Download Presented by: Barbero, Claudette G.

Eastern Samar State University
College of Nursing
Borongan City
FAMILY NURSING
CARE PROCESS
Presented by: Barbero, Claudette G.
BSN-4
Presented to: Ray Dominic Ladera, RN
Clinical Instructor
Patient no.1
I.
DEMOGRAPHIC PROFILE
Name: Mr. R
Age: 56 yrs old
Occupation: farmer
Civil status: married (Mrs. M)
Sex: Male
Educational Attainment: Elementary level
Nationality: Filipino
Admitting diagnoses:
Address: Brgy. Pagbabangnan, San
Julian, Eastern Samar
Father’s name: deceased
Mother’s name: deceased
II.
III.
Attending physician: N/A
Occupation: N/A
Occupation: N/A
NURSING CLINICAL ABSTRACT
- N/A
NURSING HISTORY
1. History of present illness
-The patient was complaining of cough and colds with on and off fever for 3 days. He doesn’t take any medications.
2. Past Health History
1. Injury:
-no known injury
2. Hospitalization:
- He was not been hospitalized according to him.
3. Immunization
- According to him, there was no immunization during their times.
4. Family Health History
4.1 Father side: unknown
4.2 Mother side: unknown
5. Allergies – no known allergies
VI.
BIOPHYSICAL ASSESSMENT
GENERAL APPEARANCE
ACTUAL FINDINGS
Posture
Posture/gestures/body movements
Language/Diction
Facial Expression
Grooming and Hygiene
Sign of distress
 Erect
 Slouch
 Stooping or swayback
 Express oneself by speech
 Unable to express oneself by speech





Appropriate
Inappropriate
Awake/ alert
Presence of Tremors
Presence of Tics




Appropriate to environment/ weather
Inappropriate to environment/ weather
Neatly dress
Untidy dress




Irritable
Apprehension
Anxious
Sleeplessness
Gesture





Emblems
Iconic gestures
Metaphoric gestures
Affect displays
Beat gestures
 Restless
Thought process, Content and Perception
V.




Alert and clear
Confuse
Disoriented/ senile
Stupurous
GORDONS TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS
Health-perception/healthmanagement pattern
NORMAL FINDINGS
ACTUAL FINDINGS
There are 3 components of
health beliefs models that may
affect health perception: 1st
involves the individuals
perception of susceptibility to an
illness, 2nd involves individuals
perception of the seriousness of
the illness, 3rd is the likelihood
that a person will take preventive
action result from the person’s
perception of the belief of and
barriers to taking action. (Kozier)
There are 3 components of
health beliefs models that may
affect health perception: 1st
involves the individuals
perception of susceptibility to an
illness, 2nd involves individuals
perception of the seriousness of
the illness, 3rd is the likelihood
that a person will take preventive
action result from the person’s
perception of the belief of and
barriers to taking action. (Kozier)
According to the patient, he
doesn’t seek medical check-up
when he was seek. They use only
herbal in treating their illness.
IMPRESSION
The patient does not prefer in going to hospital
but rather use native treatment like herbal in
treating their illness.
Nutritional/metabolic
pattern
Elimination pattern
Activity/exercise pattern
For older adult female who
perform less than 30 min of
exercise a day requires 1,600
calories consisting of the
following; grains: 5 ounces,
vegetable: 2 cups, fruit: 1.5 cup,
milk: 3 cups, meat and beans: 5
ounces. (Kozier)
The patient eat meals 3 times a
day. He consumes 5-8 glasses of
water a day according to him.
Fecal Elimination- normally feces
are soft but formed, brown in
color for adults. Shape is
cylindrical about 1 inch in
diameter. Amount varies with the
person’s diet from 100-400g/day.
(Kozier, p.1325)
The patient eliminates 2-3 times
a day and urinate 2-3 times a day.
The clients elimination pattern is normal
Exercise of 30 minutes or more
per day of moderate intensity is a
minimal requirement for physical
activity that would help maintain
mental and physical health.
(Kozier)
His way of exercise is to work in
doing ADLs. But not for a long
time because he is tired
immediately after 1-2 hours of
work and sees to it that he gets
enough rest. Now ,due to age ,
he need assistance in toileting
and doing ADL’s.
Patient sleeps 8 hours a day. But
sometimes he takes a nap in the
afternoon.
The patient tolerance to activity decline because
of age.
The patient has cannot hear clear
words or has impaired hearing
because of age. He often request
As our age declines, our body parts that
rundown with time leading to aging. The patients
hearing is impaired because the patient cannot
Sleep and rest pattern
Healthy adults need 7-9 hours of
sleep at night. However, there is
an individual’s variation as some
adults may be able to function
well at 6 hours of sleep and
others need 10 hours of sleep to
function well. (Kozier)
Cognitive/perceptual pattern
Cognitive abilities mature during
adolescence between the age 11
and 15. The adolescence begins
The patient nutritional pattern is normal
The patient sleep pattern is normal
Self-perception/self-concept
pattern
Role/relationship pattern
Sexuality/reproductive pattern
Coping/stress tolerance pattern
Piaget’s formal operation stage of
cognitive development where
person thinks beyond present.
(Kozier)
Normal vision: 20/20
Normal voice tone is audible
Able to taste sweet,sour and
bitter foods.
The patient displays activities
appropriate for developmental
level and has stable body image
and patient should demonstrate
positive concept and patient
should recognize uniqueness of
other people. (Kozier)
to repeat questions because he
cannot hear it clearly. He able to
taste sweet and bitter foods.
When I requested him to read
news paper he said that he
cannot read it without his eye
glasses.
hear normal voice tones and unable to read.
The patient considers himself to
be a strong person even his old
already and believe in the saying
that if there is a problem there is
always a solution. He never loses
hope because he knows that his
condition will improve.
The patient has a positive self-perception as
evidenced by not immediately losing hope in
time of downs in his life sickness. The positive
attitude of the patient will help hum improve his
condition.
The patient should demonstrate
functional verbal and non-verbal
communication, and then she
would participate in social
interactions then builds and
maintains meaningful
relationship.(Kozier)
The patient is a good husband
and a good grandfather. He lives
in their house together with his
family. He do not belongs to
support groups.
The patient has a good relationship with his
family. He is able to perform his role as a
grandfather and father.
The patient should have valid
knowledge about sexual
functioning and human sexuality,
also accepts sexual functions and
sexuality of human as normal.
The patient recognizes and
accepts personal sexual feelings,
and maintains healthy lifestyle
during pregnancy. (Kozier)
The patient has 4 children and
with his age and condition he is
no longer capable of any sexual
activities.
Due to aging, sexual function decreases and
because of his condition he is not anymore
capable for sexual activities.
The patient makes decision
reflecting understanding of
personal limitations, protects self
against overwhelming situation
The patient tells his problem to
his family especially to his wife.
The patients coping stress pattern is normal
and changes then manages to
keep while balancing life-role
while minimal conflict. (Kozier)
Value/belief pattern
VI.
The patient should expresses
respect for all life and the quality
of life and maintains realistic
goals for self based on value
decisions, and demonstrate a real
of life, and provides for spiritual
aspect. (Kozier)
Religion plays a vital role in his
life for it serves as a guide in his
decision making. His is a roman
catholic. Even though he doesn’t
go to church but he sees to it that
he prays everyday to thank God
for the blessings that he is
receiving.
The patient has a positive belief. He’s value
belief pattern is considered normal.
VITAL SIGNS
PARAMETER
PROCEDURE
Height
It measures with a
measuring stick
attached to weighing
scale or to a wall.
Weight
It measures with a
weighing scale in
pounds (lb) or
kilograms (Kg).
Blood Pressure(BP
Assessed client upper
arm using the
brachial artery and a
standard
stethoscope.
DATE
ACTUAL VALUES
NORMAL VALUES
ANALYSIS/
INTERPRETATION
Nov.26,2011
Not assessed
163(nutrition & client
therapy-Sue H.
Williams).
N/A
Nov.26,2011
Not assessed
55kg (nutrition &
client therapy-Sue H.
Williams).
N/A
Nov.26,2011
110/90mmHg
100/80mmHg
normal
Pulse Rate/heart rate
Respiration Rate
Temperature
Palpated by applying
moderate pressure of
the three fingers of
the hand.
Observed by the
movement of the
chest upward &
downward.
Using thermometer,
measure in common
sites, oral, rectal,
axillary, tympanic
membrane & skin.
Nov.26,2011
87bpm
60-100bpm
normal
Nov.26,2011
20cpm
12-20cpm
normal
36.5oc-37.5oc
-Due to increase
body temperature
regulatory set
point. This increase
in set point triggers
muscle tone and
shivering.
Nov.26,2011
38.1oc
-
VII.
PHYSICAL EXAMINATION (HEAD-TOE ASSESSMENT)
AREAS
ASSESSMENT
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS/INTERPRETATION
1. Head

observation
skull
Normocephalic, no
edema, no lesions
should be noted,
asymmetric
Asymmetric, no
edema, no lesions
noted
Normal

observation
hair
observation

scalp

face





observation
observation
Evenly distributed
hair ,thick, silky,
resilient ,no
infection, amount of
hair is variable
No dandruff, oily,
even in color.
Symmetrical in facial
movement.
Evenly distributed
Evenly distributed
,no infection,
amount of hair is
variable
Normal
No dandruff noted,
even in color
Symmetrical in facial
movement.
Evenly distributed
Normal
Normal
eyebrows
observation
eyelashes
observation
ears
observation
nose
observation
lips

teeth

Neck
observation
observation
2. Breast
 nipples
Normal
Slightly curved
outward
No discharges, no
lesions, symmetrical
in shape
Symmetric and
aligned, no
discharges, air can
go in and out the
nose without
occlusion
Lips should be
uniform in color,
smooth, moist
32 teeth for adults,
white, shiny tooth
enamel.
No palpable mass,
not tender, uniform
in color.
Unequal in size,
generally symmetric,
Slightly curved
outward
No discharges, no
lesions, symmetrical
in shape
Symmetric and
aligned, no
discharges, air can
go in and out the
nose without
occlusion.
Uniform in color,
moist
White, 16 teeth
No palpable mass,
not tender, uniform
in color.
Dark brown in color,
no discharges,
Normal
Normal
Normal
Normal
Due to aging
Normal
Normal
observation

areola
observation
3. abdomen
4. Upper extremities (hands,
fingers, nails, wrist elbows to
shoulders
observation
dark brown in color,
no discharges.
Brown in color, no
tenderness noted.
Uniform in color, no
palpable mass, no
lesion noted.
No tenderness, no
lesion, uniform in
color, capillary refill
1-2 seconds, nails
are short and clean.
unequal in size
No tenderness
noted, brown in
color
No palpable mass,
no lesion noted,
uniform in color
No tenderness,
uniform in color,
nails are short and
clean
Normal
Normal
Normal
Not assessed
5. genitalia
6. lower extremities (thighs,
knees, ankle, foot, and
distal)
7. Skin
observation
No tenderness, no
lesions, uniform in
color, no deformities
No tenderness, no
lesions, uniform in
color, no deformities
Normal
No edema, no
abrasions,
temperature of the
skin is uniform
within normal range,
skin varies from light
to deep brown
Flushed skin, warm
to touch. no edema
noted
Due to heat production
IX.NURSING CARE PLAN
HEALTH
PROBLEM
Altered body temperature related to
presence of condition
Subjective cues:” Mapaso manla in
nga ak inaabat”as verbalized by the
patient
Objective cues:
-flushed skin
-warm to touch
-Restless
- headache
Measurable cues:
Temp- 38.1oc
RR- 20 cpm
PR- 87 bpm
BP- 110/90mmhg
SCIENTIFIC
RATIONALE
Elevated body
temperature
condition in which an
individual’s body
temperature is
elevated above
normal range. If this
condition will not be
treated immediately
this may lead to
damaged
parenchyma of cells
throughout the body,
particularly in the
brain where
destruction of
neuronal cells is
irreversible. The liver,
kidneys and other
organs can be
impaired in
functioning. (Mosby’s
Pocket Dictionary of
Medical Nursing and
Health Professional)
GOALS AND
OBJECTIVES
After the nursing
intervention the
patient will be able to
maintain core
temperature within
normal range
NURSING
INTERVENTIONS
Objectives:
1. To evaluate
effects/degree of
hyperthermia.
INDEPENDENT:
-monitor BP
EVALUATION
After the nursing
interventions the patient
able to maintain core
temperature within normal
range.
-monitor respirations
2.To assist with
measures to reduce
body temp/restore
normal body/organ
function
RATIONALE
- administer
medications as
ordered.
- cool w/ tepid bath.
Do not use alcohol
-Central
hypertension/
postural hypotension
can occur.
-Hyperventilation
may initially be
present, but
ventilator effort may
eventually be
impaired by seizures,
hyperthermia on
blood and cardiac
tissue.
- To control shivering
and seizures.
- As it cools the skin
too rapidly, causing
shivering. Shivering
increases metabolic
demand for oxygen.
HEALTH
PROBLEM
Ineffective airway clearance r/t
retained mucus secretion
Cues:
Subjective:
“ Kinukurian ak hit paghinga dara
ada hin nga ak batok”, as
verbalized by the patient.
Objectives:
-received patient lying on bed
- (+) DOB
-(+) Cough
- crackles sound is present
SCIENTIFIC
RATIONALE
GOALS AND
OBJECTIVES
Retained mucus
secretions can
cause ineffective
airway clearance
due to the
obstruction or the
individual is unable
to clear secretions
from the respiratory
tract to maintain a
clear airway then if
this will be left
untreated
complications may
occur such as
dyspnea and other
threatening
conditions.
(ref. Mosby’s
Pocket Dictionary of
Medicine Nsg. and
Health Profession.
After nursing care
the client will
improve or maintain
clear airway.
Objectives:
-the patient will be
able to
expectorate/clear
secretions readily
NURSING
INTERVENTIONS
RATIONALE
. The goal was
met due to the
verbalization of the
patient that her airway
has improved
- offer Chest
Physiotherapy
-to expectorate
secretions
-teach pt. deep
breathing technique
-to improve airway
clearance
-teach pt. to avoid
stimulants such as
coffee, chocolates,
junk foods.
-irritating foods can
trigger sore throat
-The pt will be free
from secretions
-Encourage to
increase fluid intake
-Hydration can help
liquefy viscous
secretions an
improve secretion
clearance
The pt will be able
to verbalize
understanding of
individual risks/
responsibilities
-Encourage client to
avoid going on
dusty environment.
-Dust can obstruct
airway clearance an
be able to protect
own airway.
-the pt will be able
to be free of signs
of hypersensitivity
EVALUATION
avoiding exposure
-Administer
analegesic as
ordered
-To improve cough
when pain is
inhibiting effort
Patient no.2
I.
DEMOGRAPHIC PROFILE
Name: Mrs. M
Occupation: Housewife
Age:
Civil status: married (Mr.R)
56 yrs old
Sex: Female
Educational Attainment:
Nationality: Filipino
Admitting diagnoses: N/A
High school graduate
Address: Brgy. Pagbabangnan,
San Julian Eastern Samar
Father’s name: Stevan Acla
Mother’s name: deceased
I.
II.
Attending physician: N/A
Occupation: N/A
Occupation: N/A
NURSING CLINICAL ABSTRACT
- N/A
NURSING HISTORY
1. History of present illness
- The patient was complaining of difficulty in defecating for 3 days
2. Past Health History
Injury: - no known injury
Hospitalization: -was not been hospitalized according to her.
3. Immunization : - According to him, there was no immunization during their times
4. Family Health History
4.1 Father side: asthma
4.2 Mother side: unknown
5. Allergies – no known allergies
VI. BIOPHYSICAL ASSESSMENT
GENERAL APPEARANCE
ACTUAL FINDINGS
Posture
Posture/gestures/body movement
Language/diction
Facial expression
Grooming and hygine
 Erect
 Slouch
 Stooping or swayback
Gesture





Emblems
Iconic gestures
Metaphoric gestures
Affect displays
Beat gestures
 Express oneself by speech
 Unable to express oneself by speech





Appropriate
Inappropriate
Awake/ alert
Presence of Tremors
Presence of Tics




Appropriate to environment/ weather
Inappropriate to environment/ weather
Neatly dress
Untidy dress

Irritable
Signs of distress
Thought process, content and perception
V.




Apprehension
Anxious
Sleeplessness
Restless




Alert and clear
Confuse
Disoriented/ senile
Stupurous
GORDONS TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS
NORMAL FINDINGS
Health-perception/healthmanagement pattern
There are 3 components of health
beliefs models that may affect health
perception: 1st involves the
individuals perception of
susceptibility to an illness, 2nd
involves individuals perception of the
seriousness of the illness, 3rd is the
likelihood that a person will take
preventive action result from the
person’s perception of the belief of
and barriers to taking action. (Kozier)
There are 3 components of health
beliefs models that may affect health
perception: 1st involves the
individuals perception of
susceptibility to an illness, 2nd
involves individuals perception of the
seriousness of the illness, 3rd is the
likelihood that a person will take
preventive action result from the
person’s perception of the belief of
ACTUAL FINDINGS
The patient describes herself as
“okay”. She also verbalized that she
seldom get sick.
IMPRESSION
The patient’s health perception is
normal.
and barriers to taking action. (Kozier)
Nutritional/metabolic pattern
Elimination pattern
Activity/exercise pattern
Sleep and rest pattern
Cognitive/perceptual pattern
For older adult female who perform
less than 30 min of exercise a day
requires 1,600 calories consisting of
the following; grains: 5 ounces,
vegetable: 2 cups, fruit: 1.5 cup, milk:
3 cups, meat and beans: 5 ounces.
(Kozier)
The patient eat 3 times a day but
according to her, she eats lesser
vegetables and drink 2-3 of water a
day.
The patient has low fiber diet and low
fluid intake.
Fecal Elimination- normally feces are
soft but formed, brown in color for
adults. Shape is cylindrical about 1
inch in diameter. Amount varies with
the person’s diet from 100-400g/day.
(Kozier, p.1325)
The patient verbalized that she has
difficulty of defecating for 4 days and
urinate 1-2 times a day.
Exercise of 30 minutes or more per
day of moderate intensity is a
minimal requirement for physical
activity that would help maintain
mental and physical health. (Kozier)
Patient usual daily activities are doing
households chores and her leisure
activity was sewing clothes.
The patient has impaired bowel
movement. Impairment to bowel
elimination is an emotional and
physiologic distressing problem that
can lead to contamination and
infection to self leading to fear and
anxiety.
Patients activity and exercise pattern
is normal
Healthy adults need 7-9 hours of
sleep at night. However, there is an
individual’s variation as some adults
may be able to function well at 6
hours of sleep and others need 10
hours of sleep to function well.
(Kozier)
The patients has 8 hours of sleep and
feel rested after sleep
Patients sleep and rest pattern is
normal.
Cognitive abilities mature during
adolescence between the age 11 and
15. The adolescence begins Piaget’s
formal operation stage of cognitive
development where person thinks
beyond present. (Kozier)
The patient can hear clearly to the
question. She cannot read clearly
without the use of eyeglasses.
As our age declines, our body parts
that rundown with time leading to
aging.
Self-perception/self-concept
pattern
Role/relationship pattern
Sexuality/reproductive pattern
Coping/stress tolerance pattern
Normal vision: 20/20
Normal voice tone is audible
Able to taste sweet,sour and bitter
foods.
The patient displays activities
appropriate for developmental level
and has stable body image and
patient should demonstrate positive
concept and patient should recognize
uniqueness of other people. (Kozier)
The patient perceived herself as a
strong woman. She did not easily
looses hope wherever she had a
problem.
The patient has a positive selfperception as evidenced by not
immediately losing hope in time of
downs in her life sickness.
The patient should demonstrate
functional verbal and non-verbal
communication, and then she would
participate in social interactions then
builds and maintains meaningful
relationship.(Kozier)
The patient is a goodwife and a
grandmother to her family. She
doesn’t belong to any support
groups.
The patient has a good relationship
with her family. She is able to
perform her role as a grandmother
and mother.
The patient should have valid
knowledge about sexual functioning
and human sexuality, also accepts
sexual functions and sexuality of
human as normal. The patient
recognizes and accepts personal
sexual feelings, and maintains
healthy lifestyle during pregnancy.
(Kozier)
According to the patient she is no
longer capable of engaging sexual
activity because of her age.
Due to aging, sexual function
decreases and because of his
condition he is not anymore capable
for sexual activities.
The patient makes decision reflecting
understanding of personal
limitations, protects self against
overwhelming situation and changes
then manages to keep while
balancing life-role while minimal
conflict. (Kozier)
The patient decides on her own. She
remembers happy moments when
she is under stress.
The patient coping or stress tolerance
pattern is normal
The patient should expresses respect
for all life and the quality of life and
maintains realistic goals for self based
on value decisions, and demonstrate
a real of life, and provides for
spiritual aspect. (Kozier)
Value/belief pattern
VI.
The patient source of strength is God.
She is a roman catholic and usually
pray when she encounters challenges
in her life.
Patient’s value belief pattern is
normal
VITAL SIGNS
PARAMETERS
Height
Weight
Blood Pressure(BP)
Pulse Rate/heart rate
Respiration Rate
PROCEDURES
DATE
It measures with a
measuring stick
attached to weighing
scale or to a wa
Nov.26,2011
It measures with a
weighing scale in
pounds (lb) or
kilograms (Kg).
Assessed client upper
arm using the
brachial artery and a
standard
stethoscope.
Palpated by applying
moderate pressure of
the three fingers of
the hand.
Observed by the
movement of the
chest upward &
downward.
Using thermometer,
ACTUAL FINDINGS
NORMAL
FINDINGS
ANALYSIS/
INTERPRETATION
Not assessed
163(nutrition & client
therapy-Sue H.
Williams).
N/A
Not assessed
55kg (nutrition &
client therapy-Sue H.
Williams).
N/A
100/80mmHg
Normal
60-100bpm
Normal
12-20cpm
Normal
Nov.26,2011
Nov.26,2011
100/80mmHg
Nov.26,2011
89 bpm
Nov.26,2011
23 cpm
Temperature
VII.
measure in common
sites, oral, rectal,
axillary, tympanic
membrane & skin.
-37.1oc
Nov.26,2011
Normal
36.5oc-37.5oc
PHYSICAL ASSESSMENT ( Head-Toe-Assessment)
Areas
Assessment Technique
Normal Findings
Actual Findings
Analysis and
Interpretation
Asymmetric, no lesions
noted
normal
Evenly distributed white
hair, no infection.
normal
No dandruff, even in color
normal
Symmetrical in facial
movement.
Evenly distributed
normal
1.Head

Skull
Inspection
palpation

hair
Inspection

scalp
Inspection

face
Inspection
eyebrows
Inspection
Normocephalic, no
edema, no lesions should
be noted, asymmetric
Evenly distributed hair
,thick, silky, resilient ,no
infection, amount of hair
is variable
No dandruff, oily, even in
color.
Symmetrical in facial
movement.
Evenly distributed
eyelashes
Inspection
Slightly curved outward
Slightly curved outward
normal
ears
Inspection
nose
Inspection

lips
Inspection
No discharges, no lesions,
symmetrical in shape,
Symmetric and aligned, no
discharges, air can go in
and out the nose without
occlusion
Uniform in color, moist
normal


teeth

Neck
No discharges, no lesions,
symmetrical in shape
Symmetric and aligned, no
discharges, air can go in
and out the nose without
occlusion
Lips should be uniform in
color, smooth, moist
32 teeth for adults, white,
shiny tooth
enamel.
No palpable mass, not



Inspection
Inspection
20 teeth, present of
dental carries.
No palpable mass, not
normal
normal
normal
Due to aging the teeth
decrease
normal
Palpation
tender, uniform in color.
tender, uniform in color.
Unequal in size, generally
symmetric, dark brown in
color, no discharges.
Brown in color, no
tenderness noted.
Uniform in color, no
palpable mass, no lesion
noted.
No tenderness, no lesion,
uniform in color, capillary
refill 1-2 seconds, nails are
short and clean.
Unequal in size, generally
symmetric, dark brown in
color, no discharges.
Brown in color, no
tenderness noted.
Uniform in color, there is
palpable mass
No tenderness, no lesions,
uniform in color, no
deformities
No edema, no abrasions,
temperature of the skin is
uniform within normal
range, skin varies from
light to deep brown
No tenderness, no lesions,
uniform in color, no
deformities
No edema, no abrasions,
temperature of the skin is
uniform within normal
range, skin varies from
light to deep brown,rough
2.Breast

nipples

areola
3.abdomen
Inspection
Inspection
palpation
Inspection
palpation
4. Upper extremities (hands, fingers,
nails, wrist elbows to shoulders)
5. genitalia
6. lower extremities (thighs, knees,
ankle, foot, and distal)
7. Skin
Inspection
palpation
normal
Due to constipation,
there’s a present of mass
normal
Not assessed
Inspection
palpation
Inspection
Anatomy and Physiology
No tenderness, no lesion,
uniform in color, capillary
refill 1-2 seconds, nails are
short and clean.
normal
normal
Because of aging the skin
changes in texture
The whole digestive system is around 9 meters long. In a healthy human adult this process can take between 24 and 72 hours. Fooddigestion physiology varies
between individuals and upon other factors such as the characteristics of the food and size of the meal. [16]
Phases of gastric secretion

Cephalic phase - This phase occurs before food enters the stomach and involves preparation of the body for eating and digestion. Sight and thought stimulate
the cerebral cortex. Taste and smell stimulus is sent to the hypothalamus and medulla oblongata. After this it is routed through the vagus nerve and release of
acetylcholine. Gastric secretion at this phase rises to 40% of maximum rate. Acidity in the stomach is not buffered by food at this point and thus acts to inhibit
parietal (secretes acid) and G cell (secretes gastrin) activity via D cell secretion of somatostatin.

Gastric phase - This phase takes 3 to 4 hours. It is stimulated by distension of the stomach, presence of food in stomach and decrease in pH. Distention
activates long and myenteric reflexes. This activates the release of acetylcholine which stimulates the release of more gastric juices. As protein enters the
stomach, it binds to hydrogen ions, which raises the pH of the stomach. Inhibition of gastrin and gastric acid secretion is lifted. This triggers G cells to
release gastrin, which in turn stimulates parietal cells to secrete gastric acid. Gastric acid is about 0.5% hydrochloric acid (HCl), which lowers the pH to the
desired pH of 1-3. Acid release is also triggered by acetylcholine and histamine.

Intestinal phase - This phase has 2 parts, the excitatory and the inhibitory. Partially digested food fills the duodenum. This triggers intestinal gastrin to be
released. Enterogastric reflex inhibits vagal nuclei, activating sympathetic fibers causing the pyloric sphincterto tighten to prevent more food from entering, and
inhibits local reflexes.
Oral cavity
Mouth (human)
In humans, digestion begins in the oral cavity where food is chewed. Saliva is secreted in large amounts (1-1.5 litres/day) by three pairs of exocrine salivary glands
(parotid, submandibular, and sublingual) in the oral cavity, and is mixed with the chewed food by the tongue. The saliva serves to clean the oral cavity and moisten
the food, and contains digestive enzymes such as salivary amylase, which aids in the chemical breakdown of polysaccharides such
as starch into disaccharides such as maltose. It also contains mucus, a glycoproteinwhich helps soften the food and form it into a bolus. An additional
enzyme, lingual lipase, hydrolyzes long-chain triglycerides into partial glycerides and free fatty acids.
Swallowing transports the chewed food into the esophagus, passing through the oropharynx and hypopharynx. The mechanism for swallowing is coordinated by
the swallowing center in the medulla oblongata and pons. The reflex is initiated by touch receptors in the pharynx as the bolus of food is pushed to the back of the
mouth.
Pharynx
Main article: Human pharynx
The pharynx is the part of the neck and throat situated immediately behind the mouth and nasal cavity, and cranial, or superior, to the esophagus. It is part of
the digestive system and respiratory system. Because both food and air pass through the pharynx, a flap of connective tissue, the epiglottis closes over the
trachea when food is swallowed to prevent choking or asphyxiation.
The oropharynx is that part of the pharynx which lies behind the oral cavity and is lined by stratified squamous epithelium. The nasopharynx lies behind the nasal
cavity and like the nasal passages is lined with ciliated columnar pseudostratified epithelium.
Like the oropharynx above it the hypopharynx (laryngopharynx) serves as a passageway for food and air and is lined with a stratified squamous epithelium. It lies
inferior to the upright epiglottis and extends to the larynx, where the respiratory and digestive pathways diverge. At that point, the laryngopharynx is continuous
with the esophagus. During swallowing, food has the "right of way", and air passage temporarily stops.
Esophagus
The esophagus is a narrow muscular tube about 20-30 centimeters long which starts at the pharynx at the back of the mouth, passes through the thoracic
diaphragm, and ends at the cardiac orifice of the stomach. The wall of the esophagus is made up of two layers of smooth muscles, which form a continuous layer
from the esophagus to the colon and contract slowly, over long periods of time. The inner layer of muscles is arranged circularly in a series of descending rings,
while the outer layer is arranged longitudinally. At the top of the esophagus, is a flap of tissue called the epiglottis that closes during swallowing to prevent food
from entering the trachea (windpipe). The chewed food is pushed down the esophagus to the stomach through peristaltic contraction of these muscles. It takes
only about seven seconds for food to pass through the esophagus and now digestion takes place.
Stomach
The stomach is a small, 'J'-shaped pouch with walls made of thick, elastic muscles, which stores and helps break down food. Food which has been reduced to
very small particles is more likely to be fully digested in the small intestine, and stomach churning has the effect of assisting the physical disassembly begun in the
mouth. Ruminants, who are able to digest fibrous material (primarilycellulose), use fore-stomachs and repeated chewing to further the disassembly. Rabbits and
some other animals pass some material through their entire digestive systems twice. Most birds ingest small stones to assist in mechanical processing in gizzards.
Food enters the stomach through the cardiac orifice where it is further broken apart and thoroughly mixed with gastric acid, pepsin and other digestive enzymes to
break down proteins. The enzymes in the stomach also have an optimum, meaning that they work at a specific pH and temperature better than any others. The
acid itself does not break down food molecules, rather it provides an optimum pH for the reaction of the enzyme pepsin and kills many microorganisms that are
ingested with the food. It can also denature proteins. This is the process of reducing polypeptide bonds and disrupting salt bridges which in turn causes a loss of
secondary, tertiary or quaternary protein structure. The parietal cells of the stomach also secrete a glycoprotein called intrinsic factor which enables the absorption
of vitamin B-12. Other small molecules such as alcohol are absorbed in the stomach, passing through the membrane of the stomach and entering the circulatory
system directly. Food in the stomach is in semi-liquid form, which upon completion is known as chyme.
After consumption of food, digestive "tonic" and peristaltic contractions begin which help to break down the food and move it through. [16] When the chyme reaches
the opening to the duodenum known as the pylorus, contractions "squirt" the food back into the stomach through a process called retropulsion, which exerts
additional force and further grinds down food into smaller particles. [16] Gastric emptying is the release of food from the stomach into the duodenum; the process is
tightly controlled with liquids being emptied much more quickly than solids. [16] Gastric emptying has attracted medical interest as rapid gastric emptying is related to
obesity and delayed gastric emptying syndrome is associated with diabetes mellitus, aging, and gastroesophageal reflux.[16]
The transverse section of the alimentary canal reveals four (or five, see description under mucosa) distinct and well developed layers within the stomach:

Serous membrane, a thin layer of mesothelial cells that is the outermost wall of the stomach.

Muscular coat, a well-developed layer of muscles used to mix ingested food, composed of three sets running in three different alignments. The outermost
layer runs parallel to the vertical axis of the stomach (from top to bottom), the middle is concentric to the axis (horizontally circling the stomach cavity) and the
innermost oblique layer, which is responsible for mixing and breaking down ingested food, runs diagonal to the longitudinal axis. The inner layer is unique to
the stomach, all other parts of the digestive tract have only the first two layers.

Submucosa, composed of connective tissue that links the inner muscular layer to the mucosa and contains the nerves, blood and lymph vessels.

Mucosa is the extensively folded innermost layer. It can be divided into the epithelium, lamina propria, and the muscularis mucosae, though some consider the
outermost muscularis mucosae to be a distinct layer, as it develops from the mesoderm rather than the endoderm (thus making a total of five layers). The
epithelium and lamina are filled with connective tissue and covered in gastric glands that may be simple or branched tubular, and secrete mucus, hydrochloric
acid, pepsinogen and rennin. The mucus lubricates the food and also prevents hydrochloric acid from acting on the walls of the stomach.
Small intestine
It has three parts Duodenum, Ileum and Jejunum.
After being processed in the stomach, food is passed to the small intestine via the pyloric sphincter. The majority of digestion and absorption occurs here after the
milky chyme enters the duodenum. Here it is further mixed with three different liquids:

Bile, which emulsifies fats to allow absorption, neutralizes the chyme and is used to excrete waste products such as bilin and bile acids. Bile is produced by
the liver and then stored in the gallbladder. The bile in the gallbladder is much more concentrated.

Pancreatic juice made by the pancreas.

Intestinal enzymes of the alkaline mucosal membranes. The enzymes include maltase, lactase and sucrase (all three of which process
only sugars), trypsin and chymotrypsin.
The pH level increases in the small intestine. A more basic environment causes more helpful enzymes to activate and begin to help in the breakdown of molecules
such as fat globules. Small, finger-like structures called villi, each of which is covered with even smaller hair-like structures called microvilli improve the absorption
of nutrients by increasing the surface area of the intestine and enhancing speed at which nutrients are absorbed. Blood containing the absorbed nutrients is carried
away from the small intestine via the hepatic portal vein and goes to the liver for filtering, removal of toxins, and nutrient processing.
The small intestine and remainder of the digestive tract undergoes peristalsis to transport food from the stomach to the rectum and allow food to be mixed with the
digestive juices and absorbed. The circular muscles and longitudinal muscles are antagonistic muscles, with one contracting as the other relaxes. When the
circular muscles contract, the lumen becomes narrower and longer and the food is squeezed and pushed forward. When the longitudinal muscles contract, the
circular muscles relax and the gut dilates to become wider and shorter to allow food to enter.
Large intestine
After the food has been passed through the small intestine, the food enters the large intestine. Within it, digestion is retained long enough to allow fermentation
due to the action of gut bacteria, which breaks down some of the substances which remain after processing in the small intestine; some of the breakdown products
are absorbed. In humans, these include most complex saccharides (at most three disaccharides are digestible in humans). In addition, in many vertebrates, the
large intestine reabsorbs fluid; in a few, with desert lifestyles, this reabsorbtion makes continued existence possible.
In humans, the large intestine is roughly 1.5 meters long, with three parts: the cecum at the junction with the small intestine, the colon, and the rectum. The colon
itself has four parts: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon. The large intestine absorbs water from the bolus and
stores feces until it can be egested. Food products that cannot go through the villi, such as cellulose (dietary fiber), are mixed with other waste products from the
body and become hard and concentrated feces. The feces is stored in the rectum for a certain period and then the stored feces is eliminated from the body due to
the contraction and relaxation through the anus. The exit of this waste material is regulated by the anal sphincter.
Breakdown into nutrients
Protein digestion
Protein digestion occurs in the stomach and duodenum in which 3 enzymes: pepsin secreted by the stomach and trypsin and chymotrypsin secreted by the
pancreas breakdown food proteins intopolypeptides which are then broken down by the enzyme erepsin into amino acids.
Fat digestion
Digestion of fat begins in the mouth where lingual lipase breaks down some lipids into diglycerides. The presence of fat in the small intestine produces hormones
which stimulate the release ofpancreatic lipase from the pancreas and bile from the liver for breakdown of fats into fatty acids.
Carbohydrate digestion
Starches are broken down into sugars (glucose and fructose) by amylase and hydrochloric acid in the stomach.
DNA and RNA digestion
DNA and RNA are broken down into mononucleotides by the nucleases deoxyribonuclease and ribonuclease (DNase and RNase) from the pancreas.
VIII. NURSING CARE PLAN
HEALTH
PROBLEM
Constipation related to
decrease dietary intake
Subjective cues:
“kinukurian ak pag uuro
ngan masuol tak
tiyan”as verbalized by
the patient.
Objective cues:
-abdominal pain
-altered bowel sounds
-hard formed stool
Measurable cues:
BP- 120/80mmHg
RR-19cpm
PR-85bpm
Temp- 36.0oc
SCIENTIFIC RATIONALE
Constipation is a very
common condition that
affects people of all
ages. When you are
constipated, you feel
that you are not passing
stools(feces) as often as
your normally do, or
that you feel to strain
more than usual. It
leads to complication
such as fecal impaction
or fecal incontinence.
GOALS AND
OBJECTIVES
After the nursing
interventions, the
patient will be able to
established or return to
normal patterns of
bowel functioning.
Objectives:
1. To identify
causative/
contributing
factors
2.
To facilitate
return to
usual/acceptab
le pattern of
elimination
NURSING
INTERVENTIONS
RATIONALE
INDEPENDENT:
-Determine fluid intake
-to evaluate client’s
hydration status.
-note energy and
activity levels and
exercise pattern.
-sedentary lifestyle
may affect elimination
patterns.
-instruct in and
encourage a diet of
balanced fiber and bulk
and fiber supplements.
-to improve consistency
of stool and facilitate
passage through colon.
-encourage activity and
exercise within limits of
individual ability.
-to stimulate
contractions of the
intestines.
COLLABORATIVE:
-refer to primary care
provider for medical
therapies(eg. added
-to best treat acute
situation.
EVALUATION
After the nursing
interventions the
patient able to
established or return to
normal patterns of
bowel functioning.
emollient ,saline , or
hyperosmolar laxatives,
enemas, or
suppositories)
Teaching objectives
The client will be able
to know the
importance in
increase intake of
fiber
Strategies
Discussion
Learning content

Discuss to the
client the
importance
of fibers in
the body.
Time duration
30 minutes
Resources
Student nurse and
clients effort
Evaluation
The client able to
know the importance
of increase fiber
intake
Patient no.3
I.
DEMOGRAPHIC PROFILE
Name: Mr. V
Age: 8 yrs old
Sex: Female
Nationality: Filipino
Occupation: Student
Civil status: Single
Educational Attainment: Elementary
Admitting diagnoses: N/A
Address: Brgy. Pagbabangnan, San Julian
Eastern Samar
Father’s name: Mr.Q
Mother’s name: Mrs.N
IV.
V.
Attending physician: N/A
Occupation: laborer
Occupation: housewife
NURSING CLINICAL ABSTRACT
- N/A
NURSING HISTORY
1.
History of present illness
-The client complaints of fever for 3 days. He take Paracetamol 500 mg but it doesn’t subside because according to him it is due
to his wound in his right feet.
3. Past Health History
4. Injury:
-no known injury
5. Hospitalization:
- He was not been hospitalized according to her mother.
4. Immunization
- The patient’s was completely immunized.
5. Family Health History
5.1 Father side: unknown
5.2 Mother side: unknown
6 . Allergies – no known allergies
VI.
BIOPHYSICAL ASSESSMENT
GENERAL APPEARANCE
ACTUAL FINDINGS
Posture
Posture/gestures/body movements
Language/Diction
Facial Expression
 Erect
 Slouch
 Stooping or swayback
 Express oneself by speech
 Unable to express oneself by speech





Appropriate
Inappropriate
Awake/ alert
Presence of Tremors
Presence of Tics
Gesture





Emblems
Iconic gestures
Metaphoric gestures
Affect displays
Beat gestures
Grooming and Hygiene
Sign of distress
Thought process, Content and Perception
VI.




Appropriate to environment/ weather
Inappropriate to environment/ weather
Neatly dress
Untidy dress





Irritable
Apprehension
Anxious
Sleeplessness
restless




Alert and clear
Confuse
Disoriented/ senile
Stupurous
GORDONS TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS
Health-perception/healthmanagement pattern
NORMAL FINDINGS
ACTUAL FINDINGS
There are 3 components of
health beliefs models that may
affect health perception: 1st
involves the individuals
perception of susceptibility to
an illness, 2nd involves
individuals perception of the
seriousness of the illness, 3rd is
the likelihood that a person
will take preventive action
result from the person’s
perception of the belief of and
The family did not give much
attention in their health. Their
primary concerns were more
on on the foods they will eat
for the following days. They
used herbal plants in curing
some illness.
IMPRESSION
The family has poor health management
and perception.
barriers to taking action.
(Kozier)
There are 3 components of
health beliefs models that may
affect health perception: 1st
involves the individuals
perception of susceptibility to
an illness, 2nd involves
individuals perception of the
seriousness of the illness, 3rd is
the likelihood that a person
will take preventive action
result from the person’s
perception of the belief of and
barriers to taking action.
(Kozier)
Nutritional/metabolic
pattern
Elimination pattern
For older adult female who
perform less than 30 min of
exercise a day requires 1,600
calories consisting of the
following; grains: 5 ounces,
vegetable: 2 cups, fruit: 1.5
cup, milk: 3 cups, meat and
beans: 5 ounces. (Kozier)
According to the patient his
eating pattern was altered
because he is not feeling
well.”di ak ginaganahan pag
kaun”as verbalized by the
patient.
Fecal Elimination- normally
feces are soft but formed,
brown in color for adults.
Shape is cylindrical about 1
inch in diameter. Amount
varies with the person’s diet
from 100-400g/day. (Kozier,
The client defecates 3-2 times
a day and urinates 6 times a
day.
The patient has poor nutritional pattern
The clients elimination pattern is normal
p.1325)
Activity/exercise pattern
Sleep and rest pattern
Cognitive/perceptual pattern
Self-perception/self-concept
Exercise of 30 minutes or
more per day of moderate
intensity is a minimal
requirement for physical
activity that would help
maintain mental and physical
health. (Kozier)
He fells weak due to his
condition
Has poor activity or exercise pattern
Healthy adults need 7-9 hours
of sleep at night. However,
there is an individual’s
variation as some adults may
be able to function well at 6
hours of sleep and others
need 10 hours of sleep to
function well. (Kozier)
Cannot sleep because of pain
he felt and always irritable.
Has inadequate rest and sleep pattern
Cognitive abilities mature
during adolescence between
the age 11 and 15. The
adolescence begins Piaget’s
formal operation stage of
cognitive development where
person thinks beyond present.
(Kozier)
Normal vision: 20/20
Normal voice tone is audible
Able to taste sweet,sour and
bitter foods.
The patient displays activities
appropriate for
developmental level and has
The client has no sensory
deficit responds to verbal and
physical stimuli. The client was
oriented to time, place and
person.
Has normal cognitive or perceptual pattern
The client expresses concern
about his family and his
condition.
Has normal self perception or self concept
pattern
pattern
Role/relationship pattern
Sexuality/reproductive pattern
Coping/stress tolerance pattern
stable body image and patient
should demonstrate positive
concept and patient should
recognize uniqueness of other
people. (Kozier)
The patient should
demonstrate functional verbal
and non-verbal
communication, and then she
would participate in social
interactions then builds and
maintains meaningful
relationship.(Kozier)
The patient is a good son to his
parents. He help in the household
chores.
The patient should have valid
knowledge about sexual
functioning and human
sexuality, also accepts sexual
functions and sexuality of
human as normal. The patient
recognizes and accepts
personal sexual feelings, and
maintains healthy lifestyle
during pregnancy. (Kozier)
The client was not yet matured so
his secondary sex characteristics
was not yet develop.
The patient makes decision
reflecting understanding of
personal limitations, protects
self against overwhelming
situation and changes then
manages to keep while
balancing life-role while
minimal conflict. (Kozier)
He tells his problems to his
parents and family
Has good role/relationship pattern
normal
Has normal coping /stress tolerance pattern
Value/belief pattern
VII.
The patient should expresses
respect for all life and the
quality of life and maintains
realistic goals for self based on
value decisions, and
demonstrate a real of life, and
provides for spiritual aspect.
(Kozier)
The client is Roman Catholic.
She believes God as a source
of strength.
Has normal value/belief pattern
VITAL SIGNS
PARAMETER
Height
Weight
Blood Pressure(BP
Pulse Rate/heart rate
PROCEDURE
It measures with a
measuring stick attached
to weighing scale or to a
wall.
It measures with a
weighing scale in pounds
(lb) or kilograms (Kg).
Assessed client upper arm
using the brachial artery
and a standard
stethoscope.
Palpated by applying
moderate pressure of the
ACTUAL VALUES
NORMAL VALUES
ANALYSIS/ INTERPRETATION
Not assessed
163(nutrition & client
therapy-Sue H. Williams).
Normal
Not assessed
55kg (nutrition & client
therapy-Sue H. Williams).
N/A
N/A
N/A
N/A
60-100bpm
Normal
95bpm
three fingers of the hand.
Respiration Rate
Temperature
Observed by the
movement of the chest
upward & downward.
Using thermometer,
measure in common
sites, oral, rectal, axillary,
tympanic membrane &
skin.
23bpm
12-20cpm
38.1
36.5oc-37.5oc
tachepneic
-Due to increase body
temperature regulatory set
point. This increase in set
point triggers muscle tone
and shivering
VIII. PHYSICAL EXAMINATION (HEAD-TOE ASSESSMENT)
AREAS
ASSESSMENT
TECHNIQUE
skull
Observation
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS/INTERPRETATION
8. Head


hair
Observation
Normocephalic, no
edema, no lesions
should be noted,
asymmetric
Evenly distributed
hair ,thick, silky,
resilient ,no
Asymmetric, no
edema, no lesions
noted
Normal
Evenly distributed
,no infection,
amount of hair is
Presence of lice indicates



not assessed
scalp
observation
face
observation

ears

nose

lips
observation
observation
teeth
Neck
poor hygiene.
Normal
Symmetrical in facial
movement.
Evenly distributed
Normal
Normal
observation
eyelashes

variable, with
presence of lice.
eyebrows


infection, amount of
hair is variable
No dandruff, oily,
even in color.
Symmetrical in facial
movement.
Evenly distributed
observation
Inspection
observation
9. Breast
 nipples
Not assessed
Slightly curved
outward
No discharges, no
lesions, symmetrical
in shape
Symmetric and
aligned, no
discharges, air can
go in and out the
nose without
occlusion
Lips should be
uniform in color,
smooth, moist
32 teeth for adults,
white, shiny tooth
enamel.
No palpable mass,
not tender, uniform
in color.
Unequal in size,
generally symmetric,
dark brown in color,
no discharges.
Slightly curved
outward
No discharges, no
lesions, symmetrical
in shape
Symmetric and
aligned, no
discharges, air can
go in and out the
nose without
occlusion.
Uniform in color,
moist
14 teeth, red, not
shiny tooth enamel
No palpable mass,
not tender, uniform
in color.
Normal
Normal
Normal
Normal
Poor oral hygiene.
Normal

Not assessed
areola
10. abdomen
observation
11. Upper extremities (hands,
fingers, nails, wrist elbows to
shoulders
observation
12. lower extremities (thighs,
knees, ankle, foot, and
distal)
observation
observation
13. Skin
Brown in color, no
tenderness noted.
Uniform in color, no
palpable mass, no
lesion noted.
No tenderness, no
lesion, uniform in
color, capillary refill
1-2 seconds, nails
are short and clean.
No tenderness, no
lesions, uniform in
color, no deformities
No edema, no
abrasions,
temperature of the
skin is uniform
within normal range,
skin varies from light
to deep brown
Normal
No palpable mass,
no lesion noted,
uniform in color
No tenderness,
uniform in color,
nails are short and
dirty.
No tenderness, no
lesions, uniform in
color, no
deformities, capillary
refill 1-2 seconds,
nails are long and
dirty w/ skin abcess
on the left thigh w/
exudates.
Flushed skin, warm
to touch. no edema
noted
Normal
Normal
Has poor self hygiene.
Due to heat production
IX.NURSING CARE PLAN
HEALTH
PROBLEM
Altered thermoregulation related
to inflammatory process
SCIENTIFIC
RATIONALE
GOALS AND
OBJECTIVES
After the nursing
intervention the
patient will be able
NURSING
INTERVENTIONS
RATIONALE
EVALUATION
After the nursing
interventions the
patient was able to
to maintain core
temperature within
normal range
Subjective cues:” mapaso tak
inaabat ngan masuol it akun
habol”as verbalized by the patient
Objectives:
1.To evaluate
effects/degree of
hyperthermia.
Objective cues:
-flushed skin
-warm to touch
- headache
maintain core
temperature within
normal range.
-Monitor vital signs.
-Perform TSB.
Measurable cues:
Temp- 38.1
RR- 23
PR- 95
BP- 110/80mmhg
-To evaluate
severity.
-To lower the
temperature.
2.To assist with
measures to reduce
body temp/restore
normal body/organ
function.
-Encourage to
increase fluid
intake.
-Place in a
comfortable
position.
-To prevent
dehydration and
fluid loss.
-To promotes rest.
3.To promote
wellness
-Teach SO on how
to perform TSB.
-To enhance
knowledge.
-Advise to submit
self for checkups.
-For further
evaluation
PRIORITIZATION OF IDENTIFIED PROBLEMS
HEALTH PROBLEM
CUES
JUSTIFICATION
Altered thermoregulation r/t inflammatory
process
(+) febrile
(+) draining abcess
(+) warm to touch
Fever is a normal response of the body to
infections.
Pain r/t accumulation of pus in the thigh s/t skin
abscess
(+)PRS-5
(+) draining abscess
Pain needs prompt attention if not given
attention, it may alter the clients well being.
Ineffective tissue perfusion r/t open wound S/T
skin abscess
(+) draining abscess
Ineffective tissue perfusion may result to tissue
damaged or permanent loss of function if not
treated accordingly.
HEALTH TEACHING PLAN
TEACHING
OBJECTIVES
After nursing
interventions the SO
correctly perform
return demonstration
of wound cleansing
STRATEGIES
LEARNING CONTENT
TIME DURATION
RESOURCES
EVALUATION
Discussion and
demonstration
Discuss and
demonstrate the
proper wound
cleansing
30 minutes
Nurse –SO effort
The SO was able to
perform proper
wound cleansing
Patient no.4
I.
DEMOGRAPHIC PROFILE
Name: Mr. X
Age: 21 yrs old
Occupation: Student
Civil status: Single
Sex: Male
Educational Attainment: High School Graduate
Nationality: Filipino
Admitting diagnoses: N/A
Address: Brgy. Pagbabangnan, San Julian
Eastern Samar
Father’s name: Mr.R
Mother’s name: Mrs.M
IX.
X.
Attending physician: N/A
Occupation: N/A
Occupation: N/A
NURSING CLINICAL ABSTRACT
- N/A
NURSING HISTORY
1. History of present illness
The client has a productive cough of more than 2 weeks. He doesn’t seek any medical advices nor submit self for check- ups
and doesn’t take any medications.
Past Health History
6. Injury: has a history of fall and felt back pain.
7. Hospitalization: -Never been hospitalized
8. Immunization: unknown
4. Family Health History
4.1 Father side: unknown
4.2 Mother side: unknown
5. Allergies – no known allergies
VI.
BIOPHYSICAL ASSESSMENT
GENERAL APPEARANCE
ACTUAL FINDINGS
Posture
Gesture
Posture/gestures/body movements
Language/Diction
Facial Expression
Grooming and Hygiene
Sign of distress
Thought process, Content and Perception
 Erect
 Slouch
 Stooping or swayback





 Express oneself by speech
 Unable to express oneself by speech





Appropriate
Inappropriate
Awake/ alert
Presence of Tremors
Presence of Tics
 Appropriate to environment/ weather
 Inappropriate to environment/ weather
 Neatly dress
 Untidy dress





Irritable
Apprehension
Anxious
Sleeplessness
restless




Alert and clear
Confuse
Disoriented/ senile
Stupurous
Emblems
Iconic gestures
Metaphoric gestures
Affect displays
Beat gestures
V. GORDONS TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERN
Health-perception/healthmanagement pattern
NORMAL FINDINGS
ACTUAL FINDINGS
IMPRESSION
There are 3 components of
health beliefs models that may
affect health perception: 1st
involves the individuals
perception of susceptibility to
an illness, 2nd involves
individuals perception of the
seriousness of the illness, 3rd is
the likelihood that a person
will take preventive action
result from the person’s
perception of the belief of and
barriers to taking action.
(Kozier)
There are 3 components of
health beliefs models that may
affect health perception: 1st
involves the individuals
perception of susceptibility to
an illness, 2nd involves
individuals perception of the
seriousness of the illness, 3rd is
the likelihood that a person
will take preventive action
result from the person’s
perception of the belief of and
barriers to taking action.
(Kozier)
“Diri ma kmi hit mahilig mag
pa check –up ngan mas inuuna
nam am pangangaunon kysa
hit..kaluuyan la hit ginoo”.as
verbalized by the patient.
Due to poverty the clients cannot managed
well their health. The mone they earned was
not enough for buying foods. Instead of
buying medicines they buy it for food.
Nutritional/metabolic
pattern
Elimination pattern
Activity/exercise pattern
Sleep and rest pattern
For older adult female who
perform less than 30 min of
exercise a day requires 1,600
calories consisting of the
following; grains: 5 ounces,
vegetable: 2 cups, fruit: 1.5
cup, milk: 3 cups, meat and
beans: 5 ounces. (Kozier)
The client eats rice and
vegetables. He said it is rare
for them to eat meat. Most of
the time they shared foods
like fish and some sea shells.
Clients nutritional intake composes of
carbohydrates, proteins from fish and
vitamins and minerals from vegetables.
Fecal Elimination- normally
feces are soft but formed,
brown in color for adults.
Shape is cylindrical about 1
inch in diameter. Amount
varies with the person’s diet
from 100-400g/day. (Kozier,
p.1325)
The client defecates once a
day and urinates 6 times a
day.
Exercise of 30 minutes or
more per day of moderate
intensity is a minimal
requirement for physical
activity that would help
maintain mental and physical
health. (Kozier)
The client doesn’t perform the
usual exercise but his work
compensates. He can perform
his ADL. He work us a farmer.
The client can perform his ADL with no
muscular impairment.
Healthy adults need 7-9 hours
of sleep at night. However,
there is an individual’s
variation as some adults may
be able to function well at 6
hours of sleep and others
need 10 hours of sleep to
function well. (Kozier)
Patient sleeps 6-8 hours a day.
But sometimes she takes a
nap in the afternoon.
This indicates adequate mind and body
functions in order to perform his ADL.
normal
Cognitive/perceptual pattern
Self-perception/self-concept
pattern
Role/relationship pattern
Cognitive abilities mature
during adolescence between
the age 11 and 15. The
adolescence begins Piaget’s
formal operation stage of
cognitive development where
person thinks beyond present.
(Kozier)
Normal vision: 20/20
Normal voice tone is audible
Able to taste sweet, sour and
bitter foods.
The client has no sensory
deficit responds to verbal and
physical stimuli. The client was
oriented to time, place and
person.
Has normal cognitive/perceptual pattern.
The patient displays activities
appropriate for
developmental level and has
stable body image and patient
should demonstrate positive
concept and patient should
recognize uniqueness of other
people. (Kozier)
The client is contented with
his life, he is happy having/
being with his family.
Has positive outlooks to his life.
The patient should
demonstrate functional verbal
and non-verbal
communication, and then she
would participate in social
interactions then builds and
maintains meaningful
relationship.(Kozier)
Client is a father and a lovable
husband to his wife.
The patient has a good relationship with her
family. He was able to perform his role.
The patient should have valid
knowledge about sexual
The client is on child rearing
stage. Presently, his wife was
Sexuality/reproductive pattern
Coping/stress tolerance pattern
Value/belief pattern
functioning and human
sexuality, also accepts sexual
functions and sexuality of
human as normal. The patient
recognizes and accepts
personal sexual feelings, and
maintains healthy lifestyle
during pregnancy. (Kozier)
bearing their 3rd child.
The patient makes decision
reflecting understanding of
personal limitations, protects
self against overwhelming
situation and changes then
manages to keep while
balancing life-role while
minimal conflict. (Kozier)
The client tells his problem to
his family. they help each
other in solving it.
The patients coping stress pattern is normal
The patient should expresses
respect for all life and the
quality of life and maintains
realistic goals for self based on
value decisions, and
demonstrate a real of life, and
provides for spiritual aspect.
(Kozier)
The client is Roman Catholic.
She believes God as a source
of strength.
The value/belief pattern is normal
Normal
VITAL SIGNS
PARAMETER
PROCEDURE
ACTUAL VALUES
NORMAL VALUES
ANALYSIS/ INTERPRETATION
It measures with a
measuring stick
attached to weighing
scale or to a wall.
Height
It measures with a
weighing scale in
pounds (lb) or
kilograms (Kg).
Weight
Blood Pressure(BP
Pulse Rate/heart
rate
Respiration Rate
VII.
AREAS
Not assessed
163(nutrition & client therapySue H. Williams).
N/A
Not assessed
55kg (nutrition & client
therapy-Sue H. Williams).
N/A
Assessed client
upper arm using the
brachial artery and a
standard
stethoscope.
100/80mmHg
Palpated by applying
moderate pressure
of the three fingers
of the hand.
98bpm
Observed by the
movement of the
chest upward &
downward.
23bpm
120/80mmHg
normal
60-100bpm
normal
12-20cpm
normal
PHYSICAL EXAMINATION (HEAD-TOE ASSESSMENT
ASSESSMENT
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS/INTERPRETATIO
N
Head


skull
inspection
hair
inspection

scalp

face






Inspection and
palpation
inspection
inspection
Normocephalic, no edema,
no lesions should be noted,
asymmetric
Evenly distributed hair ,thick,
silky, resilient ,no infection,
amount of hair is variable
No dandruff, oily, even in
color.
Symmetrical in facial
movement.
Evenly distributed
Asymmetric, no edema, no
lesions noted
Normal
Evenly distributed ,no
infection, amount of hair is
variable
No lesion, oily, no mass and
with dandruff.
Symmetrical in facial
movement.
Evenly distributed
Normal
Normal
eyebro
ws
inspection
Slightly curved outward
Slightly curved outward
Normal
eyelash
es
inspection
Pinkish in color
Pinkish in color
Normal
lower
palpebr
al
conjunc
tiva
inspection
ears
inspection
nose
inspection
lips
Normal
Dandruffs indicates poor
hygiene.
No discharges, no lesions,
symmetrical in shape
Symmetric and aligned, no
discharges, air can go in and
out the nose without
occlusion
Lips should be uniform in
color, smooth, moist
No discharges, no lesions,
symmetrical in shape
Symmetric and aligned, no
discharges, air can go in and
out the nose without occlusion.
Dry and cyanotic
Normal
Normal
Due to smoking


teeth
Neck
14. Breast
 nipples

areola
Inspection
Inspection and
palpation
Inspection and
palpation
Inspection and
palpation
inspection
32 teeth for adults, white,
shiny tooth enamel.
20 teeth, with dental caries and
plaques
No palpable mass, not
tender, uniform in color.
Unequal in size, generally
symmetric, dark brown in
color, no discharges.
Brown in color, no
tenderness noted.
No palpable mass, not tender,
uniform in color.
No discharge, pointing
outward, dark brown in color.
Indicates poor oral hygiene
Normal
Normal
Brown in color
Normal
Flat and no umbilical discharge
Normal
15. abdomen
auscultation
16. thorax and
breathing
pattern
17. Upper
extremities
(hands, fingers,
nails, wrist
elbows to
shoulders
18. lower
extremities
(thighs, knees,
Presence of bowel sound at
RUQ
Percussion and
palpation
Inspection and
auscultation
No enlarge organ
With difficulty of breathing and
crackles
Inspection and
palpation
No tenderness, no lesion,
uniform in color, capillary
refill 1-2 seconds, nails are
short and clean.
No tenderness, uniform in
color, capillary refill 1-2
seconds, nails are long and
dirty.
Inspection and
palpation
No tenderness, no lesions,
uniform in color, no
deformities
No tenderness, no lesions,
uniform in color, no
deformities
Presence of cough
Indicates poor self
hygiene.
Indicates poor self
hygiene.
ankle, foot, and
distal)
Prioritization of identified problems
cues
Health problem
Ineffective airway clearance r/t
retained secretions
Chest pain r/t excessive coughing
secondary to mucus production
PART 2



(+) difficulty of breathing
(+) productive cough
(+) crackles


Chest pain-PRS:6/10
(+) facial grimace
justification
The function of the respiratory system is gas exchange. O2
from inspired air diffuses from alveoli in the lungs into the
blood in pulmonary capillaries. This facilitates gas
exchange and protects the foreign matter such as
pathogens. Air is one needed for body system to be
function.(Kozier, vol.2, pp.1357)
Pain is more than a symptom of a problem; it is a high
priority problem in itself. Pain present both physiologic &
psychologic danger to health. It affect all body system
causing potentially serious health problem while
increasing the risk of complication, delays in healing, & an
accelerated progression of fatal illnesses. Thus it viewed as
an emergency situation.(Kozier,vol 2,pp1187)
Family living space
Toilet
kitchen
bedroom
chilren’s bedroom
Living room
I.
Initial Database for Family Nursing Practice
a. Family Structure, characteristics and dynamics
1. Members of the household and relationship to the head of the family
Family Member
Relationship to the head of the family
1. Mrs. M
Wife
2. Mr. X
Son
3. Mr. Q
Son in law
4. Mr. V
Grandson
5. Mrs.N
Daughter
2. Demographic Data
Name of Family
Member
1.Mr.R
2. Mrs. M
3. Mr. X
4. Mr. Q
5. Mr. V
6. Mrs.N
3. Place of Residence
Age
Sex
Position in the family
Civil Status
56
male
Head of the family
married
56
21
40
8
35
Female
Male
Male
Male
female
housewife
son
Laborer
Son/ grandson
housewife
Married
Single
Married
Single
Married
1. Barangay Pagbabangnan, San Julian, Eastern Samar
4. Type of Family Structure
1. Extended Type of family
5. Dominant family members in terms of decision making
1. Mr. R
2. Mrs. M
6. General family relationship/ dynamics
1. It has sometimes conflict between the family members
b. Socio-economic and cultural characteristics
1. Income and expenses
Name of
Occupation
Place of work
Family
Member
1. Mr .R
Farmer
Barangay pagbabangnan,
San Julian, Eastern
Samar
2. Mr. Q
Laborer
Barangay Pagbabangnan,
San Julian, Eastern
Samar
Monthly
income
Adequacy to meet
basic needs
Php 1500
Not adequate to
Support their daily
needs
Not adequate to
Support their daily
needs
Php 1000
ii.Educational Attainment
Family Members Name
1. Mr. R
2. Mrs.M
3. Mr X
4. Mr Q
5. Mr.V
6. Mrs N
Educational Attainment
Elementary Level
High school Graduate
High school Graduate
High school level
Currently studying in Elementary
College level
2. Ethnic Background and Religious Affiliation
Family Members Name
1. Mr R
2. Mrs M
3. Mr X
4. Mr.Q
5. Mr.V
6. Mrs.N
Ethnic Background
None
None
None
None
None
None
Religion
Roman Catholic
Roman Catholic
Roman Catholic
Roman Catholic
Roman Catholic
Roman Catholic
3. Relationship of the family to larger community:
1. They participates when there is a community assembly.
c. Home and Environment
1. Housing:
1. Sleeping Arrangement
Mr.R and Mrs. M sleep in one room while Mr Q and Mrs N together with Mr V sleep in the children’s
room and Mr X sleeps at the living room.
2. Presence of breeding or resting sites of vectors of disease:
There are mosquitoes, roaches, flies and rodents in there resience.
3. Presence of accident hazards:
There house is built near a river and a sea, therefore they are prone in tsunami and flood.
4. Food storage and cooking facilities
a. Food storage: Basket
b. Cooking facilities: Use firewood as their cooking facility
5. Water Supply: Community Artesian
6. Toilet Facility: They have an own toilet facility
7. Garbage disposal: dumping
8. Drainage System: None
2. Kind of Neighborhood:
3. Social and health facilities available:
1. Sari-Sari store
2. Barangay Health Clinic
3. Barangay Plaza
4. Communication and Transportation:
1. Communication: cellphone
2. Transportation: Jeepney, and Trycicle
5. Health Status of each family member:
6. Medical and nursing history:
1. Illness:
2. Beliefs and practices: Believes in God
7. Nutritional Assessment
1. Anthropometric Data
2. Dietary History:
Frequency of meal
Meal taken
Break fast
Rice, Fish
Lunch
Rice,fish, vegetables
Dinner
Rice, Sardines
3. Eating habits/ practices: the family eats 3 times a day and rarely 2 times a day.
:
d. Values, habits, practices on health promotion, maintenance, and disease prevention
1. Immunization Status:
There are two member of the family that are fully immunized the other are not.
2. Healthy lifestyle practices:
1. Daily bathing
2. Tooth brushing after meals
3. Adequacy of:
1. Rest and Sleep:
a. Mr.R- 6 hours of sleep
b. Mrs. M- 7 hours of sleep
c. Mr. X- 8 hours of sleep
d. Mr. Q- 7 to hours of sleep
e. Mr.V- 10 hours of sleep
f. Mrs.N - 6
2. Exercise/ Activities:
a. Mr.R- his source of exercise is doing farming
b. Mrs. M- her source of exercise is doing household chores an sometimes farming
c. Mr. X- His source of exercise is playing basketball
d. Mr. Q- His source of exercise is when he is working
e. Mr.V- His source of exercise is playing outside with his peers
f. Mrs.N - His source of exercise doing household chores
3. Use of protective measures:
Use mosquito net while sleeping at nighttime and they uses katol.
4. Relaxation and Stress management:
Reading novels and playing cards
4. Use of Promotive:
None
e. List of Identified Problems
Health Problem
1. Cross infection
3.Faulty eating habits
4.Unhealthy lifestyle and personal
habits
Cues/ Data
Family Nursing Problem
It has one family member
that has cough
Deficient knowledge of protective measures
between family Members
The family members
Inability to recognize the presence of the
seldom eat vegetables and condition or problem due to lack of or inadequate
fruits
knowledge
Cigarette/ tobacco
Inability to recognize the presence of the
smoking,drinking alcohol condition or problem due to attitude/ philosophy
inadequate rest or sleep, in life which hinders recognition/ acceptance of a
lack of exercise
problem.
FAMILY NURSING CARE PLAN
HEALTH
PROBLEM
Cough and
Colds
FAMILY NURSING
PROBLEM
Inability to make
decisions with respect to
taking appropriate health
actions due to:
a. Low salience of the
problem/condition
GOALS AND OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
After the nursing
intervention the family
will be able to eliminate
the cough and colds and
will prevent the
recurrence of the
disease in the future.
1. Discuss with the family
the causes, effects and
complications of cough and
cold.
-to be aware to
the possible
complications.
2. Provide adequate
knowledge on the various
ways of maintaining
cleanliness in their
surroundings.
-to reduce risk of
diseases.
3.Explain the importance of
proper food preparation,
good nutrition, rest and
sleep in strengthening
one’s resistance against
illness, so as to prevent
occurence of cough and
colds
-to prevent
contamination
Objectives:
a. acquire adequate
information about the
disease, including signs
and symptoms of the
disease, immediate
health care assistance
and preventive
measures;
b. be aware on how to
reduce the chances of
spreading
communicable diseases
to other family
members;
c. utilize community
resources openly
available in resolving the
condition experienced.
4. Cite ways in eliminating
the disease and limiting the
occurence of transmission
by suggesting courses of
action such as medications
(e.g. measures like the
application of alternative
medicines like lagundi if
-To eliminate
further
complications.
RESOURCES
REQUIRED
- Material
Resources:
- Visual Aids and
low- cost materials
needed for
demonstration
-Time and effort on
the part of the nurse
and family
EVALUATION
After the
nursing
intervention
the family
able to
eliminate the
coughs and
colds and
prevent the
occurrence
of the
disease in the
future.
resources in the
community is inadequate)
and preventive measures
such as covering the mouth
when sneezing or coughing
and proper disposal of
nasal or oral discharges.
5. Promote proper
personal and
environmental hygiene
among all members of the
family.
6. Provide information on
health centers in the
vicinity for immediate care
assistance.
-to prevent
transfer of
diseases.
-to promote and
to reduce the risk
to health and
safety.