drugs.com/drug-interactions/folic-acid.html

10. Kluwer, W. (July 31, 2019). Drugs. Retrieved August 22, 2019 from

https://www.drugs.com/ppa/ferrous-sulfate.html

11. Folic Acid. (n.d). Webmd. Retrieved August 22, 2019 from

https://www.webmd.com/vitamins/ai/ingredientmono-1017/folic-acid

42
12. Folic Acid. (n.d). Rx List. Retrieved August 22 2019 from https://www.rxlist.com/folic-

acid-drug.htm#description

43
DRUG STUDY

DRUG MECHANISMS OF ACTION INDICATIO CONTRAINDICATIO ADVERSE SIDE NURSING


NAME N N EFFECT EFFECT RESPONSIBILITI
ES
Generic The proposed mechanisms of this Folic Folic Gastrointestinal effec Redness, Ensuring the
Name: following 10 rights
FOLIC ACID phenomenon include an increase acid helps your acid is contraindicated f ts, including skin rashes, when administering
the medication to the
Brand Name: in folate catabolism, folate malabsorp body produce or use in patients anorexia, nausea, itching, client:
FOLVITE 1. Right route
tion, or use of folic acid secondary to and maintain with folic abdominal feeling (Rationale:
Classification administer
s: enzyme induction by phenytoin. new cells, and acid hypersensitivity. F distention, unwell, medicine via
Vitamin prescribed
supplement also helps olic acid should be used flatulence, and a respirator route and site)
2. Right time
Dosage: prevent with extreme caution in bitter or bad taste, difficulty (Rationale:
600 administer
micrograms/d changes to patients with due to medicine at
ay prescribed
DNA that may undiagnosed anemia. broncospas time and
Frequency: prescribed
Daily lead to cancer. m. intervals)
3. Right dosage
Route: As a (Rationale:
Oral Confirm that
medication, fol the dose of
medicine
ic acid is used being
administered
is exactly the

4
to treat folic dose
prescribed.)
acid deficiency 4. Right Form
(Rationale:
and certain confirm that
the form of
types of medicine that
has been
anemia (lack dispensed,
matches with
of red blood the specified
route of
cells) caused administration
.)
by folic 5. Right patient
(Rationale: be
acid deficiency certain of
identity of
. patient by
verifying the
identification
wristband,
name and date
of birth on the
medicine
chart.)
6. Right
medicine
(Rationale:
Name of
medicine to
be
administered

46
must be
correspond
with generic
or brand name
of prescribed
medicine,
stored
correctly,
properly
packed and
within its
expiry date.)
7. Right Reason
(Rationale:
Understand
the intend
purpose of the
medicine to
be
administered.)
8. Right Action
(Rationale:
Ensure
medicine is
prescribed for
the
appropriate
reason, and
state to the
patient and
watcher, the
action of the
medication

47
and why it is
prescribed.)
9. Right
documentatio
n
(Rationale:
Sign, date all
documentatio
n recording
the
administration
of the
medicine in
medicine
administration
s chart.)
10. Right
response
(Rationale:
Observe the
patient for
adverse
effect, assess
patient to
determine that
the desired
effect of the
medicine has
been
achieved.)

www.nursinghealth.c
om

48
Drugs Mechanism of Indication Contraindication Side Effects Adverse Effects Nursing Responsibility

Action

Brand Name: Iron combines Prevention or Contraindicated in  Constipation  Signs of an  Advise patient to take

with porphyrin treatment of iron patients receiving  Contact allergic medicine as

Generic Name: and globin deficiency anemia repeated blood irritation reaction, like prescribed.

Ferous Sulfate chains to form due to inadequate transfusions and in  Diarrhea rash; hives;

hemoglobin, diet, those with  Dark stools itching; red,  Encourage patient to

Classification: which is critical malabsorption, hemosiderosis,  GI swollen, comply with

Blood Former for oxygen pregnancy and primary hemorrhage blistered, or additional

Coagulant delivery from the blood loss hemochromatosis, (rare) peeling skin intervention for

lungs to other hemolytic anemia  GI irritation with or hypertension like

Route: Oral tissues. Iron unless iron without proper diet, regular
 GI
deficiency deficiency anemia is fever; exercise, lifestyle
obstruction
Dosage: causes a also present, peptic wheezing; changes and stress
(wax matrix
Pregnancy: 110 to microcytic ulceration, tightness in management.

4
135 mg/day anemia due to ulcerative colitis, or products; the chest or

FeSO4 (22 to 27 the formation of regional enteritis rare) throat;  10 rights of

mg/day small  GI perforation trouble medication

elemental) erythrocytes with (rare) breathing, administration

insufficient  Nausea swallowing,


1. Right Patient
Frequency: hemoglobin  Stomach pain or talking;
2. Right Dosage
Daily  Superficial unusual
3. Right time
tooth hoarseness;
4. Right reason
discoloration or swelling of
5. Right form
(oral the mouth,
6. Right Action
solutions) face, lips,
7. Right
 Urine tongue, or
Medicine
discoloration throat.
8. Right
 Vomiting  Black, tarry,
documentation
or bloody
9. Right
stools.
response

2
 Fever. 10. Right to

 Very upset education

stomach or

throwing up.

 Very bad

belly pain.

 Throwing up

blood or

throw up that

looks like

coffee

grounds.

3
4

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