Fncp- (1) Sample

FAMILY NURSING CARE PLAN WRITTEN OUTPUT Introduction I.

Family Initial Database (Use Guide by Maglaya)

II. First and Second Level Assessment A. Health Strengths 1. Potential for enchanced capability health nutrition/lifestyle

Health Strengths for

2. Readiness for enhanced capability for a healthy lifestyle

3. Potential for enhanced capability for health maintenance / health management

B. Health Problem (First Assessment) A. Health Deficits

and

“Sige po iiwasan ko na kumain ng noodles na sunod sunod/almost every kainan, tsaka medyo mag eexercise na po kami, encourage ko po sila na wag na kaming masyadong higa higa lang at lutaytay kundi galaw galaw din kami at mag increase po kami ng pag inom ng tubig” “opo mag papacheck up na po ako sa dentist, tsaka sabihin ko rin po sa mga kapatid ko na bumisita sa health center, tsaka opo iinom na po kami ng madaming tubig at mag eexercise nap o.”

Health Problems Level

1. Pain

2. Cough (Coryza)

Supporting Cues “Madalas po gulay kinakain namin, mostly po mga sayote, ampalaya, at iba pa po, pero medyo ayaw ko lang po ng saluyot, pero pag yung ibang mga green leafy vegetables naman nap o madami po akong nakakain, tsaka mahilig rin po kami sa sili tas regular naman po yung pagkain naming at nauubos po naming yung mga naiihanda sa lamesa, tsaka mag babawas bawas narin po ako ng rice at maaalat”

Colds

Supporting Cues

Second Level Assessment (Family Nursing Diagnosis)

“Febie Lictao is complaining of tooth pain and upon assessment the certain tooth causing pain is already accumulating plaques’ and already showing signs of necrosis, also there is minimal bleeding noted. “Febie and her cousin Dexter are sniffing in their mucus, and they were also coughing, they also admitted that they are feeling some presence of phlegm in their chest and neck”

Inability to make decisions with respect to taking appropriate healthy actions due to the far distances of health care facilities

3. Hypertension

“Their grandmother nanay paulene ramos had a BP of 150/90 and she was feeling dizzy and weak

4. Hyperthermia

“Nanay paulene Ramos was warm to touch and upon taking her V/S she had an RR of 26 and HR: 80, SPo2: 93%, and Temperature of 38.5 degrees celcius”

Inability to recognize the presence of threats of the condition and how important early treatment is, due to lack of attention given to the condition Inability to make decisions in respect to taking appropriate health actions due to misconceptions or erroneous information about proposed courses of action Inability to provide adequate nursing care to the sick, disabled and at risk members of the family due to lack of the necessary facilities, equipments and supplies for care.

B. Health Threats 1.Unhealthy lifestyle personal habits

and

“Febie: Mahilig po kasi ako sa instant noodles at minsan napapadami ko yung kain ko lalo nap o ng rice dahil sa sili mahilig din po kasi ako sa maaanghang,

Inability to provide a home environment conducive to health maintenance and personal development due to lack of knowledge of importance of

Kulang din po kami sa tubig at hindi po masyado nag eexercise” “Paulene Ramos: nakaka 8 cups of coffee ako per day”

hygiene, sanitation and lack of knowledge of preventive measures Inability to recognize presence of the condition (aggravating factor) due to philosophy in life and habitual actions and dietary practices which hinders the recognition of its effect to herself.

2. Lack of Immunization

“paulene ramos and Wilda Lictao: medyo hindi naming na kumpleto yung mga bakuna naming noon at hindi pa naman uso kasi noon yung mga ganyan ganyan.”

3.Poor environmental sanitation, presence of nesting places for mosquitoes and improper drainage disposal

Open drums, pots, cans tires, and wooden feeding long bowl that are full of water around the environment, it is a little bit messy and there are some hanged clothes in the inside of the house but mostly are outside, Febie Stated: “ Opo may nadengue na ditto dati”

Failure to utilize community resources for health care due to failure to recognize its benefits for each member of the family and if left untreated its severity and impact to the family members.

“Febie and dexter have Cough and Colds, They live at the same house, and they tend to cling and they are close to their younger siblings” “High intake of Caffeine can lead to vasoconstriction and increased intake of sodium and processed foods hence increase the blood pressure” “Febie is a little bit heavy for her height and she admits it, also she stated that she is a heavy eater and eat lots of ric, who sits around all day and has minimal exercise, and also is not a fan of water (drinking water)”

Inability to recognize the health threat of the condition due to lack of knowledge on how it is transmitted

C. Foreseeable Situation

Crisis

1.Possible spread of Cough and colds to younger siblings

2.Aggravate hypertension

3.Potential for Obesity

Inability to recognize the health threats of the condition due to lack of knowledge of how it develops

III. Prioritization of Health Problems i. Computations Problem: pain as a Health Deficit Criteria Computation 1. Nature of the (3/3)X1 Problem 2. Modifiability of the (½)X2 Problem 3. Preventive Potential (3/3)x1 4. Salience of the (2/2)X1 Problem TOTAL SCORE Problem: Cough and colds as a Health Criteria Computation 1. Nature of the (3/3)X1 Problem 2. Modifiability of the (½)X2 Problem 3. Preventive Potential (3/3)X1 4. Salience of the (2/2)X1 Problem

Score 1 1 1 1 4

Inability to recognize the health threat to one’s self due to lack of knowledge and information about the lifestyle, products and things that they use or consume in their daily lives.

Justification This factor can alter the patients comfort and even her immune system, it could lead to fever and can alter the mobility of the patient, it could also make her irritable and have other complications if left untreated

Deficit Score 1 1 1 1

Justification This is one factor that could alter the state of the patient because it is concerned with her airway giving her discomforts and also can hinder her mobility, and

TOTAL SCORE Problem: Hypertension as a Health Criteria Computation 1. Nature of the (3/3)X1 Problem 2. Modifiability of the (½)X2 Problem 3. Preventive Potential (2/3)X1 4. Salience of the (2/2)X1 Problem TOTAL SCORE

Deficit

Problem: Hyperthermia as a Health Criteria Computation 1. Nature of the (3/3)X1 Problem 2. Modifiability of the (½)X2 Problem 3. Preventive Potential (2/3)X1 4. Salience of the (2/2)X1 Problem TOTAL SCORE

Deficit

4

also lead to infection if left untreated

Score 1

Justification She already has hypertension and she is maintaining it the only threat here is when it has fluctuations and when her BP goes up it could alter her general health status and lead to several discomforts such as pain

1 0.67 1 3.67

Score 1 1 0.67 1 3.67

Justification She is already feeling the fever but it may be caused by other factors this could also alter the comfort of the patient but pain would still be prevalent and this problem has lots of interventions that could ease the patient.

Problem: Unhealthy lifestyle and personal habits as a Health Threat Criteria Computation Score Justification 1. Nature of the (3/3)x1 1 This is one major threat Problem because today lifestyle shapes our life, and if 2. Modifiability of the (1/2)x2 1 not corrected lots of Problem complications would 3. Preventive Potential (2/3)x1 0.67 arise 4. Salience of the (1/2)x1 0.50 Problem TOTAL SCORE 3.17 Problem: Lack of Immunization as a Health Threat Criteria Computation Score Justification 1. Nature of the (3/3)x1 1 This is also a factor that Problem could expose the patient to different threats for 2. Modifiability of the (1/2)x2 1 not having a fortified Problem defense but atleast we 3. Preventive Potential (2/3)x1 0.67 have our natural 4. Salience of the (1/2)x1 0.50 antibodies Problem TOTAL SCORE 3.17 Problem: Poor environmental sanitation, presence of nesting places for mosquitoes and improper drainage disposal as a Health Threat Criteria Computation Score Justification 1. Nature of the (3/3)x1 1 This could lead to health Problem problems specially on dengue and on diarrhea 2. Modifiability of the (1/2)x2 1 and the place could Problem culture bacteria wherein 3. Preventive Potential (2/3)x1 0.67 they would acquire 4. Salience of the (1/2)x1 0.50 different types of Problem disease because of the TOTAL SCORE 3.17 said cultured bacteria Problem: Possible spread of Cough and colds to younger siblings as a Foreseeable Crisis Criteria Computation Score Justification 1. Nature of the (3/3)x1 1 This could hinder the Problem family because if the other members would 2. Modifiability of the (1/2)x2 1 get infected it would be Problem hard to eradicate and it 3. Preventive Potential (2/3)x1 0.67 would also immobilize 4. Salience of the (1/2)x1 0.50 Problem

TOTAL SCORE

3.17

the family so this should be one of our concerns

Problem: Potential for Obesity as a Foreseeable Crisis Criteria Computation Score 1. Nature of the (3/3)x1 1 Problem 2. Modifiability of the (1/2)x2 1 Problem 3. Preventive Potential (2/3)x1 0.67 4. Salience of the (1/2)x1 0.50 Problem TOTAL SCORE 3.17 Problem: Aggravate hypertension as a Foreseeable Crisis Criteria Computation Score 1. Nature of the (3/3)x1 1 Problem 2. Modifiability of the (1/2)x2 1 Problem 3. Preventive Potential (2/3)x1 0.67 4. Salience of the (1/2)x1 0.50 Problem TOTAL SCORE 3.17 1. Problem: Potential for enchanced capability for health nutrition/lifestyle as a Health Strength Criteria Computation Score 1. Nature of the (2/3)x1 0.67 Problem 2. Modifiability of the (1/2)x2 1 Problem 3. Preventive Potential (2/3)x1 0.67 4. Salience of the (1/2)x1 0.50 Problem TOTAL SCORE 2.84 1. Problem: Readiness for enhanced capability for a healthy lifestyle as a Health Strength Criteria Computation Score 1. Nature of the (2/3)x1 0.67 Problem 2. Modifiability of the (1/2)x2 1 Problem 3. Preventive Potential (2/3)x1 0.67 4. Salience of the (1/2)x1 0.50 Problem TOTAL SCORE 2.84 Problem: Potential for enhanced capability for health maintenance / Strength Criteria Computation Score 1. Nature of the (2/3)x1 0.67 Problem 2. Modifiability of the (1/2)x2 1 Problem 3. Preventive Potential (2/3)x1 0.67 4. Salience of the (1/2)x1 0.50 Problem TOTAL SCORE 2.84

ii. List of Prioritized Health Problem 1. Pain as a Health Deficit

Justification This is still a potentiality but Febie might get to this point if she doesn’t modify her diet

Justification This could aggravate the condition of lola ramos but this is still a risk so lola should also modify her consumptions to prevent further complications

Justification This is one of our greatest on concerns but at last priority because they already know some part of what a health nutrition is

Justification This is also one of our greatest concerns but not our most priority because at least they already know how to manage their lifestyle in some way but they are still lacking some health management as a Health Justification They are able to do interventions of their own In terms of disease processes but they still need to learn a lot of things and interventions so we just need to fortify them so I placed this as last priority because at least they already know a lot it just needs polishing.

Health Problems

2. Cough and Colds as a Health Deficit

Rank

Total Score st

1

4pts

2nd

4pts

3. Hypertension as a Health Deficit

3rd

4.Hyperthermia Deficit

4th

as

a

Health

3.67pts 5th

5.Unhealthy lifestyle personal habits as a Threat

and Health

6. Lack of Immunization as a Health as a Health Threat 7. Poor environmental sanitation, presence of nesting places for mosquitoes and improper drainage disposal as a Health Threat 8. Possible spread of Cough and colds to younger siblings as a foreseeable crisis 9. Potential for Obesity as a foreseeable crisis

3.67pts

6th 7th

3.17pts

8th 9th

3.17pts

10th

3.17pts

11th

3.67pts 12th

3.17pts 13th

10. Aggravate hypertension as a foreseeable crisis

3.17pts

11.Potential for enchanced capability for health nutrition/lifestyle as a Health strength

2.84pts

12. Readiness for enhanced capability for a healthy lifestyle as a Health Strength

2.84pts

13. Potential for enhanced capability for health maintenance / health management as a Health Strength

2.84pts

IV. Family Nursing Care Plan (Top 2 Problems) A. Health Problem (First Level Assessment): Cough as a Health Deficit 1. Family Nursing Diagnosis/es (Second Level Assessment): a. Acute pain related to physical agent and inflammatory process b. Ineffective airway clearance related to presence of secretions in the tracheobronchial tree 2. Supporting Cues

a. Subjective Data: Pain: “masakit po yung ngipin ko sa lower left na part ng bunganga ko” Cough and Colds: “opo meron po akong nararamdaman na plema sa leeg at dibdib ko tsaka meron din kaming ubot sipon ng pinsan kong si dexter” b. Objective Data: Pain: Defensive mechanism when pressure is applied to the site of pain, Grimaces when tooth is touched with tongue depressor, There is presence of plaque, bleeding and a minimal necrosis of the tooth, tooth appears to be color dark green, gums are inflamed and left cheek is warm to touch. Pricking Pain is felt on the lower left tooth aggravated by chewing and alleviated by stabilizing the site, intermittent and rated as 7/10.

Cough and Colds: Coughing and blowing her nose, Productive cough and running nose, secretions characterized as minimal, viscous and green in color, with clear breath sounds, DOB noted, mouth breather and with a VS of: RR 25, PR 93, Temp: 36.9, SPo2: 91%. 2. Goal/s: Pain: after 8 hours of nursing interventions, the patient will be able to experience gradual reduction/relief of pain, the patient will display improved well being such as baseline levels for pulse Bp respirations and relaxed muscle tone or body posture, patient will describe satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10 Cough and Colds: After 2-4 hours of nursing intervention the client will demonstrate enhanced breathing pattern, after 2-4 hours of nursing interventions respiratory status of the patient will become patent as evidenced by not compromised respiratory rate, moves sputum out of airway and no adventitious breath sounds 4. Objectives a. Long-term Objectives: Pain: After 3 days of nursing interventions the client will describe satisfactory pain control at a level less than 1-2 on a pain scale of 0 to 10 Cough and Colds: After 3 days of nursing intervention the client will be able to expectorate retained secretions and maintain normal breathing pattern and be relieved from any difficulties and irritability and have normal respirations and other vital signs, even without the supervision of a health care provider, B. Short-term Objectives: Pain: After 3 hours of nursing interventions the patient will be able to report that pain is relieved with a pain scale of 5/10 from 7/10, after 10 minutes of nursing interventions the patient will be able to verbalize understanding of why is she experiencing pain, after 5 minutes of health teaching s the patient will show signs of interest to have a check up to her dentist, after 10minutes of health teachings the patient will demonstrate use of relaxation skills and divisional activities and verbalize methods that provide relief, after 2minutes of health teaching the patient will perform Deep breathing exercises. Cough and Colds: after 1 hour of nursing interventions the client will be able to maintain airway patency and clear breath sounds, after 5minutes of health teaching the client will be able to understand and perform DBE and coughing exercises to facilitate expectoration of phlegm, after 30 minutes of nursing interventions the client will be able to verbalize signs of relief from DOB.

5. Nursing Interventions Interventions

Rationale

Pain:

Pain

Provide comfortmeasures such asuse of incentivespiromet ry or blow bottles. Encouragerelative s to perform touchtherapy

Discussion and To providenonpharmacologic pa health teaching Health in management.

Encourage andassist client to dodeep breathingexercise s.

Encourage adequate rest and

The human bodyis believed to haveenergy fields thatexpress aberrant patterns when bodysystems areinsulted.Therapeutic Touchis thought torealign aberrantfields. Deep breathing for relaxatio n is easyto learn andcontributes to painrelief and/or reduction by reducing muscle tension and anxiety To prevent fatigue

Method of Nurse-Family Interaction Activities:

Return Demonstration

Motivate and support ideas and eradicate erroneous beliefs One on discussion

one

Home visits Oberservation

Resources Needed

Remarks

Assessment tools and confidence

Patient is able to acknowledge health teachings and able to perform the desired tasks

teachings Correct information

Family members are cooperative and a teamplayer.

sleep Encourage mobilization of the left upper extremity to assist with ROM exercises Assess for signs and symptoms relating to pain

To promote circulation.

7.Assess to what degree cultural environmental intrapersonal and intrapsychic factors may contribute to pain or pain relief

Cough and Colds:

Cough and Colds Establish Rapport Monitor V/S

Elevate head of bead Auscultate breath sounds

Monitor respiratory patterns, including rate, depth, and effort

Help client to deep breathe and perform controlled coughing.

Some people deny the existence of pain Such variables play a bif role in modifying the patients expression of pain

To gain clients and relatives trust To obtain baseline data To take advantage of gravity Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction. A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles. This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. To clear the airway

Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest.

Assist with clearing secretions from pharynx by offering tissues Assess airway for patency. 5. Evaluation -Patient acknowledged health teachings and she responded to the nursing interventions making her relieved from DOB, able to facilitate movement of secretions and expectorate them, stabilizing her vital signs with the latest V/S of BP:100/80 RR:19, HR: 82, Temperature: 36.5, SPo2: 96% her pain rate was decreased from 7/10 to 4/10 in the pain scale and she acknowledged that she would have a check-up in the nearest clinic, barangay health center and dentist, she also acknowledged that she would do our health teachings, cover the open waters, and to do the preventive measures that we have taught. V.

Learning Insights - There are lots of people who are in need of health teachings and nursing interventions, a lot of people, especially in the community are in need of our tender loving care, many needs to be motivated to consult or seek for check-up, and many needs to learn how to counter diseases prevent them and promote health, they also need to learn what are the simple interventions that they could do and use to uphold their well-being and health. -

truly It is a beauty to help others we are able to see smiles of relief and we are able to help in every way we can

-

Kapangan truly is one of the wondrous places of the Philippines.