MALANA, ALTHEA VIE M.

BSN 2-J
CHN RLE
Activity: FAMILY NURSING CARE PLAN

Scenario 1
On an afternoon at the clinic, the community health nurse decided to do a home visit in one of the barangays in the community. The
Community health nurse saw Mrs.VU on their back yard and she observe that she looks pregnant but did not pay any visit at the clinic.
On the course of their conversation, she obtained the following data: Mr. and Mrs. VU have been living together for 13 years on their
two- room house made of light materials. They have 5 children, 3 girls and 2 boys, 4 were studying and she is six months pregnant.
Her 4 children are all in the school and her youngest daughter Maan, 3-year-old who appears to be thin for her age and kept scratching
her rashes over her arms and legs. Mrs. VU, 38-year-old, a high school graduate same as with her husband. She is a vendor, and her
husband is a tricycle driver.
Mrs. VU verbalized that her pregnancy is unwanted, and she never submitted herself for medical checkup and even never visited the
health center for prenatal checkup due to financial constraints. The following data are taken during the home visit.

G6P5
Age of gestation: 24 weeks
Blood pressure: 140/90; weight: 120 lbs.
Abdominal palpation: breech presentation, fetal heart tone: 140 beats/minute
Significant finding: slight pedal edema
Management: low salt diet, urinalysis, to come for prenatal checkup at the health center
Furthermore, Mrs. VU stated that she experienced severe bleeding after delivery

PROBLEM: SUSPECTED MALNUTRITION

1st Level Assessment: Presence of Health Deficit: Malnutrition

2nd Level Assessment: Inability to recognize the presence of the condition or problem due to attitude recognition of a
problem

Cues Analysis of Objectives Nursing Rationale Method of Resources Expected

the Problem Interventions Family Required Outcome
Contact

Subjective: Lack Short-term: 1. Discuss the 1. Helps the > Home Visits > Sufficient Short-term:
Verbalization of/inadequate implication of family to > Health knowledge of
of Mrs.VU of knowledge Within an signs and expand teaching/educ the student After an hour
her family, about child hour of symptoms of knowledge ation nurse of nursing
describing her development nursing malnutrition and enlighten > Assessment regarding the intervention,
children and care intervention, and its them to take through problem the family
including her the family will possible further action interview and understood the
youngest be able to consequences to the problem observation > Time and urgency of
daughter understand the if left effort of the needed care
Maan, 3-year- urgency of untreated student nurse for the child
old who needed care suffering from
appears to be for the child 2. Educate 2. Promote > Full malnutrition.
thin for her suffering from about the early cooperation of - GOA
age. malnutrition. reasons and prevention the family L
possible and assigned to MET.
Objective: causes of identification the student
Long term: malnutrition of causative nurse
> Thin body factors Long term:
for Maan’s Within one > Needed
age week of 3. Promote to 3. Serves as a materials that After one
nursing about the guide to have will aid in week of
intervention, nutritional an adequate imparting nursing
the family will needs of the nutrition knowledge intervention,
be able to children by intake and new the family
improve the recommendin information to improvd the
weight of the g proper the family weight of the
 malnourished nutritional malnourished
child with the intake (RENI) > CHN Bag child with the
help of the for different help of the
health age group health
teachings teachings
being taught 4. Develop 4. Proper being taught
to eat various proper food nutritional to eat various
kinds of food. selection and planning and kinds of food.
plan (e.g. application - GOA
powdered increase the L
protein weight of the MET.
concentrates child within
such as the normal
mongo, small range
fish that can
be added to
the diet)

5. Inform the 5. Utilization

family about of community
the feeding resources
programs helps them to
present in achieve proper
their health benefits
community

Scenario 2

As a community health nurse in Brgy. Masagana, you decided to do a home visit for U family. The U family’s main source of
income is coming from Mr. U’s farming. Mr. U earns about Php 6,000.00 a month. Mrs. U does not work, she is in charge of the
house and in taking care of their children. They have 3 children: Ian, 5 years old, diagnosed with primary complex 5 months ago;
weight – 14 kg, he has not completed immunizations. Ana, four years old, diagnosed with parasitic infection; weight – 11 kg, she has
not completed immunizations.
Josh, 3 years old, with many allergies and rashes seen on his legs.
The CHN observes that the house is made of wood, mostly bamboo. The house has only 2 windows and no bedrooms. The
house serves as a bedroom, living/dining room, and kitchen. Mrs. U uses charcoal in cooking, and she cooks inside their house. Mr.
and Mrs. U, sleeps together with the children. The U family has no comfort room. They usually urinate and remove bowels anywhere
near their house. The drainage system of the family is an open type wherein the drainage flows anywhere and is continuous.

PROBLEM: IMPROPER DRAINAGE SYSTEM

1st Level Assessment: Presence of Health Threat: Drainage System

2nd Level Assessment: Inability to provide a home environment conducive to health due to inadequate knowledge regarding
the importance of proper hygiene and sanitation

Cues Analysis of Objectives Nursing Rationale Method of Resources Expected

the Problem Interventions Family Required Outcome
Contact

Subjective: Lack of skill Short term: 1. Discuss the Encourages > Home Visits > Sufficient Short term:
Verbalization in carrying out Within one importance of the family to > Health knowledge of After one hour
of Mr. U of measures to hour of having a maintain teaching/educ the student of nursing
their way of improve home nursing proper hygiene to ation nurse intervention,
living and environment intervention, drainage prevent > Assessment regarding the the family
sanitary the family will system transmission through problem understood the
condition of be able to of diseases interview and meaning of
his house, understand the observation > Time and personal
meaning of 2. Elaborate effort of the hygiene and
Objective: personal the 2. Acquiring student nurse its benefits to
hygiene and disadvantages knowledge of health.
> Open type its benefits to of having an proper > Full - GOA
drainage health. improper hygiene cooperation of L
system with drainage inorder to the family MET.
vectors and system (ex. apply to daily assigned to
scattered Long term: risk of activities the student
wastes vectors) nurse Long term:

Within one 3. Explain 3. > Needed

week of illnesses that Handwashing materials that After one
nursing may acquire is the most will aid in week of
intervention, of having an most effective imparting nursing
the family will improper way of knowledge intervention,
be able to drainage preventing the and new the family
demonstrate system transmission information to demonstrated
ways and of illnesses the family ways and
implement and implemented
certain types maintaining > CHN Bag certain types
of sanitation proper of sanitation
measures hygiene measures
maintaining maintaining
personal 4. Discuss 4. Allows to personal
hygiene. and avoid things hygiene.
demonstrate that may - GOA
preventive hinder the L
measures or process of MET.
actions to having a
manage the proper
improper personal
drainage hygiene
system

5. Encourage 5. Maintain
to participate the family
on the health and
well-being
barangay’s
monthly
drainage
management