Intoduction To Recommendations 2
Intoduction To Recommendations 2
Intoduction To Recommendations 2
INTRODUCTION
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
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
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
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
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
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
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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
i. Nursing Education
This case study can help nursing students gain knowledge and gather
issues can hinder the health of normal pregnancy. Thus, implementing and
This study can further help in the advancement of nursing practices. Health
more efficient way to provide care to pregnant woman. Researchers can also
benefit from this study by observing problems that might hinder the normal
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
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.
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
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Gestational Age: 3 weeks.
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
blood and urine between 6 and 14 days after fertilization. Fatigue and swollen or tender
The embryo is the size of a pinhead. Usually, most pregnancy tests will be positive
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Gestational Age: 5 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
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.
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
or greater.
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
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Gestational Age: 9 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.
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.
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
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
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
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Second Trimester of Pregnancy
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.
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.
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.
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
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
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
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
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%.
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
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Gestational Age 24 weeks
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
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
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Gestational Age: 26 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%.
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%.
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
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
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Gestational Age: 34 to 36 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.
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
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
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
Based on Composition
Based on Locus of Power Based on Place of Residency
Nuclear Family Stepfamily/Blended Patrifocal / Patriarchal Patrilocal
Observable conflicts between family members None No conflicts observe between the family
Interaction patterns among members Strong Open relationship; strong bond with one another
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B. SOCIO-ECONOMIC & CULTURAL CHARACTERISTICS
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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 ____________________________________________________________________________________________________
1. Home
Ownership: owned rented free Constructional material used: light mixed strong
__________________________________________________________________________
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: ___________________________________________________________________________________________________________
4. Water Disposal
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
___________________________________________________________________________________________________
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5. Domestic Animals
Kind Number Where Kept
Cat 1 Inside the house
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
b. Dietary History specifying quality & quantity of food/nutrient intake per day
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________________________________________________
______________________________________________________________________________________________________________________________
3. Adequacy of:
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a. Rest & Sleep 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
a. Type
Natural
Abstinence Lactational Amenorrhea Method Basal Body Temperature Cervical Mucus Method
Artificial
Hormonal
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Oral Contraceptives Specify: Progesterone – Only Oral Contraceptive Low- Dose Combined Oral Contraceptive
Norplant Implants
Barrier
Permanent
None
What hinders you from practicing Family Planning Method? Biological Psychological Social Cultural
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a. Do you know side effects of family planning method as a result of its use? Yes No
Enlargement of ovaries/ovarian cyst hair loss breast tenderness others; specify _________________________________________
Some FP Methods cause abortion Using Contraceptives will render couples sterile
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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.
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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
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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.
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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.
Total: 3.49
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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
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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
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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
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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
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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.
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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
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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.
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A.1. Biographic Data Nursing Health History
I. Biographic Data
A. Name: Patient X
E. Sex: Female
F. Race: Filipino
H. Occupation: None
J. Health Care Financing and usual source of medical care: Not Stated
The patient was not doing any strenuous activities, only the usual activities such as
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
The family member of the client had a history of hypertension and diabetes mellitus.
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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
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
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
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,
8. Mercedo,R. (October 13, 2019). Drugs for Nursing Students. Retrieved August 22, 2019
from http://drugsfornursingstudents.blogspot.com/2009/10/ferrous-sulfate.html
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
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
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
Blood Former for oxygen pregnancy and primary hemorrhage blistered, or additional
Coagulant delivery from the blood loss hemochromatosis, (rare) peeling skin intervention for
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
2
Fever. 10. Right to
stomach or
throwing up.
Very bad
belly pain.
Throwing up
blood or
throw up that
looks like
coffee
grounds.
3
4